Service billed is bundled with another service and cannot be reimbursed separately. Timely Filing Request Denied. Admission Denied In Accordance With Pre-admission Review Criteria. Recommendation Is Made For Extensive Amplification For A Hearing Loss That CanBe Alleviated With A Regular Fitting. Please Review All Provider Handbook For Allowable Exception. The National Drug Code (NDC) was reimbursed at a generic rate. Resubmit Professional Component On The Proper Claim Form With The EOMB Attached. Hospital And Nursing Home Stays Are Not Payable For The Same DOS Unless The Nursing Home Claim Indicated Hospital Bedhold Days. Pharmacuetical care limitation exceeded. No More Than 2 Medication Check Services (30 Minutes) Are Payable Per Date Of Service(DOS). Maximum Reimbursement Amount Has Been Determined By Professional Consultant. A code with no Trip Modifier billed on same day as a code with Modifier U1 are considered the same trip. Denied due to Detail Dates Are Not Within Statement Covered Period. Level, Intensity Or Extent Of Service(s) Requested Has Been Modified Consistent With Medical Need As Defined In The Plan Of Care. The Member Was Not Eligible For On The Date Received the Request. Medicare Part A Services Must Be Resubmitted. Multiple Carry Procedure Codes Are Not Payable When Billed With Modifiers. Denied. A National Provider Identifier (NPI) is required for the Performing Provider listed in the header. Denied/Cuback. Preventive Medicine Code Billed Is Allowed For Health Check Agencies Only With The Appropriate Healthcheck Modifier. Occurrence Codes 50 And 51 Are Invalid When Billed Together. Service(s) Billed Are Included In The Total Obstetrical Care Fee. NDC was reimbursed at brand WAC (Wholesale Acquisition Cost) (Wholesale Acquisition Cost) rate. Patient Status Code is incorrect for Long Term Care claims. Complex care of 17-plus hours and complex care of less than 17 hours are not allowed on the same Date Of Service(DOS). Contact Provider Services For Further Information. A statistician who computes insurance risks and premiums. Timely Filing Deadline Exceeded. Denied due to Statement Covered Period Is Missing Or Invalid. This Procedure, When Billed With Modifier HK, Is Payable Only If The Member Is Under The Age Of 19. Restorative Nursing Can Provide Follow-through, Based On Diagnosis Of Long-standing Nature, And The Amount Of Therapy. Prior Authorization (PA) required for payment of this service. Other Amount Submitted Not Reimburseable. Other Therapies Currently Provide Sufficient Services To Meet The Members Needs. Member has Medicare Supplemental coverage for the Date(s) of Service. This drug is not covered for Core Plan members. Replacement and repair of this item is not covered by L&I. NULL CO 96, A1 N171 Header Billing Provider used as Detail Performing Provider, Header Performing Provider used as Detail Performing Provider. Split Decision Was Rendered On Expansion Of Units. The Performing Provider Id, Member Id, And Date Of Service(DOS) Must Match The Completion Certificate Received From Ddes. Please Correct and Resubmit. Prospective DUR denial on original claim can not be overridden. Benefit Payment Determined By DHS Medical Consultant Review. The relationship between the Billed and Allowed Amounts exceeds a variance threshold. NDC was reimbursed at State Maximum Allowable Cost (SMAC) rate. Resubmit With All Appropriate Diagnoses Or Use Correct HCPCS Code. 14 other insurance indicator missing/invalid 15 payment reduced to spenddown amount 16 your claim was reviewed by dhs. Date Of Service/procedure/charges Billed On The Adjustment/reconsideration Request Do Not Match The Original Claim. Please Clarify. Modification Of The Request Is Necessitated By The Members Minimal Progress. Reimbursement For Panel Test Only- Individual Tests In Addition To Panel Test Disallowed. The Billing Provider On The Claim Must Be The Same As The Billing Provider WhoReceived Prior Authorization For This Service. Once Therapy Is Prior Authorized, All Therapy Must Be Billed With A Valid Prior Authorization Number. Dates of Service reflected by the Quantity Billed for dialysis exceeds the Statement Covers Period. According To Our Records, The Surgeon For This Sterilization Procedure Has NotSubmitted The Members Consent Form. Claim Paid In Accordance With Family Planning Contraceptive Services Guidelines. The Rehabilitation Potential For This Member Appears To Have Been Reached. The Documentation Submitted Indicates The Tasks Specified Can Be Completed During The Visits Approved. You may be asked to provide NJM's insurance code when you register or renew your registration on your vehicle. Pricing Adjustment/ Maximum Allowable Fee pricing used. Other Insurance/TPL Indicator On Claim Was Incorrect. Service is reimbursable only once per calendar month. An ICD-9-CM Diagnosis Code of greater specificity must be used for the Fifth Diagnosis Code. the medical services you received. What your insurance agreed to pay. Payment Recovered For Claim Previously Processed Under Wrong Member ID Number. Psych Evaluation And/or Functional Assessment Ser. CPT and ICD-9- Coding 5. Refer To Your Pharmacy Handbook For Policy Limitations. Good Faith Claim Correctly Denied. Resubmit Complete And/or Second Page Of Medicares EOMB Showing All Total And Payments. A Qualified Provider Application Is Being Mailed To You. This notice gives you a summary of your prescription drug claims and costs. Revenue Code 0001 Can Only Be Indicated Once. Denied/cutback. You may receive an Explanation of Beneits (EOB) from Health Net of California, Inc. or Health Net Life Insurance Company . -OR- The claim contains value code 48, 49, or 68 but does not contain revenue codes 0634 or 0635. Home care ongoing assessments are allowed once every sixty days per member.nt, But Arepayable Every Fifty-fourth Day For Flexibility In Scheduling. The Skills Of A Therapist Are Not Required To Maintain The Member. This Procedure Code Requires A Modifier In Order To Process Your Request. Supplemental tests billed on the same Date Of Service(DOS) as vision examination are not payable. The condition code is not allowed for the revenue code. This Information Is Required For Payment Of Inhibition Of Labor. Denied. Dosings for Narcotic Treatment Service program are limited to six per Sunday thru Saturday calendar week. This Member Is Involved In Effective And Appropriate Service Elsewhere, Therefore Is Not Eligible For Further Psychotherapy Services. Denied. Pricing Adjustment/ Claim has pricing cutback amount applied. your insurance plan will begin sharing the cost with you (see "co-insurance"). Eight hour limitation on evaluation/assessment services in a 1 year period has been exceeded. Services Not Provided Under Primary Provider Program. Claim Denied. Additional servcies may be billed with H0046 and will count toward mental health and/or substance abuse treatment policy limits for prior authorization. Duplicate ingredient billed on same compound claim. Claim Denied Due To Invalid Pre-admission Review Number. Recoding/adjusting claim may result in a different DRG code assignmentand reimbursement. Member has commercial dental insurance for the Date(s) of Service. Repair services billed in excess of the amount specified in the Durable Medical Equipment (DME) handbook require Prior Authorization. Pricing Adjustment/ Repackaging dispensing fee applied. Review Patient Liability/paid Other Insurance, Medicare Paid. Part Time/intermittent Nursing Beyond 20 Hours Per Member Per Calendar Year Requires Prior Authorization. Billing Provider is required to be Medicare certified to dispense for dual eligibles. Billing Provider Received Payment From Both Medicare And For Clai m. An Adjustment/reconsideration Request Has Been Made To The Billing Providers Account. Modifier invalid for Procedure Code billed. The service was previously paid for this Date Of Service(DOS). Please Correct And Resubmit. Service not allowed, benefits exhausted occurrence code billed. Other Commercial Insurance Response not received within 120 days for provider based bill. Timely Filing Deadline Exceeded. Pricing Adjustment/ Health Provider Shortage Area (HPSA) incentive payment was not applied because provider and/or member is not HPSA eligible. Pricing Adjustment/ Ambulatory Payment Classification (APC) pricing applied. Recasing Or Replacement Of Hearing Aid Case Is Limited To Once Per 2 Year Period Per Member Per Provider. Member Has Already Been Granted Actute Episode for 3 Months In This Cal Yr. Reimb Is Limited To Average Monthy NH Cost And Services Above That Are Consider Non-covered Services. Partial Payment Withheld Due To Previous Overpayment. Claim or Adjustment received beyond 365-day filing deadline. Service(s) Approved By DHS Transportation Consultant. AODA Day Treatment Is Not A Covered Service For Members Who Are Residents Of Nursing Homes or Who Are Hospital Inpatients. The From Date Of Service(DOS) for the Second Occurrence Span Code is invalid. The Member Has Received A 93 Day Supply Within The Past Twelve Months. 0394 MEDICARE CO-INSURANCE AMOUNT MISSING. The EOB is an overview of medical services you received. 2. Please Select A Procedure Code In The 58980-58988 Range That Best Describes The Procedure Being Performed. What is the 3 digit code for Progressive Insurance? Please Resubmit. A Reimbursement Request For A Level I Screen Must Be Received At Within A Year Of The Screen Date. The Procedure Requested Is Not Appropriate To The Members Sex. A Payment Has Already Been Issued To A Different Nf. Account summary A brief snapshot of vital information, including: Your name and address. Member has Medicare Managed Care for the Date(s) of Service. Health plan member's ID and group number. The Rendering Providers taxonomy code is missing in the detail. Please Indicate Anesthesia Time For Services Rendered. Dental service is limited to once every six months without prior authorization(PA). Denied due to Claim Or Adjustment Received After The Late Billing Filing Limit. Review Billing Instructions. Rebill Using Correct Claim Form As Instructed In Your Handbook. Adjustment/reconsideration Denied, Provider Signature/date Was Not Provided OnThe Adjustment/reconsideration Request. Reason Code 159: State-mandated Requirement for Property and Casualty, see Claim Payment Remarks Code for specific explanation. Professional Service code is invalid. Rendering Provider is not a certified provider for Wisconsin Chronic Disease Program. Speech Therapy Evaluations Are Limited To 4 Hours Per 6 Months. Claim or adjustment/reconsideration request must have both a Revenue Code and either a HCPCS Code or CPT Code. Additional rental of a negative pressure wound therapy pump is limited to 90 days in a 12 month period. Up to a $1.10 reduction has been applied to this claim payment. The National Drug Code (NDC) is not payable for the Provider Type and/or Specialty. Sign up for electronic payments and statements before it's your turn. Denied. Ulcerations Of The Skin Do Not Warrant A New Spell Of Illness. Other Medicare Managed Care Response not received within 120 days for providerbased bill. Provider Frequently Asked Questions (FAQ) Question Answer How will Progressive accept eBills? Claim Detail Is Pended For 60 Days. Procedure Code 59420 Must Be Used For 5 Or More Prenatal Visits With One Charge. Primary Tooth Restorations Limited To Once Per Year Unless Claim Narrative Documents Medical Necessity. Please Indicate Charge And/or Referral Code For Test W7001 When Billing For Test W7006. The Competency Test Date On The Request Does Not Match The CNAs Test Date OnThe WI Nurse Aide Registry. Date Of Service Must Fall Between The Prior Authorization Grant Date And Expiration Date. If Required Information Is not received within 60 days, the claim detail will be denied. Please watch future remittance advice. This Payment Is To Satisfy The Amount Owed For OBRA Nurse Aid Training. Claim Denied For No Consent And/or PA. This service is payable at a frequency of once per 12-month period, per provider, per hearing aid. Pricing Adjustment/ Third party liability deducible amount applied. The sum of the Accommodation Days is not equal to the sum of Covered plus Non-Covered Days, or the From and To Dates of Service cannot be the same. Policy override must be granted by the Drug Authorizationand Policy Override Center to dispense early. Watch FutureRemittance And Status Reports For Its Finalization Before Resubmitting. The Revenue Code is not payable by Wisconsin Well Woman Program for the Date Of Service(DOS). Only Medicare Crossover claims are reimbursed for coinsurance, copayment, and deductible. EOB Code Description Rejection Code Group Code Reason Code Remark Code 074 Denied. Individual Vaccines And Combination Vaccine Code May Not Be Billed For The Same Dates Of ervice. Second Surgical Opinion Guidelines Not Met. Service Fails To Meet Program Requirements. Correct And Resubmit. 51.42 Board Stamp Required On All Outpatient Specialty Hospital Claims For Dates Of Service On Or After January 1, 1986. Only two dispensing fees per month, per member are allowed. Glass lens enhancement code is not allowed with a non-glass lens enhancement code . This Dental Service Limited To Once Every Six Months, Unless Prior Authorized. Member enrolled in Medicare Part D for the Dispense Date Of Service(DOS). Member is assigned to an Inpatient Hospital provider. We have created a list of EOB reason codes for the help of people who are working on denials, AR-follow-up, medical coding, etc. The Other Payer ID qualifier is invalid for . Learn more about Ezoic here. Member Expired Prior To Date Of Service(DOS) On Claim. Denied due to The Members Last Name Is Incorrect. The Diagnosis Code is not payable for the member. Third Diagnosis Code (dx) (dx) is not on file. Service(s) Must Be Submitted On Paper Claim Form Along With Preoperative History And Physical Report And Operation Report. The service is not reimbursable for the members benefit plan. A valid procedure code is required on WWWP institutional claims. Claim Detail Denied Due To Required Information Missing On The Claim. One or more Diagnosis Code(s) is not payable by Wisconsin Chronic Disease Program for the Date Of Service(DOS). Quantity Would Always Be 00010 If Number Of Pounds Not Indicated. Please Resubmit Using Newborns Name And Number. There is no action required. SMV Or Prescribing Provider Description Code(s) Missing OrInvalid. Unable To Process Your Adjustment Request due to Financial Payer Not Indicated. A Pharmaceutical Care Code (PCC) must include a valid diagnosis code. This Individual Is Either Not On The Registry Or The SSN On The Request D oesnt Match The SSN Thats Been Inputted On The Registry. This Member Has Received Primary AODA Treatment In The Last Year And Is Therefore Not Eligible For Primary Intensive AODA Treatment At This Time. Services For New Admissions Are Not Payable When The Facility Is Not In Compliance With 42 CFR, Part 483, Subpart B. Has Recouped Payment For Service(s) Per Providers Request. Medically Needy Claim Denied. The Related Surgical Procedure is not a covered service under Wisconsin Medicaid or BadgerCare Plus. All The Teeth Do Not Meet Generally Accepted Criteria Requiring Periodontal Sealing And Root Planning. All Day Treatment Services For Members With Nursing Home Status Should Be Billed Under Procedure Code W8912(pre 10/1/03)/h2012(post 10/1/03) And Require PriorAuthorization. The Services Requested Do Not Meet Criteria For An Acute Episode. A Google Certified Publishing Partner. Prescription limit of five Opioid analgesics per month. The Primary Occurrence Code Date is invalid. Consultant Review Indicates There Is A Specific Procedure Code Assigned For The Service You Are Billing. 100 Days Supply Opportunity. Denied. Member is enrolled in Medicare Part A and/or Part B on the on the Dispense Dateof Service. Resubmit Using Valid Rn/lpn Procedure Codes And A Valid PA Number. One BMI Incentive payment is allowed per member, per renderingprovider, per calendar year. Resubmit Claim Once Election Form Requirements Are Met Per The Hospice Provider Handbook. HMO Payment Equals Or Exceeds Hospital Rate Per Discharge. WWWP Does Not Process Interim Bills. Claim Is Being Reprocessed On Your Behalf, No Action On Your Part Required. Please Clarify. Incorrect Liability Start/end Dates Or Dollar Amounts Must Be Corrected Through County Social Services Agency Before Claim/Adjustment/Reconsideration RequestCan be Processed. The Fifth Diagnosis Code (dx) is invalid. Member last name does not match Member ID. Documentation Provided Indicates A Less Elaborate Procedure Should Be Considered. Denied/Cutback. Claim Or Adjustment/reconsideration Request Should Include An Operative Or Pathology Report For This Procedure. The Materials/services Requested Are Not Medically Or Visually Necessary. Claim Denied. Denied. CORE Plan Members are limited to 25 non-emergency outpatient hospital visits per enrollment year. If you owe the doctor, hospital or dentist, they'll send you an invoice. This drug is a Brand Medically Necessary (BMN) drug. Service(s) paid at the maximum daily amount per provider per member. Services billed exceed prior authorized amount. Inpatient Respite Care Is Not Covered For Hospice Members Residing In Nursing Homes. Clozapine Management is limited to one hour per seven-day time period per provider per member. Information inadequate to establish medical necessity of procedure performed.Please resubmit with additional supporting documentation. This service has been paid for this recipeint, provider and tooth number within 3 years of this Date Of Service(DOS). No Action On Your Part Required. Remark Code Description: additional explanation of the Remark or Discount Code will appear in this section. Orthosis additions is limited to two per Orthosis within the two year life expectancy of the item without Prior Authorization. Unable To Process Your Adjustment Request due to Provider Not Found. Claim Denied. The sum of the Accommodation Days is not equal to the sum of Covered plus Non-Covered Days. Referral/treatment Procedures Are Not Payable When Billed With A Complete Refusal Detail. The Medical Need For Some Requested Services Is Not Supported By Documentation. 2 above. This drug/service is included in the Nursing Facility daily rate. Denied/Cutback. Refer To The Wisconsin Website @ dhs.state.wi.us. Pricing Adjustment/ Spenddown deductible applied. Please Bill Appropriate PDP. Service(s) Denied. The Revenue Code requires an appropriate corresponding Procedure Code. Value Code 48 And 49 Must Have A Zero In The Far Right Position. All services should be coordinated with the Hospice provider. Please Refer To The Original R&S. Please Rebill Inpatient Dialysis Only. The Primary Diagnosis Code is inappropriate for the Surgical Procedure Code. Per Information From Insurer, Claims(s) Was (were) Paid. One or more To Date(s) of Service is missing for Occurrence Span Codes in positions three through 24. Service(s) exceeds four hour per day prolonged/critical care policy. Reason Code 117: Patient is covered by a managed care plan . Eighth Diagnosis Code (dx) is not on file. The Travel component for this service must be billed on the same claim as the associated service. Header Rendering Provider number is not found. Paid In Accordance With Dental Policy Guide Determined By DHS. Medicare Deductible Is Paid In Full. This Unbundled Procedure Code Remains Denied. Dispense Date Of Service(DOS) is required. Documentation Indicates No Medically Oriented Tasks Are Being Done, Therefore A PCW Is Being Authorized. Consultation or surgical procedures are not reimbursable in conjuctions with Emergency Room services. Questionable Long-term Prognosis Due To Decay History. Progressive has chosen AccidentEDI as our designated eBill agent. The billing provider number is not on file. This Procedure Code Is Denied As Incidental/Integral To Another Procedure CodeBilled On This Claim. The Member Is Involved In group Physical Therapy Treatment. Good Faith Claim Denied. Services Not Payable When Rendered To An Individual Aged 21-64 Who Is A Resident Of A Nursing Home Imd. Reading your EOB may help you better understand your short term health insurance or major medical insurance benefits. The sum of all Value Code amounts must be numeric and less than or equal to 999.999.999. Please Correct And Resubmit. See Provider Handbook For Good Faith Billing Instructions. Detail From Date Of Service(DOS) is after the ICN Date. Other Coverage Code is missing or invalid. eBill Clearinghouse. Reimbursement Based On Members County Of Residence. Assessment Is Not A Covered Service Unless All Four Components Of Skilled Nursing Are Present: Assessment, Planning, Intervention And Evaluation. Revenue code billed with modifier GL must contain non-covered charges. It has now been removed from the provider manuals . Do not leave blank fields between the multiple occurance codes. Quantity Billed is not equally divisible by the number of Dates of Service on the detail. Please Resubmit Medicares Nursing Home Coinsurance Days As A New Claim RatherThan An Adjustment/reconsideration Request. Medicare Coinsurance Amount Was Not Provided On Crossover Claim. Request Denied Due To Late Billing. Co. 609 . No Complete Program Enrollment Form Is On File For This Client Or The Client Is Not Eligible For The Date Of Service(DOS) On The Clai im. Denied. Services Denied In Accordance With Hearing Aid Policies. Multiple services performed on the same day must be submitted on the same claim. Claimchecks Editing And Your Supporting Documentation Was Reviewed By The DHS Medical Consultant. Please Furnish A Breakdown Of Your Procedure Code And Charge In Question GivenOn The Adjustment/reconsideration Request.
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