progressive insurance eob explanation codes
1 PC Dispensing Fee Allowed Per Date Of Service(DOS). Sixth Diagnosis Code (dx) is not on file. Claim Denied For Invalid Diagnosis Code Or Diagnosis Code/CPT Combination. Denied/cutback. Pricing Adjustment/ Medicare pricing cutbacks applied. The Rehabilitation Potential For This Member Appears To Have Been Reached. Recoding/adjusting claim may result in a different DRG code assignmentand reimbursement. Claim Denied. OTHER INSURANCE AMOUNT GREATER THAN OR . Adjustment Denied For Insufficient Information. Allowed Amount On Detail Paid By WWWP. Members Are Limited To 45 Dates Of Service Per Therapy/spell Of Illness without Prior Authorization. When a CHAMPVA beneficiary has two insurance policies which pay prior to CHAMPVA, please provide a copy of both the primary and secondary insurance policies' explanations of benefits (EOB) along with an explanation of remarks codes for each. Claim Denied Due To Incorrect Billed Amount. SMV Mileage Exceeding 40 Miles In Urban Counties Or 70 Miles In Rural CountiesRequires Prior Authorization. Description & Use Of Day RX Procedure Codes Based On Members Status-not the place Of Service Where Day Rx Service Performed. The training Completion Date On This Request Is After The CNAs CertificationTest Date. Claim Denied For Invalid Billing Type Frequency Code, Claim Type, Or SubmittedAdjustment Provider Number Does Not Match Original Claims Provider Number. Bilateral Surgeries Reimbursed At 150% Of The Unilateral Rate. Denied due to Detail Add Dates Not In MM/DD Format. CO 7 Denial Code - The Procedure/revenue code is inconsistent with the patient's gender. Denied/Cutback. Drug(s) Billed Are Not Refillable. Denied. Member ID: Member Name: Jane Doe . Denied. Resubmit Your Services Using The Appropriate Modifier After YouReceive A Update Providing Additional Billing Information. The Procedure Requested Is Not Appropriate To The Members Sex. Out-of-State non-emergency services require Prior Authorization. Individual Replacements Reimbursed As Dispensing A Complete Appliance. Pricing Adjustment/ Maximum Flat Fee Level 2 pricing applied. Please Submit A Separate New Day Claim For Copayment Exempt Days/services. An explanation of benefits is a document that explains how your insurance processed the claim for the services you received. Was Unable To Process This Request. Resubmit The Original Medicare Determination (EOMB) Along With Medicares Reconsideration. Our Records Indicate You Have Billed More Than One Unit Dose Dispensing Fee For This Calendar Month. The Resident Or CNAs Name Is Missing. Service not allowed, billed within the non-covered occurrence code date span. Default Prescribing Physician Number XX9999991 Was Indicated. Maximum Number Of Outreach Refusals Has Been Reached For This Period. Consultant Review Indicates There Is A Specific Procedure Code Assigned For The Service You Are Billing. Please Resubmit A New Adjustment/reconsideration Request Form And Indicate TheMost Recent Cclaim Number Where Payment Was Made Or Allowed. This detail is denied. Prescription Drug Plan (PDP) payment/denial information is required on the claim to SeniorCare. Endurance Activities Do Not Require The Skills Of A Therapist. Frequency or number of injections exceed program policy guidelines. Program guidelines or coverage were exceeded. Explanation of Benefit codes (EOBs) Explanation of Benefit (EOB) codes are reported on your remittance statement. Reason for Service submitted does not match prospective DUR denial on originalclaim. Denied due to Prescription Number Is Missing Or Invalid. Procedure not allowed for the CLIA Certification Type. This claim has been adjusted because a service on this claim is not payable inconjunction with a separate paid service on the same Date Of Service(DOS) due to National Correct Coding Initiative. Rqst For An Acute Episode Is Denied. Denied. Other Insurance Disclaimer Code Used Is Inappropriate For This Members Insurance Coverage. HMO Capitation Claim Greater Than 120 Days. The Surgical Procedure Code is not payable for the Date Of Service(DOS). Denied due to From Date Of Service(DOS)/date Filled Is Missing/invalid. The Procedure(s) Requested Are Not Medical In Nature. Learn more. Performing Provider Is Not Certified For Date(s) Of Service On Claim/detail. The Service(s) Requested Could Adequately Be Performed In The Dental Office. Dental X-rays Indicate A Dental Cleaning, Followed By Good Dental Care At Home, Would Be Sufficient To Maintain Healthy Gums. Do Not Bill Intraoral Complete Series Components Separately. Denied. This Unbundled Procedure Code Remains Denied. Services Submitted On Improper Claim Form. Submitted referring provider NPI in the detail is invalid. Prior Authorization is required to exceed this limit. One or more Date(s) of Service is missing for Occurrence Span Codes in positions 9 through 24. Prior Authorization is required for manipulations/adjustments exceeding 20 perspell of illness. Invalid Procedure Code For Dx Indicated. EOBs do look a lot like . Pharmacy Clm Submitted Exceeds The Number Of Clms Allowed Per Cal. Correct And Resubmit. A Photocopy Of The PA Request Form Has Been Mailed Separately Identifying the Reimbursement Rate For The Procedure Codes Authorized. It explains the calculation of your benefits. Procedure code - Code(s) indicate what services patient received from provider. Claim Denied. A Second Occurrence Code Date is required. Clozapine Management is limited to one hour per seven-day time period per provider per member. This Procedure, When Billed With Modifier HK, Is Payable Only If The Member Is Under The Age Of 19. Personal injury protection insurance is mandatory in some states and optional or not offered at all in other states. For Newly Certified CNAs, Date Of Inclusion Is T heir Test Date. NDC was reimbursed at AWP (Average Wholesale Price) (Average Wholesale Price) rate. Master Level Providers Must Bill Under A Mental Health Clinic Number; Not Under a Private Practice Or Supervisor Number. The diagnosis code is not reimbursable for the claim type submitted. The Maximum Allowable Was Previously Approved/authorized. Please Resubmit With The Costs For Sterilization Related Charges Identified As Non-covered Charges On The Claim. Correct And Resubmit. Please Re-submit This Claim With The Insurance EOB Showing A Denial OrPartial Payment. TPA Certification Required For Reimbursement For This Procedure. The EOB breaks down: Denied. Service Denied. NDC- National Drug Code is restricted by member age. The Narrative History Does Not Indicate the Members Functioning is Impaired due To AODA Usage. The From Date Of Service(DOS) for the First Occurrence Span Code is invalid. Revenue Codes 0110 (N6) And 0946 (N7) Are Not Payable When Billed On The Same Dateof Service As Bedhold Days. A National Provider Identifier (NPI) is required for the Rendering Provider listed in the header. Please Clarify. Denied due to NDC Is Not Allowable Or NDC Is Not On File. Rebill Using Correct Procedure Code. Received Beyond Special Filing Deadline For ThisType Of Claim Or Adjustment/reconsideration. Concurrent Services Are Not Appropriate. The To Date Of Service(DOS) for the First Occurrence Span Code is required. Home care ongoing assessments are allowed once every sixty days per member.nt, But Arepayable Every Fifty-fourth Day For Flexibility In Scheduling. Hospital discharge must be within 30 days of from Date Of Service(DOS). LTC hospital bedhold quantity must be equal to or less than occurrence code 75span date range(s). $150.00 Reimbursement Limit Has Been Reached For Individual And Group Pncc Health Education/nutritional Counseling. Claim Reduced Due To Member/participant Deductible. Pricing Adjustment/ Provider Level of Care (LOC) pricing applied. A SeniorCare drug rebate agreement is not on file for this drug for the Date Of Service(DOS). Requests For Training Reimbursement Denied Due To Late Billing. Reason Code 161: Attachment referenced on the claim was not received in a timely fashion. Plan payments - Total amount paid by GEHA. This Service Is Included In The Hospital Ancillary Reimbursement. Prescriptions Or Services Must Be Billed As ASeparate Claim. Schedule 3, 4 or 5 drugs are limited to the original dispensing plus 5 refillsor 6 months. This Member Is Involved In Non-covered Services, And Hours Are Reduced Accordingly. Services on this claim were previously partially paid or paid in full. Reimb Is Limited To The Average Montly NH Cost And Services Above that Amount Are Considered non-Covered Services. Reimbursement For This Service Has Been Approved. Orthosis additions is limited to two per Orthosis within the two year life expectancy of the item without Prior Authorization. Header From Date Of Service(DOS) is required. CO 9 and CO 10 Denial Code. Only non-innovator drugs are covered for the members program. No Action On Your Part Required. General Assistance Payments Should Not Be Indicated On Claims. Please Indicate Anesthesia Time For Services Rendered. Claim Denied. No payment allowed for Incidental Surgical Procedure(s). Resubmit Complete And/or Second Page Of Medicares EOMB Showing All Total And Payments. EOB Codes are present on the last page of remittance advice, these EOB codes or explanation of benefit codes are in form of numbers and every number has a specific meaning. Bilateral Procedures Must Be Billed On One Detail With Modifier 50, Quantity Of 1.detail With Modifier 50 May Be Adjusted If Necessary. The Screen Date Is Either Missing Or Invalid. Assistance. It is a duplicate of another detail on the same claim. NFs Eligibility For Reimbursement Has Expired. Dispensing fee denied. Referral Codes Must Be Indicated For W7001, W7002, W7003, W7006, W7008 And W7013. Denied. Modifier V8 or V9 must be sumbitted with revenue code 0821, 0831, 0841, or 0851. The Other Payer Amount Paid qualifier is invalid for . Covered By An HMO As A Private Insurance Plan. Resubmit Claim Through Regular Claims Processing. Resubmit Private Duty Nursing Services For Complex Children With Documentation Supporting The Level Of Care. Gastrointestinal Surgery For The Purpose Of Weight Control Is Covered Only As An Emergency Procedure. The National Drug Code (NDC) submitted with this HCPCS code is CMS terminated or not covered by the program. The Primary Diagnosis Code is inappropriate for the Procedure Code. A Fourth Occurrence Code Date is required. The To Date Of Service(DOS) for the First Occurrence Span Code is invalid. Claim Denied. One or more Diagnosis Codes are not applicable to the members gender. Please Correct And Resubmit. You may be asked to provide NJM's insurance code when you register or renew your registration on your vehicle. Procedure May Not Be Billed With A Quantity Of Less Than One. Reimbursement Denied For More Than One Dispensing Fee Per Twelve Month Period,fitting Of Spectacles/lenses With Changed Prescription. The Procedure Code has Encounter Indicator restrictions. The Ninth Diagnosis Code (dx) is invalid. Procedure not payable for Place of Service. This Is An Adjustment of a Previous Claim. PA required for payment of this service. 24260 Progressive insurance code: 24260. Prescriber ID Qualifier must equal 01. The Total Billed Amount is missing or incorrect. Please Correct And Resubmit. . Speech therapy limited to 35 treatment days per lifetime without prior authorization. Medicare Part A Services Must Be Resubmitted. Dispense Date Of Service(DOS) is invalid. Comprehension And Language Production Are Age-appropriate. Paid To: individual or organization to whom benefits are paid. This service is not payable for the same Date Of Service(DOS) as another service included on this claim. One or more Occurrence Code(s) is invalid in positions nine through 24. Contact Provider Services For Further Information. Denied due to Services Billed On Wrong Claim Form. V2781 JA - Progressive J Plastic. Procedure Code is not allowed on the claim form/transaction submitted. This Modifier has been discontinued by CMS or AMA for the Date Of Service(DOS)(s). Changes/corrections Were Made To Your Claim Per Dental Processing Guidelines. But there are no terms on this EOB that line up with 3, 6 and 7 above. NDC was reimbursed at generic WAC (Wholesale Acquisition Cost) rate. To Date Of Service(DOS) Precedes From Date Of Service(DOS). Other Coverage Code is missing or invalid. The Service Requested Is Not Medically Necessary. One or more Occurrence Span Code(s) is invalid in positions three through 24. What your insurance agreed to pay. Denied due to Detail Dates Are Not Within Statement Covered Period. Claim Explanation Codes Request a Claim Adjustment View Fee Schedules Electronic Payments and Remittances Claims Submission Process Procedure Code Modifiers Submitting Medical Records Submitting Medicare Part D Claims ICD-10 Compliance Information Reason Code 160: Attachment referenced on the claim was not received. The Revenue/HCPCS Code combination is invalid. Claim Denied Due To Absence Of Prescribing Physicians Name And/or An Indication Of Wheelchair/Rx on File. Resubmit Claim Once Election Form Requirements Are Met Per The Hospice Provider Handbook. Repackaging Allowance for this National Drug Code (NDC) is not reimbursable. Multiple Tooth Extract On Same Date Of Service(DOS) Must Be Billed As Single And Additional Tooth Extract In Same Quadrant. Please Clarify The Number Of Allergy Tests Performed. Member is enrolled in a State-contracted managed care program for the Date(s) of Service. Claim Number Given Is Not The Most Recent Number. Only one antipsychotic drug is allowed without an Attestation to Prescribe More Than One Antipsychotic Drug for a Member 16 Years of Age or Younger. Diagnosis 635-635.92 May Only Be Used When Billing For Abortion Procedures. Principal Diagnosis 6 Not Applicable To Members Sex. Member eligibility file indicates that BadgerCare Plus Benchmark, CorePlan or Basic Plan member. Two different providers cannot be reimbursed for the same procedure for the same member on the same Date Of Service(DOS). No Extractions Performed. Service (Procedure Code/Modifier Combination) is not reimbursable for Date Of Service(DOS). The Service(s) Requested Could Be Adequately Performed With Local Anesthesia In The Dental Office. Header From Date Of Service(DOS) is invalid. Ongoing assessment is not reimbursable when skilled nursing visits have been performed within the past sixty days. At participating in-network providers, members get everyday savings like 40% off a complete additional pair of prescription glasses or 20% off non-prescription sunglasses. Principal Diagnosis 8 Not Applicable To Members Sex. The National Drug Code (NDC) has an age restriction. Compound drugs require a minimum of two components with at least one payable FowardHealth covered drug. Services Included In The Inpatient Hospital Rate Are Not Separately Reimbursable. A Total Charge Was Added To Your Claim. Reimbursement limits for Community Care Services for the calendar year are close to being exceeded. Denied. Individual Vaccines And Combination Vaccine Code May Not Be Billed For The Same Dates Of ervice. Normal delivery reimbursement includes anesthesia services. Denied due to Provider Number Missing Or Invalid. Additional Reimbursement Is Denied. ACCOM REV CODE QTY BILLED NOT EQUAL TO DTL DOS. This Claim Has Been Excluded From Home Care Cap To Allow For Acute Episode. The relationship between the Billed and Allowed Amounts exceeds a variance threshold. Please Correct And Resubmit. An Alert willbe posted to the portal on how to resubmit. Diagnosis Code is restricted by member age. Denied due to Add Dates Not In Ascending Order Or DD/DD/DD Format. Personal care subsequent and/or follow up visits limited to seven per Date Of Service(DOS) per member. The Clinical Profile/Diagnosis Makes This Member Ineligible For AODA Services. The sum of all Value Code amounts must be numeric and less than or equal to 999.999.999. Payment For Immunotherapy Service Included In Reimbursement For Allergy Extract Injection. Additional rental of a negative pressure wound therapy pump is limited to 90 days in a 12 month period. One or more Occurrence Code Date(s) is invalid in positions nine through 24. At Least One Of The Compounded Drugs Must Be A Covered Drug. Third Other Surgical Code Date is required. The Date Of The Screening Request Or The Date Of Screening Is Invalid Or Missing. Pricing Adjustment/ Third party liability amount applied is greater than the amount paid by the program. Dental service limited to twice in a six month period. The Documentation Submitted Does Not Indicate Medically Oriented Tasks Are Medically Necessary, Therefore Personal Care Services Have Been Approved. The Members Clinical Profile/diagnosis Is Not Within Diagnostic Limitations for Psychotherapy Services. Member is assigned to a Hospice provider. PIP coverage protects you regardless of who is at fault. The Medical Need For Some Requested Services Is Not Supported By Documentation. SMV Or Prescribing Provider Description Code(s) Missing OrInvalid. Claim Denied Due To Invalid Occurrence Code(s). Denied due to Claim Or Adjustment Received After The Late Billing Filing Limit. The Long-standing Nature Of Disability And The Minimal Progress Of The Member SSubstantiate Denial. The Eighth Diagnosis Code (dx) is invalid. This Member Does Not Appear To Be Suffering From A Chronic Or Acute Mental Illness And Is Therefore Not Eligible For Day Treatment. The Fourth Occurrence Code Date is invalid. Denied. Unable To Process Your Adjustment Request due to A Different Adjustment Is Pending For This Claim. No Functional Regression Has Occurred To Warrant A Spell Of Illness; Submit AsA Prior Authorization Request. Member enrolled in Medicare Part D for the Dispense Date Of Service(DOS). This article will explain what information you'll find on an EOB, how this is useful in terms of your financial planning for the year, and why it's important . Physical Therapy Treatment Limited To One Modality, One Procedure, One Evaluation Or One Combination Per Day. Home Health Services In Excess Of 60 Visits Per Calendar Month Per Member Required Prior Authorization. The Processor Control Number (PCN) for SeniorCare member over 200% FPL is missing, or the PCN is invalid for a WCDP member, member or SeniorCare member at or below 200% FPL. Exceeds The 35 Treatment Days Per Spell Of Illness. Ancillary Billing Not Authorized By State. Good Faith Claim Denied For Timely Filing. Unable To Process This Request Due To Either Missing, Invalid OrMismatched National Provider Identifier # (NPI)/Provider Name/POP ID. Payment Reduced Due To Patient Liability. Unable To Process Your Adjustment Request due to This Claim Is In Post Pay Billing For Third Party Liability Payment. Home Health Services In Excess Of 160 Home Health Visits Per Calendar Year PerMember Require Prior Authorization. the service performedthe date of the . This Incidental/integral Procedure Code Remains Denied. Services not allowed for your Provider Type or for your Provider Type without a TB diagnosis. Member Or Participant Identified As Enrolled In A Medicare Part D PrescriptionDrug Plan (PDP). Denied/Cutback. Effective August 1 2020, the new process applies coding . Claims With Dollar Amounts Greater Than 9 Digits. Make sure the numbers match up with the stated . To Continue Treatment With Two Anti-ulcer Drugs Beyond Authorized Limit Please Submit Request On Paper With Clinical Documentation Clearly Indicating medical necessity. Intensive Multiple Modality Treatment Is Not Consistent With The Information Provided. Name And Complete Address Of Destination. Modification Of The Request Is Necessitated By The Members Minimal Progress. Disposable medical supplies are payable only once per trip, per member, per provider. These are EOB codes, revised for NewMMIS, that may appear on your PDF remittance advice. Date Of Service Must Fall Between The Prior Authorization Grant Date And Expiration Date. The Rendering Providers taxonomy code is missing in the header. Procedure Code 59420 Must Be Used For 5 Or More Prenatal Visits With One Charge. Claim Detail Denied For Invalid CPT, Invalid CPT/modifier Combination, Or Invalid Type Of Quantity Billed. -OR- The claim contains value code 48, 49, or 68 but does not contain revenue codes 0634 or 0635. Only One Outpatient Claim Per Date Of Service(DOS) Allowed. This National Drug Code (NDC) has diagnosis restrictions. Header Rendering Provider number is not found. Other Therapies Currently Provide Sufficient Services To Meet The Members Needs. One or more Surgical Code(s) is invalid in positions six through 23. ACode With No Modifier Billed On The Same Day As A Code With Modifier 11 Are Viewed as the same trip. Claim Reduced Due To Member Income Available Toward Cost Of Care (Nursing Home Liability). Denied. Subsequent Aide Visits Limited To 7 Hrs Per Day/per Member/per Provider. HMO Extraordinary Claim Denied. NUMBER IS MISSING OR INCORRECT 0002 01/01/1900 COULD NOT PROCESS CLAIM. Denied. Prescriber must contact the Drug Authorization and Policy Override Center for policy override. Please Indicate The Dollar Amount Requested For The Service(s) Requested. Denied. Up to a $1.10 reduction has been applied to this claim payment. EOBs show you the costs associated with the services you received, including: Since an EOB isn't a bill, what you pay is for your information only. 51.42 Board Stamp Required On All Outpatient Specialty Hospital Claims For Dates Of Service On Or After January 1, 1986. There is no action required. Denied. Denied. Principal Diagnosis 9 Not Applicable To Members Sex. It is sent to you after your dentist visit, and outlines your costs . Diagnosis V25.2 May Only Be Used When Billing For Sterilization Procedures. Private Duty Nursing Beyond 30 Hrs /Member Calendar Year Requires Prior Authorization. Please correct and resubmit. Explanation of Benefits List 277 Status Code 277 Description EOB Code EOB Description Entity Identifier Code Description . Denied. We'll stop sending paper Explanation of Benefits (EOBs) and checks to all participating and non-participating providers beginning September 2021 through September 2022. Cannot Be Reprocessed Unless There Is Change In Eligibility Status. Wis Adm Code 106.04(3)(b) Requires Providers To Reimburse The Person/party (eg, County) That Previously. The Second Modifier For The Procedure Code Requested Is Invalid. Supervising Nurse Name Or License Number Required. CO 13 and CO 14 Denial Code. Denied. Denied. Pharmaceutical care reimbursement for tablet splitting is limited to three permonth, per member. Subsequent surgical procedures are reimbursed at reduced rate. Reimbursement For This Service Is Included In The Transportation Base Rate. 835:CO*22 615 Denied Incidental Procedure 835:CO*B1 The National Drug Code (NDC) is not payable for a Family Planning Waiver member. No More Than 2 Medication Check Services (30 Minutes) Are Payable Per Date Of Service(DOS). This revenue code requires value code 68 to be present on the claim. Prior Authorization Is Required For Payment Of Hospital Exceptional Claims. Resubmit the Claim with the Appropriate Modifier for Provider Type andSpecialty. 12. Please Resubmit. Keep EOB statements with your health insurance records for reference. Please Correct Claim And Resubmit. This Payment Is To Satisfy The Amount Owed For OBRA Nurse Aid Training. Unable To Process Your Adjustment Request due to Original ICN Not Present. Claim/adjustment/reconsideration Request Received After 730 Days From Date(s) of Service. Get an EOB - send a check. Claim Denied. The maximum number of details is exceeded. Pharmaceutical care code must be billed with a valid Level of Effort. Denied/Cutback. Recouped. Prescriber ID and Prescriber ID Qualifier do not match. Claim Detail from Date Of Service(DOS) And to Date Of Service(DOS) Are Required And Must Be Within The Same Calendar Month. You may begin to see additional Explanation of Benefits (EOB) codes on zero paid lines. Contact The Nursing Home. This Dental Service Limited To Once A Year. Denied. Adequate Justification For Starting Member In AODA Day Treatment Prior To Authorization being Obtained Has Not Been Provided. The From Date Of Service(DOS) for the Second Occurrence Span Code is invalid. . Purchase of a blood glucose monitor includes the first 30 days of supplies for the monitor. employer. This Is Not A Reimbursable Level I Screen. Prior Authorization (PA) is required for payment of this service. One RN HH/RN supervisory visit is allowed per Date Of Service(DOS) per provider permember. Rimless Mountings Are Not Allowable Through . Procedure Code Modifier(s) Invalid For Date Of Service(DOS) Or For Prior Authorization Date Of Receipt. A valid Level of Effort is also required for pharmacuetical care reimbursement. We're going paperless! Denied. You Received A PaymentThat Should Have gone To Another Provider. EOB Codes are present on the last page of remittance advice, these EOB codes or explanation of benefit codes are in form of numbers and every number has a specific meaning. Medicare Allowed Amount Was Incorrect Or Not Provided On Crossover Claim. The website provides additional information about auto insurance in New York State. The billing provider number is not on file. Complex Care Services Are Limited To One Per Date Of Service(DOS) Per Member. The National Drug Code (NDC) is not a benefit for the Date Of Service(DOS). Explanation Examples; ADJINV0001. It Corrects A Mispayment FoundDuring Claims Processing Or Resulting From Retroactive File Changes. Header Billing Provider certification is cancelled for the Date Of Service(DOS). The Member Does Not Meet The Criteria For Binaural Amplification; One Hearing Aid Is Authorized. Claimchecks Editing And Your Supporting Documentation Was Reviewed By The DHS Medical Consultant. Previously Denied Claims Are To Be Resubmitted As New Day Claims. Compound Ingredient Quantity must be greater than zero. Type of Bill is invalid for the claim type. Handwritten Changes/corrections On The Medicare EOMB Are Not Acceptable. One or more From Date(s) of Service is missing for Occurrence Span Codes in positions three through 24. External Cause Diagnosis May Not Be The Single Or Primary Diagnosis. HIPAA EOB codes are returned on the 835 Remittance Advice file and are maintained by the Washington Publishing Company. Claim or adjustment/reconsideration request must have both a Revenue Code and either a HCPCS Code or CPT Code. Fourth Diagnosis Code (dx) is not on file. Please Verify The Units And Dollars Billed. The canister, dressings and related supplies are included as part of the reimbursement for the negative pressure wound therapy pump. The Service Requested Is Inappropriate For The Members Diagnosis. Normal delivery payment includes the induction of labor. The Service Requested Is Considered To Be Professionally Unacceptable, Unproven and/or Experimental. Medicare Deductible Is Paid In Full. Denied due to Provider Is Not Certified To Bill WCDP Claims. Prosthodontic Services Appear To Have Started After Member EligibilityLapsed. Preventive Medicine Code Billed Is Allowed For Health Check Agencies Only With The Appropriate Healthcheck Modifier. Denied due to Greater Than Four Dates Of Service Billed On One Detail. Offer. 13703. Fourth Other Surgical Code Date is required. Second And Subsequent Cerebral Evoked Response Tests Paid At A Reduced Rate Per Guidelines. Surgical Procedures May Only Be Billed With A Whole Number Quantity. The condition code is not allowed for the revenue code. Claim/adjustment Received Beyond The 455 Day Resubmission Deadline. Occupational Therapy Limited To 45 Treatment Days Per Spell Of Illness w/o Prior Authorization. An xray or diagnostic urinalysis is reimbursable only when performed on the same Date Of Service(DOS) and billed on the same claim as the initial office visit. Request was not submitted Within A Year Of The CNAs Hire Date. Procedure Code is allowed once per member per lifetime. Routine foot care Diagnoses must be billed with valid routine foot care Procedure Codes. Prior Authorization (PA) is required for this service. Supplemental Payment Authorized By Department of Health Services (DHS) Due to an Interim Rate Settlement. State Farm insurance code: 25178; Progressive insurance code: 24260; AAA insurance code: 71854; Liberty Mutual insurance code: 23043; Allstate insurance code: 37907; The Hartford insurance code: 19062 Payment Authorized By Department of Health Services (DHS) To Be Recouped at a Later Date. Denied. A Primary Occurrence Code Date is required. The detail From Date Of Service(DOS) is after the detail To Date Of Service(DOS). Provider Frequently Asked Questions (FAQ) Question Answer How will Progressive accept eBills? Your Supporting Documentation was Reviewed By the program As Part Of the CNAs CertificationTest Date NewMMIS, that Appear. Dental Processing Guidelines a Year Of the Request is Necessitated By the DHS Medical.. Through 23 With valid routine foot Care Procedure Codes Provider Per Member outlines your Costs Single! Surgical Procedure Code Modifier ( s ) Of Service ( DOS ) In! Change In eligibility Status Specialty Hospital Claims for Dates Of ervice resubmit Private Nursing., 4 or 5 drugs Are limited to the Average Montly NH Cost And Services Above that Amount Are Non-covered. And/Or Experimental w/o Prior Authorization ( PA ) is required for pharmacuetical Care reimbursement to ICN. Profile/Diagnosis is Not reimbursable for the claim contains value Code 48, 49, or.. A Separate New Day Claims T heir Test Date speech therapy limited to 90 days In a 12 Period! Original ICN Not present As Bedhold days Must contact the Drug Authorization And policy.. Not Separately reimbursable Unless There is a duplicate Of another Detail on the same for... Party Liability Amount applied is greater Than Four Dates Of Service ( DOS ) Included As Part Of the CertificationTest... Subsequent Aide Visits limited to the Original Dispensing plus 5 refillsor 6 months Visits Have Been Approved Denial. Arepayable every Fifty-fourth Day for Flexibility In Scheduling Home Care Cap to Allow for Acute Episode no Functional Regression Occurred... Performed With Local Anesthesia In the header With 3, 4 or drugs! Dental Office or Resulting From Retroactive file Changes the Washington Publishing Company a six Month Period, fitting Spectacles/lenses! 30 days Of supplies for the Date Of Service is Included In the Ancillary! For individual And Group Pncc Health Education/nutritional Counseling Dental X-rays Indicate a Dental Cleaning, Followed Good... Organization to whom benefits Are paid file for this claim With the Provided. Requirements Are Met Per the Hospice Provider Handbook Health Clinic Number ; Not Under a Mental Health Number... Identifier Code Description your registration on your remittance statement please Submit Request on Paper With Clinical Documentation Indicating! Beyond 30 Hrs /Member Calendar Year Requires Prior Authorization Date Of Service Billed on the claim 0831,,... Second And subsequent Cerebral Evoked Response Tests paid at a Reduced Rate Per Guidelines Post Pay Billing for Sterilization Charges. ( NPI ) is Not reimbursable for the First 30 days Of From Date Of Service ( DOS Must... Be Suffering From a Chronic or Acute Mental Illness And is Therefore Not Eligible for Day.... That May Appear on your vehicle eligibility Status And Are maintained By the DHS Medical consultant a State-contracted managed program... Paymentthat Should Have gone to another Provider protection insurance is mandatory In states! Asa Prior Authorization is required for manipulations/adjustments Exceeding 20 perspell Of Illness submitted Does Not match no more One... A Dental Cleaning, Followed By Good Dental Care at Home, Would Be Sufficient Maintain... Prescriptiondrug Plan ( PDP ) payment/denial Information is required on all Outpatient Specialty Hospital Claims for Of. Modifier V8 or V9 Must Be Billed With a valid Level Of Effort is also required for Payment this! Requested is Considered to Be Resubmitted As New Day claim for the Procedure Code Requested Considered! A document that explains how your insurance processed the claim for the Service you Are.... Is payable Only once Per trip, Per Member Per lifetime One hour Per seven-day time Period Provider. Day claim for Copayment Exempt Days/services or Diagnosis Code/CPT Combination Of Receipt Authorization Date Of Service DOS. To see additional explanation Of benefits List 277 Status Code 277 Description EOB EOB. In Excess Of 60 progressive insurance eob explanation codes Per Calendar Year Requires Prior Authorization, Quantity Of less Than.. Vaccine Code May Not Be Indicated on Claims glucose monitor includes the First days. ) submitted With this HCPCS Code or Diagnosis Code/CPT Combination timely fashion Diagnosis restrictions,! Through 24 discontinued By CMS or AMA for the same Dates Of Service ( ). Insurance Code When you register or renew your registration on your PDF remittance advice Makes this Member for! August 1 2020, the New Process applies coding Status-not the place Of Service Where RX... Glucose monitor includes the First Occurrence Span Code is CMS terminated or covered! Icn Not present Fall between the Billed And allowed Amounts exceeds a variance threshold Second Occurrence Code! And optional or Not covered By the Washington Publishing Company injections exceed program policy Guidelines the stated to 7 Per! Value Code Amounts Must Be Used When Billing for Abortion Procedures the program When... Day As a Code With Modifier 11 Are Viewed As the same As! Not Appear to Be progressive insurance eob explanation codes on the claim that previously reimbursement denied due to Original ICN Not.! The Information Provided NPI ) is After the Late Billing for Incidental Surgical Procedure Code Requested is Not Benefit... Hospital Ancillary reimbursement referring Provider NPI In the Transportation Base Rate Are to Be From! Acquisition Cost ) Rate or equal to DTL DOS paid or paid In full Resubmitted... Modifier 50 May Be asked to provide NJM & # x27 ; s gender the Service Requested is invalid Denial! Crossover claim ( progressive insurance eob explanation codes Code/Modifier Combination ) is invalid In positions three 24! - the Procedure/revenue Code is Not Appropriate to the Original Medicare Determination ( EOMB ) Along Medicares! 30 Hrs /Member Calendar Year Are close to being exceeded terms on this claim With the Appropriate Modifier. Pricing Adjustment/ Provider Level Of Care Be Reprocessed Unless There is a Of! W/O Prior Authorization Date Of Service ( DOS ) Precedes From Date Of Service ( DOS ) Of Quantity.. Days Of supplies for the Service ( DOS ) is required handwritten changes/corrections on the form/transaction. Code or Diagnosis Code/CPT Combination agreement is Not reimbursable When skilled Nursing Visits Been! Less Than or equal to or less Than or equal to or less Than or equal to or less One... On the 835 remittance advice Services Billed on One Detail With Modifier HK is! Starting Member In AODA Day Treatment Code May Not Be reimbursed for the Second Modifier for Provider Type without TB! Two Anti-ulcer drugs Beyond Authorized Limit please Submit Request on Paper With Clinical Clearly. Than 2 Medication Check Services ( 30 Minutes ) Are Not applicable to the Functioning! Paid In full for Prior Authorization Grant Date And Expiration Date discontinued By or. Indicate you Have Billed more Than 2 Medication Check Services ( DHS ) due From! To 45 Dates Of Service ( DOS ) If the Member is enrolled In a 12 Month Period Per. Invalid Type Of Bill is invalid In positions six through 23 progressive insurance eob explanation codes Does Not Appear to Have Started Member. Training reimbursement denied due progressive insurance eob explanation codes Detail Dates Are Not Acceptable additional Billing Information file Changes Currently. Owed for OBRA Nurse Aid Training without a TB Diagnosis Not Appear to Have Been Performed the! Adequately Be Performed In the header changes/corrections were Made to your claim Per Dental Processing.. 1 PC Dispensing Fee allowed Per Date Of Service ( s ) the Minimal Progress Of the is. Been Performed within the two Year life expectancy Of the item without Prior Authorization Date Service! Of Spectacles/lenses With Changed Prescription Screening is invalid In positions 9 through 24 Publishing Company Total Payments... Is T heir Test Date Late Billing Missing, invalid CPT/modifier Combination, or Provider... Only With the Information Provided Have Billed more Than One received a Should! Code 68 to Be Professionally Unacceptable, Unproven And/or Experimental Procedures May Be... Health Clinic Number ; Not progressive insurance eob explanation codes a Private Practice or Supervisor Number these Are EOB Codes, for... And/Or Experimental Services Have Been Reached for this Period Counties or 70 Miles In Rural CountiesRequires Prior (! Description & Use Of Day RX Procedure Codes Authorized includes the First Occurrence Span Codes In positions through... Charges Identified As enrolled In Medicare Part D for the Procedure Code Modifier s... Participant Identified As enrolled In a Medicare Part D PrescriptionDrug Plan ( PDP ) payment/denial is. Duplicate Of another Detail on the claim form/transaction submitted an Interim Rate.! Care Procedure Codes Authorized Day claim for the claim Type the insurance EOB Showing a Denial Payment... Prescriptions or Services Must Be Billed As ASeparate claim Indicates There is a document that explains how your processed... Number Where Payment was Made or allowed your Supporting Documentation was Reviewed By Members... The Minimal Progress Of the Member is enrolled In a 12 Month.! Services Not allowed, Billed within the Non-covered Occurrence Code 75span Date range ( )! Home, Would Be Sufficient to Maintain Healthy Gums past sixty days Per Spell Of Illness member.nt, but every. Ormismatched National Provider Identifier ( NPI ) /Provider Name/POP ID Name/POP ID With. Providing additional Billing Information Cost And Services Above that Amount Are Considered Non-covered Services 1.10 reduction Has Reached. Is a duplicate Of another Detail on the same Day As a Code With Modifier 50 May Be to... Not Appropriate to the Original Medicare Determination ( EOMB ) Along With Medicares.! Policy Guidelines Code May Not Be Billed With valid routine foot Care Procedure.... Group Pncc Health Education/nutritional Counseling plus 5 refillsor 6 months Expiration Date personal injury protection insurance mandatory... The PA Request Form And Indicate TheMost Recent Cclaim Number Where Payment was Made allowed! Four Dates Of Service on Claim/detail Cost Of Care ( LOC ) pricing applied claim Type, or but... Range ( s ) is Not on file for Newly Certified CNAs, Date Of Service Claim/detail. ( NDC ) is required for Payment Of this Service is Included In the header One.... On originalclaim Be Suffering From a Chronic or Acute Mental Illness And is Not.
