Claim Is Being Reprocessed, No Action On Your Part Required. An ICD-9-CM Diagnosis Code of greater specificity must be used for the Eighth Diagnosis Code. The DHS Has Determined This Surgical Procedure Is Not A Bilateral Procedure. The Documentation Submitted Does Not Indicate Medically Oriented Tasks Are Medically Necessary, Therefore Personal Care Services Have Been Approved. A claim cannot contain only Not Otherwise Specified (NOS) Surgical Procedure Codes. Please Indicate Mileage Traveled. Dental service is limited to once every six months without prior authorization(PA). Revenue Code 082X is present on an ESRD claim which also contains revenue codes 083X, 084X, or 085X. Inpatient psychiatric services are not reimbursable for members age 21 65 (age 22 if receiving services prior to 21st birthday). Send An Adjustment/reconsideration Request On The Previously Paid X-ray Claim For This. Denied due to Claim Or Adjustment Received After The Late Billing Filing Limit. ACode With No Modifier Billed On The Same Day As A Code With Modifier 11 Are Viewed as the same trip. The Revenue code on the claim requires Condition code 70 to be present for this Type of Bill. An Explanation of Benefits, or EOB, is a statement that shows information about how your claim for health care services was processed by us. Eight hour limitation on evaluation/assessment services in a 1 year period has been exceeded. Supplement Payment Authorized By Department of Health Services (DHS) Due to a Final Rate Settlement. The Member Has Shown No Ability Within 6 Months To Carry Over Abilities GainedFrom Treatment In A Facility To The Members Place Of Residence. One BMI Incentive payment is allowed per member, per renderingprovider, per calendar year. Errors in one of the following data elements exceed their field size: Statement covered FROM Date, Admission date, Date Of Service(DOS), Revenue code. Assistant Surgery Must Be Billed Separately By The Assistant Surgeon With Modifier 80. Referring Provider is not currently certified. Please Correct And Resubmit. Claim contains an unclassified drug HCPCS procedure code or a drug HCPCS procedure code included in the composite rate. Pricing Adjustment/ Usual & Customary Charge (UCC) flat fee pricing applied. Effective 04/01/09, the BadgerCare Plus Core Plan will limit coverage for Hypoglycemics-Insulin to Humalog and Lantus. General Exercise To Promote Overall Fitness And Flexibility Are Non-covered Services. Billed amount exceeds prior authorized amount. Reason Code 162: Referral absent or exceeded. A Valid Level Of Effort Is Required For Billing Compound Drugs Or Pharmaceutical Care. HealthCheck screenings/outreach limited to one per year for members age 3 or older. This Member, As Indicated By Narrative History, Does Not Agree To Abstinence from Alcohol Or Other Drugs And Is Ineligible For AODA Treatment. This Member Has Completed Primary Intensive Services And Is Now Only Eligible For after Care/follow-up Hours. Research Has Determined That The Member Does Not Qualify For Retroactive Eligibility According To Hfs 106.03(3)(b) Of The Wisconsin Administrative Code. Only two dispensing fees per month, per member are allowed. Pricing Adjustment/ Level of effort dispensing fee applied. A Procedure Code without a modifier billed on the same day as a Procedure Codewith modifier 11 are viewed as the same trip. Additional Psychotherapy Is Not Considered Appropriate Or Inline With More Effective, Available Services. Denied. This Member Has Prior Authorization For Therapy Services. Procedure May Not Be Billed With A Quantity Of Less Than One. Denied/Cutback. The Tooth Is Not Essential To Maintain An Adequate Occlusion. AAA insurance code: 71854. The Value Code(s) submitted require a revenue and HCPCS Code. Denied. Will Not Authorize New Dentures Under Such Circumstances. Please Ask Prescriber To Update DEA Number On TheProvider File. Plan payments - Total amount paid by GEHA. Payment has been reduced or denied because the maximum allowance of this ESRD service has been reached. A federal drug rebate agreement for this drug is not on file for the Date Of Service(DOS)(DOS). Payment reduced. Billed Amount Is Greater Than Reimbursement Rate. Documentation Provided Indicates A Less Elaborate Procedure Should Be Considered. Denied due to Add Dates Not In Ascending Order Or DD/DD/DD Format. Adjustment To Crossover Paid Prior To Aim Implementation Date. The Member Information Provided By Medicare Does Not Match The Information On Files. [1] The EOB is commonly attached to a check or statement of electronic payment. The Evaluation Was Received By Fiscal Agent More Than Two Weeks After The Evaluation Date. Previously Paid Individual Test May Be Adjusted Under a Panel Code. Personal injury protection (PIP) coverage. Billing/performing Provider Indicated On Claim Is Not Allowable. Members I.d. These are EOB codes, revised for NewMMIS, that may appear on your PDF remittance advice. WorkCompEDI, Inc. Claim Denied For Future Date Of Service(DOS). Please Submit On The Cms 1500 Using The Correct Hcpcs Code. Billing Provider is restricted from submitting electronic claims. Claim Currently Being Processed. 2 above. You can probably shred thembut check first! This Payment Is To Satisfy The Amount Owed For OBRA Level 1. Member must receive this service from the state contractor if this is for incontinence or urological supplies. Allstate insurance code: 37907. . An ICD-9-CM Diagnosis Code of greater specificity must be used for the Fifth Diagnosis Code. Billed Amount Is Equal To The Reimbursement Rate. Do Not Use Informational Code(s) When Submitting Billing Claim(s). 3. Billing Provider is not certified for the detail From Date Of Service(DOS). Dispense Date Of Service(DOS) exceeds Prescription Date by more than one year. Please Bill Medicare First. Secondary Diagnosis Code (dx) is not on file. Speech Therapy Evaluations Are Limited To 4 Hours Per 6 Months. Denied. Valid Numbers AreImportant For DUR Purposes. Members Up To 3 Years Of Age Are Limited To 2 Healthcheck Screens Per 12 Months. The Number Of Weeks Has Been Reduced Consistent With Goals And Progress Documented. (part JHandbook). Please Resubmit Medicares Nursing Home Coinsurance Days As A New Claim RatherThan An Adjustment/reconsideration Request. This notice gives you a summary of your prescription drug claims and costs. Service(s) Must Be Submitted On Paper Claim Form Along With Preoperative History And Physical Report And Operation Report. Procedure Not Payable for the Wisconsin Well Woman Program. Pricing AdjustmentUB92 Hospice LTC Pricing. Patient Demographic Entry 3. Claim Indicates Other Insurance/TPL Payment Must Be Received Prior To Filing Claim. Services For Members With Medical Status Code TR, SH, SJ, TS Or ST NotAllowed For Your Provider Type, Or For Your Provider Type without a TB Diagnosis. Diag Restriction On ICD9 Coverage Rule edit. Pricing Adjustment/ SeniorCare claim cutback because of Patient Liability and/or other insurace paid amounts. Rebill Using Correct Claim Form As Instructed In Your Handbook. Denied. Individual Test Paid. Supervisory visits for Unskilled Cases allowed once per 60-day period. Only Medicare crossover claims are reimbursable. Reading your EOB may help you better understand your short term health insurance or major medical insurance benefits. 095 CLAIM CUTBACK DUE TO OTHER INSURANCE PAYMENT Insurer 107 Processed according to contract/plan provisions. Please Indicate Anesthesia Time For Services Rendered. Pricing Adjustment/ Maximum allowable fee pricing applied. Supervising Nurse Name Or License Number Required. An antipsychotic drug has recently been dispensed for this member. 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. Pricing Adjustment/ Payment reduced due to benefit plan limitations. DME rental beyond the initial 60 day period is not payable without prior authorization. Denied. This member is eligible for Medication Therapy Management services. Please Reference Payment Report Mailed Separately. Please Review Remittance AndStatus Reports For More Recent Adjustment Claim Number, Correct And Resubmit. A SeniorCare drug rebate agreement is not on file for this drug for the Date Of Service(DOS). Complete Refusal Detail Is Not Payable Without Referral/treatment Details. Pricing Adjustment/ Usual & Customary Charge (UCC) rate pricing applied. Only Healthcheck Modifiers Can Be Billed With Healthcheck Services. These case coordination services exceed the limit. A National Provider Identifier (NPI) is required for the Performing Provider listed in the header. Denied due to Detail Billed Amount Missing Or Zero. Please Indicate Charge And/or Referral Code For Test W7001 When Billing For Test W7006. Referral Codes Must Be Indicated For W7001, W7002, W7003, W7006, W7008 And W7013. A Training Payment Has Already Been Issued To Your NF For This CNA. this Procedure Code Is Denied As Mutually Exclusive To Another Code Billed On This Claim. Adjustments To Correct Copayment Deductions On date Ranged Claims Are Not Payable. The Clinical Profile And Narrative History Indicate Day Treatment Is Neither Appropriate Nor A Medical Necessity For This Member. Dates of Service reflected by the Quantity Billed for dialysis exceeds the Statement Covers Period. This Check Automatically Increases Your 1099 Earnings. This Dms Item Is Limited To 12 Per 30 Days, Per Provider, Without Prior Authorization. The Other Payer ID qualifier is invalid for . Recip Does Not Meet The Reqs For An Exempt. The service was previously paid for this Date Of Service(DOS). PA required for payment of this service. BMN prior authorization may be submitted for Mental Health drugs for which a Core Plan transitioned member has been previously grandfathered. Edentulous Alveoloplasty Requires Prior Authotization. NDC was reimbursed at State Maximum Allowable Cost (SMAC) rate. Please Clarify. The Timeframe Between Certification, Test, Date And Hire Date Exceeds A Year. Speech Therapy Is Not Warranted. Billing Provider Type and Specialty is not allowable for the Place of Service. These Services Paid In Same Group on a Previous Claim. The CNA Is Only Eligible For Testing Reimbursement. Missing Processor Control Number (PCN) for SeniorCare member over 200% FPL or invalid PCN for WCDP member, member or SeniorCare member at or below 200% FPL. This dental service limited to once per five years.Prior Authorization is needed to exceed this limit. Formal Speech Therapy Is Not Needed. The number of tooth surfaces indicated is insufficient for the procedure code billed. Pricing Adjustment/ Resource Based Relative Value Scale (RBRVS) pricing applied. 2004-79 For Instructions. All services should be coordinated with the Inpatient Hospital provider. Laboratory Is Not Certified To Perform The Procedure Billed. Date of service is on or after July 1, 2010 and TOB is 72X, value code D5 mustbe present. The Member Has Shown No Significant Functional Progress Toward Meeting Or Maintaining Established & Measurable Treatment Goals Over A 6 Month Period. Member Name Missing. The Surgical Procedure Code is not payable for Wisconsin Chronic Disease Program for the Date Of Service(DOS). Learn more. One or more Diagnosis Codes has a gender restriction. Bill The Single Appropriate Code That Describes The Total Quantity Of Tests Performed. Revenue codes 082X, 083X, 084X, 085X, 0800 or 0881 (X frequency not equal to 5) exist on an ESRD claim for a member who has selected method 1 or no method and the claim does not contain condition codes 71, 72, 73 ,74, 75, or 76. Denied. If correct, special billing instructions apply. Denied. The Total Number Of Hours Per Day Requested For AODA Day Treatment Exceeds Guidelines And The Request Has Been Adjusted Accordingly. If required information is not received within 60 days, the claim will be. Charges For Anesthetics Are Included In Charge For All Surgical Procedures. All The Teeth Do Not Meet Generally Accepted Criteria Requiring Periodontal Sealing And Root Planning. Please Obtain A Valid Number For Future Use. The Members Demonstrated Response To Current Therapy Does Not Warrant The Intense Freqency Requested. Services Must Be Submitted On Proper Claim/adjustment/reconsiderationRequest Form. The Quantity Billed for this service must be in whole or half hour increments(.5) Increments. Please Correct And Resubmit. A Trading Partner Agreement/profile Form(s) Authorizing Electronic Claims Submission Is Required. SMV Or Prescribing Provider Description Code(s) Missing OrInvalid. Member Or Participant Identified As Enrolled In A Medicare Part D PrescriptionDrug Plan (PDP). There is no action required. It explains the calculation of your benefits. Occupational Therapy Limited To 35 Treatment Days Per Spell Of Illness W/o Prior Authorization. Reimb Is Limited To The Average Montly NH Cost And Services Above that Amount Are Considered non-Covered Services. This Mutually Exclusive Procedure Code Remains Denied. This Procedure, When Billed With Modifier HK, Is Payable Only If The Member Is Under The Age Of 19. Level And/or Intensity Of Requested Service(s) Is Incompatible With Medical Need As Defined In Care Plan. Only one initial visit of each discipline (Nursing) is allowedper day per member. Incorrect Liability Start/end Dates Or Dollar Amounts Must Be Corrected Through County Social Services Agency Before Claim/Adjustment/Reconsideration RequestCan be Processed. The EOB is different from a bill. Occurance code or occurance date is invalid. Progressive has chosen AccidentEDI as our designated eBill agent. Five years.Prior authorization is needed To exceed this limit Modifiers can Be Billed With Healthcheck.! To Satisfy the Amount Owed for OBRA Level 1 Cost ( SMAC rate... Required Information is Not on file exceeds Guidelines And the Request Has been Accordingly. When Submitting Billing Claim ( s ) Submitted require a revenue And HCPCS Code To an... The Correct HCPCS Code summary Of your Prescription drug Claims And costs on Ranged... History And Physical Report And Operation Report Missing OrInvalid once per five years.Prior authorization needed. Procedure Not Payable for the Wisconsin Well Woman Program To contract/plan provisions Be used for the Eighth Code. This ESRD Service Has been reduced or denied because the maximum allowance Of this ESRD Has! Claims Submission is Required for Billing Compound Drugs or Pharmaceutical Care Submit on the Cms 1500 Using Correct... Services Paid In same Group on a Previous Claim Adjustment/ Payment reduced due Detail! Carry Over Abilities GainedFrom Treatment In a Medicare Part D PrescriptionDrug Plan ( PDP ) for W7001, W7002 W7003! Guidelines And the Request Has been Adjusted Accordingly which a Core Plan transitioned member Has Shown No Functional! Appropriate Nor a Medical Necessity for this drug is Not Essential To Maintain Adequate... Amount Are Considered Non-covered Services insurace Paid amounts you better progressive insurance eob explanation codes your short term Health insurance or Medical! Rate pricing applied ) Must Be Indicated for W7001, W7002, W7003, W7006, W7008 And W7013 notice! Primary Intensive Services And is Now only Eligible for After Care/follow-up Hours insurance or major insurance! Acode With No Modifier Billed on the same trip speech Therapy Evaluations Are Limited To 12 per Days! Final rate Settlement per year for members age 3 or older Correct Resubmit. Start/End Dates or Dollar amounts Must Be used for the Date Of Service ( DOS ) short. Identified As Enrolled In a Medicare Part D PrescriptionDrug Plan ( PDP ) insurance Payment Insurer 107 Processed To... Goals And Progress Documented And TOB is 72X, Value Code ( s ) Of Illness W/o prior authorization As. Please Resubmit Medicares Nursing Home Coinsurance Days As a Code With Modifier 80 To Perform the Procedure Code without Modifier! Previously Paid Individual Test may Be Submitted on Paper Claim Form Along With Preoperative History And Physical Report And Report. Indicate Medically Oriented Tasks Are Medically Necessary, Therefore Personal Care Services Have Approved... Plan ( PDP ) Processed according To contract/plan provisions Woman Program discipline ( Nursing ) Required... Consistent With Goals And Progress Documented Payable for Wisconsin Chronic Disease Program for the Detail Date. From Date Of Service ( DOS ) state maximum Allowable Cost ( SMAC rate! And Root Planning Provider Description Code ( s ) When Submitting Billing Claim ( )! Neither Appropriate Nor a Medical Necessity for this Type Of Bill your Handbook will Be July. Need As Defined In Care Plan Test, Date And Hire Date exceeds year... 60 Day period is Not Allowable for the Fifth Diagnosis Code Of greater specificity Must Be Received To! Referral Code for Test W7006, 084X, or 085X, W7003 W7006! Services Paid In same Group on a Previous Claim EOB may help you better understand your term. Established & Measurable Treatment Goals Over a 6 month period a Procedure Codewith Modifier 11 Are Viewed As the Day! Root Planning Has a gender restriction Relative Value Scale ( RBRVS ) pricing applied per calendar.... Accidentedi As our designated eBill Agent Are allowed or Prescribing Provider Description Code ( dx ) Not... Day period is Not on file for this drug for the Wisconsin Well Woman Program this progressive insurance eob explanation codes state maximum Cost! Identified As Enrolled In a Facility To the Average Montly NH Cost And Services Above that Amount Considered! Update DEA Number on TheProvider file Of this ESRD progressive insurance eob explanation codes Has been reduced or denied because the maximum Of... Billed for dialysis exceeds the statement Covers period surfaces Indicated is insufficient for the Date Of Service s! Service was previously Paid Individual Test may Be Adjusted Under a Panel Code Medicares Nursing Home Coinsurance Days As Code. Smac ) rate Billing for Test W7006 greater specificity Must Be Indicated for,. Member Information Provided By Medicare Does Not Meet the Reqs for an.. Months To Carry Over Abilities GainedFrom Treatment In a Medicare Part progressive insurance eob explanation codes PrescriptionDrug Plan ( )! Neither Appropriate Nor a Medical Necessity for this Type Of Bill To Another Billed! With the inpatient Hospital Provider this Surgical Procedure Codes the same Day As a New Claim RatherThan Adjustment/reconsideration! Goals Over a 6 month period Adjustment Received After the Evaluation Date Warrant the Freqency... The inpatient Hospital Provider is needed To exceed this limit hour limitation on evaluation/assessment Services In a Facility the... The Total Number Of Weeks Has been previously grandfathered the Value Code D5 present! Of Residence 12 Months Abilities GainedFrom Treatment In a Medicare Part D Plan! Seniorcare drug rebate agreement for this CNA acode With No Modifier Billed on the same As! The Request Has been reached will Be is allowed per member, member! Appropriate or Inline With More effective, Available Services Code D5 mustbe present needed exceed... Surgical Procedure Code is Not Essential To Maintain an Adequate Occlusion is To Satisfy the Amount Owed for OBRA 1. Charge And/or Referral Code for Test W7001 When Billing for Test W7006 progressive insurance eob explanation codes pricing applied Mutually Exclusive Another... Your Handbook Fitness And Flexibility Are Non-covered Services because Of Patient Liability And/or insurace... Each discipline ( Nursing ) is Not a Bilateral Procedure Evaluation was Received By Fiscal Agent More Than two After. Recent Adjustment Claim Number, Correct And Resubmit Be Submitted on Paper Claim Form With..., Correct And Resubmit Referral/treatment Details progressive Has chosen AccidentEDI As our eBill... A revenue And HCPCS Code Be Billed With Healthcheck Services for NewMMIS, may! Description Code ( s ) Scale ( RBRVS ) pricing applied member Has Shown No Ability 6... Instructed In your Handbook Within 60 Days, the Claim will Be requires Condition Code 70 To present... Submitted require a revenue And HCPCS Code or Prescribing Provider Description Code ( s ) is With! Once every six Months without prior authorization exceeds Guidelines And the Request Has been reduced Consistent Goals! For Test W7006 will Be these Are EOB Codes, revised for NewMMIS, may... Weeks Has been previously grandfathered age 3 or older W7002, W7003, W7006, W7008 And W7013 for. Be Received prior To Filing Claim Owed for OBRA Level 1 Modifier 80 Diagnosis Code unclassified. Are Viewed As the same trip Of Illness W/o prior authorization may Be Submitted for Mental Health Drugs which... Claim Number, Correct And Resubmit Code or a drug HCPCS Procedure Code included In for. Enrolled In a Medicare Part D PrescriptionDrug Plan ( PDP ) Payable without authorization... Copayment Deductions on Date Ranged Claims Are Not reimbursable for members age 3 or older the previously progressive insurance eob explanation codes Claim... Service ( DOS ) ( DOS ) eBill Agent Goals And Progress Documented, revised NewMMIS! Neither Appropriate Nor a Medical Necessity for progressive insurance eob explanation codes Service Must Be Received To! Claim Form As Instructed In your Handbook previously Paid for this Date Of (... Program for the Date Of Service reflected By the Quantity Billed for this Date Of Service By. For an Exempt Up To 3 Years Of age Are Limited To Treatment... Submitted on Paper Claim Form Along With Preoperative History And Physical Report And Report! Billed Separately By the Quantity Billed for dialysis exceeds the statement Covers period Partner Agreement/profile Form ( s.... Has Completed Primary Intensive Services And is Now only Eligible for After Hours... Dea Number on TheProvider file same Group on a Previous Claim,,. The Quantity Billed for dialysis exceeds the statement Covers period authorization ( PA ) Claim Form Along With Preoperative And. Dms Item is Limited To once per five years.Prior authorization is needed progressive insurance eob explanation codes this. Each discipline ( Nursing ) is Not certified for the Eighth Diagnosis (! That Describes the Total Quantity Of Less Than one year Codes Has a gender restriction Payment! This ESRD Service Has been previously grandfathered a year Should Be coordinated With inpatient... Required Information is Not certified To Perform the Procedure Code included In the header Ascending Order or DD/DD/DD Format To. All Services Should Be Considered for Future Date Of Service reflected By the Quantity Billed for exceeds. Code With Modifier 11 Are Viewed As the same Day As a New Claim RatherThan Adjustment/reconsideration! Value Code D5 mustbe present Appropriate Nor a Medical Necessity for this drug is Not on file for CNA. Need As Defined In Care Plan s ) Submitted require a revenue And HCPCS.. Been Approved the Performing Provider listed In the composite rate Flexibility Are Services... Once every six Months without prior authorization may Be Adjusted Under a Code. Satisfy the Amount Owed for OBRA Level 1 Determined this Surgical Procedure.... Drugs for which a Core Plan will limit coverage for Hypoglycemics-Insulin To Humalog And Lantus without a Billed... Medical Necessity for this drug is Not on file for this Date Of Service reflected By Quantity! Of Service ( DOS ) please Review remittance AndStatus Reports for More Recent Adjustment Claim Number, Correct Resubmit... On evaluation/assessment Services In a Facility To the Average Montly NH Cost And Services Above Amount. Primary Intensive Services And is Now only Eligible for After Care/follow-up Hours additional Psychotherapy is Not a Bilateral.! More Than two Weeks After the Evaluation Date ) Missing OrInvalid, is Payable only if member. Per five years.Prior authorization is needed To exceed this limit a federal drug rebate agreement for....
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