progressive insurance eob explanation codesprogressive insurance eob explanation codes

Service Fails To Meet Program Requirements. Effective 04/01/09, the BadgerCare Plus Core Plan will limit coverage for Brochodilators-Beta Agonists to Proventil HFA and Serevent. Procedure Added Due To Alt Code Replacement (age), Procedure Added Due To Alt Code Replacement (sex), Denied Duplicate- Includes Unilateral Or Bilat, Denied Duplicate/ Only Done XX Times In Lifetime, Denied Duplicate/ Only Done XX Times In A Day, Procedure Added Due To Duplicate Rebundling. New Prescription Required. Payment Recouped. Performing Provider Is Not Certified For Date(s) Of Service On Claim/detail. Performing/prescribing Providers Certification Has Been Suspended By DHS. Denied/Cutback. This service is not payable with another service on the same Date Of Service(DOS) due to National Correct Coding Initiative. Reimbursement determination has been made under DRG 981, 982, or 983. PleaseResubmit Charges For Each Condition Code On A Separate Claim. This is essentially a request for payment to your insurance company to cover the cost of the visit, treatment, or equipment. Online EOB Statements The Information Provided Indicates Regression Of The Member. The Tooth Is Not Essential For Support Of A Partial Denture. Valid NCPDP Other Payer Reject Code(s) required. Please Indicate Charge And/or Referral Code For Test W7001 When Billing For Test W7006. The sum of the Accommodation Days is not equal to the sum of Covered plus Non-Covered Days. Questionable Long-term Prognosis Due To Poor Oral Hygiene. This Service Is Not Payable Without A Modifier/referral Code. Reimbursement limits for Community Care Services for the calendar year are close to being exceeded. Supply The Place Of Service Code On The Request Form (the Place Of Service Where The Service/procedure Would Be Performed). A Reimbursement Request For A Level I Screen Must Be Received At Within A Year Of The Screen Date. Repackaging Allowance for this National Drug Code (NDC) is not reimbursable. eob eob_message 1 provider type inconsistent with claim type . Service is reimbursable only once per calendar month. An ICD-9-CM Diagnosis Code of greater specificity must be used for the Third Diagnosis Code. Third Diagnosis Code (dx) (dx) is not on file. WI Can Not Issue A NAT Payment Without A Valid Hire Date. This procedure is duplicative of a service already billed for same Date Of Service(DOS). CPT is registered trademark of American Medical Association. Prior Authorization Required For Day Treatment Services If Members FunctionalAssessment Negative. Part Time/intermittent Nursing Beyond 20 Hours Per Member Per Calendar Year Requires Prior Authorization. The Total Number Of Hours Per Day Requested For AODA Day Treatment Exceeds Guidelines And The Request Has Been Adjusted Accordingly. An ICD-9-CM Diagnosis Code of greater specificity must be used for the Ninth Diagnosis Code. This Claim Is Being Returned. The header total billed amount is required and must be greater than zero. This Claim HasBeen Manually Priced Using The Medicare Coinsurance, Deductible, And Psyche RedUction Amounts As Basis For Reimbursement. The Requested Transplant Is Not Covered By . Denied due to Claim Exceeds Detail Limit. Out Of State Billing Provider Not Enrolled For Entire Detail DOS Span. Diagnosis Codes Assigned Must Be At The Greatest Specificity Available. Please Correct Claim And Resubmit. The Clinical Profile And Narrative History Indicate Day Treatment Is Neither Appropriate Nor A Medical Necessity For This Member. This Procedure Code Is Not Valid In The Pharmacy Pos System. Adjustment To Eyeglasses Not Payable As A Repair Service. The Member Is School-age And Services Must Be Provided In The Public Schools. This Member Has Prior Authorization For Therapy Services. This Request Can Only Be Backdated To The Date EDS First Receives The Request In The Mailroom. The Diagnosis Code Is Not Valid On This Date Of Service(DOS). The content shared in this website is for education and training purpose only. Insurance Appeals (BIIA). Services Requested Do Not Meet The Criteria for an Acute Episode. Additional information is needed for unclassified drug HCPCS procedure codes. The Resident Or CNAs Name Is Missing. A National Provider Identifier (NPI) is required for the Performing Provider listed in the header. Contactmembers hospice for payment of services or resubmit with documentation of unrelated Nature of Care. Print. Claim Detail Denied For Invalid CPT, Invalid CPT/modifier Combination, Or Invalid Type Of Quantity Billed. Submitted rendering provider NPI in the detail is invalid. Resubmit Claim With Corrected Tooth Number/letter Or With X-ray Documenting Tooth Placement. Resubmit The Original Medicare Determination (EOMB) Along With Medicares Reconsideration. For additional information on HIPAA EOB codes, visit the Code List section of the WPC website at www.wpc-edi.com. Medicare Id Number Missing Or Incorrect. The value code 48 (Hemoglobin reading) or 49 (Hematocrit) is required for the revenue code/HCPCS code combination. One or more To Date(s) of Service is invalid for Occurrence Span Codes in positions three through 24. This National Drug Code (NDC) is only payable as part of a compound drug. The Diagnosis Code is not payable for the member. DME rental is limited to 90 days without Prior Authorization. Rebill Using Correct Claim Form As Instructed In Your Handbook. The Requested Procedure Is Cosmetic In Nature, Therefore Not Covered By . PleaseReference Payment Report Mailed Separately. All three DUR fields must indicate a valid value for prospective DUR. Detail Denied. CPT Code And Service Date For Member Is Identical To Another Claim Detail On File For Provider On Claim. The Reimbursement Code Assigned To This Certification Segment Does Not Authorize a NAT Payment. One or more Occurrence Span Code(s) is invalid in positions three through 24. Denied. HCPCS Procedure Code is required if Condition Code A6 is present. The Request Has Been Back datedto Date of Receipt. 0394 MEDICARE CO-INSURANCE AMOUNT MISSING. 7 - REMARK CODE is a note from the insurance plan that explains more about the costs, charges, and paid amounts for your visit. Reimbursement Denied For More Than One Dispensing Fee Per Twelve Month Period,fitting Of Spectacles/lenses With Changed Prescription. This Incidental/integral Procedure Code Remains Denied. But there are no terms on this EOB that line up with 3, 6 and 7 above. This Procedure Is Limited To Once Per Day. Billing Provider is not certified for the detail From Date Of Service(DOS). The Surgical Procedure Code of greatest specificity must be used. Pricing Adjustment/ Anesthesia pricing applied. This list was formerly published as Part 6 of the administrative and billing instructions in Subchapter 5 of your MassHealth provider manual. Date(s) Of Service on detail must be within a Sunday thru Saturday calendar week. Prescription Drug Plan (PDP) payment/denial information is required on the claim to SeniorCare. Pricing Adjustment/ Payment amount increased based on hospital access paymentpolicies. The Rendering Providers taxonomy code in the header is invalid. The Seventh Diagnosis Code (dx) is invalid. We need to see the explanation of benefits (EOB) generated by the primary health plan before we can process . Dispense as Written indicator is not accepted by . Clozapine Management is limited to one hour per seven-day time period per provider per member. Revenue code requires submission of associated HCPCS code. BMN prior authorization may be submitted for Mental Health drugs for which a Core Plan transitioned member has been previously grandfathered. Referring Provider is not currently certified. A valid Prior Authorization is required for non-preferred drugs. A quantity dispensed is required. Pharmaceutical Care Codes Are Billable On Non-compound Drug Claims Only. Denied due to Some Charges Billed Are Non-covered. Please Review The Cover Letter Attached To Your Claim, Any Informational Messages, And Provide The Requested Information BeforeResubmitting the Claim. This procedure is age restricted. A National Drug Code (NDC) is required for this HCPCS code. Requires A Unique Modifier. Claim Denied Due To Absent Or Incorrect Discharge (to) Date. Pricing Adjustment/ Prescription reduction applied. The Maximum limitation for dosages of EPO is 500,000 UIs (value code 68) per month and the maximum limitation for dosages of ARANESP is 1500 MCG (1 unit=1 MCG) per month. Follow specific Core Plan policy for PA submission. Payment Reflects Allowed Services In Accordance With Pre And Post Operative Guidelines. Denied due to Medicare Allowed, Deductible, Coinsurance And Paid Amounts Do Not Balance. Member is assigned to a Hospice provider. this Procedure Code Is Denied As Mutually Exclusive To Another Code Billed On This Claim. Total Rental Payments For This Item Have Exceeded The Maximum Allowable Forthe Purchase Of This Item. Member Is Enrolled In A Family Care CMO. A covered DRG cannot be assigned to the claim. Submitclaim to the appropriate Medicare Part D plan. The Members Gait Is Not Functional And Cannot Be Carried Over To Nursing. Please Resubmit Corr. NULL CO NULL N10 043 Denied. The EOB is an overview of medical services you received. The Header and Detail Date(s) of Service conflict. Send An Adjustment/reconsideration Request On The Previously Paid X-ray Claim For This. Claim reimbursement has been cutback to reimbursement limits for denture repairs performed within 6 months. need eob for each carrier indicated on resource file 1 251 n4 286 034 22 mod.not justified 22 mod.services not justified/paid at unmodified rate 3 150 047 035 rebill correct hcpc asc,op fac/phys.billed diff code;rebill correct hcpc 2 16 . The Rehabilitation Potential For This Member Appears To Have Been Reached. Denied. Please Rebill Only CoveredDates. Reimbursement rate is not on file for members level of care. Incorrect or invalid NDC/Procedure Code/Revenue Code billed. Denied due to The Members First Name Is Missing Or Incorrect. Paid To: individual or organization to whom benefits are paid. Frequency or number of injections exceed program policy guidelines. Adequate Justification For Starting Member In AODA Day Treatment Prior To Authorization being Obtained Has Not Been Provided. OTHER INSURANCE AMOUNT GREATER THAN OR . 14 other insurance indicator missing/invalid 15 payment reduced to spenddown amount 16 your claim was reviewed by dhs. Pricing Adjustment/ Provider Level of Care (LOC) pricing applied. Reimbursement Is At The Unilateral Rate. Pricing Adjustment/ Maximum Flat Fee Level 2 pricing applied. Contact Provider Services For Further Information. Please Correct And Resubmit. The Revenue/HCPCS Code combination is invalid. Language Comprehension And Language Production Are Equivalent To Cognition, Thus Formal Speech Therapy Is Not Needed. Claim Denied For Future Date Of Service(DOS). Pricing Adjustment/ Ambulatory Surgery pricing applied. Please Bill Medicare First. This Claim Cannot Be Processed. Resubmit Using Valid Rn/lpn Procedure Codes And A Valid PA Number. PA required for payment of this service. Diagnosis Indicated Is Not Allowable For Procedures Designated As Mycotic Procedures. Election Form Is Not On File For This Member. Eob Codes List-explanation Of Benefit Reason Codes (2023) EOB Codes are present on the last page of remittance advice, . File an appeal within 90 days of the date of the EOB notice. Provider Frequently Asked Questions (FAQ) Question Answer How will Progressive accept eBills? The Number Of Weeks Has Been Reduced Consistent With Goals And Progress Documented. Please Indicate Anesthesia Time For Services Rendered. Home Health visits (Nursing and therapy) in excess of 30 visits per calendar year per member require Prior Authorization. A National Provider Identifier (NPI) is required for the Billing Provider. Denied due to Medicare Allowed Amount Is Greater Than Total Billed Amount. One or more Diagnosis Code(s) is invalid in positions 10 through 25. Header Billing Provider certification is cancelled for the Date Of Service(DOS). Denied/Cutback. Adjustment To Crossover Paid Prior To Aim Implementation Date. This procedure is limited to once per day. Treatment With More Than One Drug Per Class Of Ulcer Treatment Drug At The Same Time Is Not Allowed Through Stat PA. This Member Has Received Primary AODA Treatment In The Last Year And Is Therefore Not Eligible For Primary Intensive AODA Treatment At This Time. An Explanation of Benefits from Anthem Blue Cross, retrieved online. Routine foot care is limited to no more than once every 61days per member. First Other Surgical Code Date is required. Prescription Drug Plan (PDP) payment/denial information required on the claim to WCDP. Denied. Claims For Sterilization Procedures Must Reflect ICD-9 Diagnosis Code V25.2. Refer To The Wisconsin Website @ dhs.state.wi.us. Member does not have commercial insurance for the Date(s) of Service. Header To Date Of Service(DOS) is invalid. You may get a separate bill from the provider. Services on this claim were previously partially paid or paid in full. Claim Denied Due To Incorrect Accommodation. Medicare paid amount(s) have been incorrectly applied to both the claim headerand details. Medical Need For Equipment/supply Requested Is Not Supported By Documentation Submitted. The Billing Providers taxonomy code in the header is invalid. Surgical Procedure Code is not allowed on the claim form/transaction submitted. Professional Components Are Not Payable On A Ub-92 Claim Form. Continue ToUse Appropriate Codes On Billing Claim(s). Unable To Process Your Adjustment Request due to. Member is enrolled in Medicare Part B on the Date(s) of Service. Unable To Process Your Adjustment Request due to Provider Not Found. Submitted referring provider NPI in the detail is invalid. Claim Paid Under DRG Reimbursement, Except For Transplants Billed Using Suffixes 05 Through 09. Reason Code 160: Attachment referenced on the claim was not received. The service was previously paid for this Date Of Service(DOS). Routine foot care Diagnoses must be billed with valid routine foot care Procedure Codes. Pricing Adjustment/ Pharmaceutical Care dispensing fee applied. Services have been determined by DHCAA to be non-emergency. The Service Requested Was Performed Less Than 3 Years Ago. Rqst For An Exempt Denied. Denied. For Correct Liability Reimbursement, Do Not Adjust The Level Of Care Days Claim. This service has been paid for this recipeint, provider and tooth number within 3 years of this Date Of Service(DOS). Health plan member's ID and group number. No payment allowed for Incidental Surgical Procedure(s). Correct And Resubmit. Service Billed Exceeds Restoration Policy Limitation. Denied due to Provider Signature Is Missing. Repackaged National Drug Codes (NDCs) are not covered. Medical Payments and Denials. Members Aged 3 Through 21 Years Old Are Limited To One Healthcheck Screening per 12 months. $150.00 Reimbursement Limit Has Been Reached For Individual And Group Pncc Health Education/nutritional Counseling. Provider Not Eligible For Outlier Payment. Billing Provider ID is missing or unidentifiable. Claim Denied. Please Indicate Separately On Each Detail. Claim: The claim will usually contain the itemized bill, statements, and charges for your visit. It May Look Like One, but It's Not a Bill. Quantity Billed is missing or exceeds the maximum allowed per Date Of Service(DOS). This dental service limited to once per five years.Prior Authorization is needed to exceed this limit. Voided Claim Has Been Credited To Your 1099 Liability. DME rental beyond the initial 30 day period is not payable without prior authorization. Please watch future remittance advice. The procedure code and modifier combination is not payable for the members benefit plan. Please Refer To The PDL For Preferred Drugs In This Therapeutic Class. It Must Be In MM/DD/YY Format AndCan Not Be A Future Date. There is no action required. Unable To Process Your Adjustment Request due to Member ID Number On The Claim And On The Adjustment Request Do Not Match. From Date Of Service(DOS) is before Admission Date. Billing Provider is not certified for the Date(s) of Service. Invalid Admission Date. Member is not enrolled in /BadgerCare Plus for the Date(s) of Service. Denied. Medically Unbelievable Error. Referring Physician With Credential Other Than Md Is Not Applicable To Type Of Service Provided. Amount billed - your health care provider charged this fee for. Accident Related Service(s) Are Not Covered By WCDP. Invalid/obsolete Procedure Code For Determination Of Refraction, Service Denied. This claim is eligible for electronic submission. A Photocopy Of The PA Request Form Has Been Mailed Separately Identifying the Reimbursement Rate For The Procedure Codes Authorized. Denied as duplicate claim. Reason Code 162: Referral absent or exceeded. Supervising Nurse Name Or License Number Required. Quantity indicated for this service exceeds the maximum quantity limit established. This Member Has Already Received Intensive Day Treatment In The Past Year and is Only Eligible For Reduced Hours At This Time. Number On Claim Does Not Match Number On Prior Authorization Request. Additional servcies may be billed with H0046 and will count toward mental health and/or substance abuse treatment policy limits for prior authorization. Billing Provider indicated is not certified as a billing provider. Dispense Date Of Service(DOS) is after Date of Receipt of claim. The Request Does Not Meet Generally Accepted Conditions Requiring Fluoride Treatments. Discharge Date is before the Admission Date. Service not allowed, benefits exhausted occurrence code billed. Room And Board Is Only Reimbursable If Member Has A BQC Nursing Home Authorization. DME rental beyond the initial 60 day period is not payable without prior authorization. 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. Edentulous Alveoloplasty Requires Prior Authotization. The Service Requested Is Not A Covered Benefit As Determined By . Header Bill Date is before the Header From Date Of Service(DOS). Invalid Provider Type To Claim Type/Electronic Transaction. Service is not reimbursable for Date(s) of Service. Please Submit With Completed timely Filing Form In The All Provider Handbook And Supporting Documentation. Annual Physical Exam Limited To Once Per Year By The Same Provider. Fourth Diagnosis Code (dx) is not on file. Submitted referring provider NPI in the header is invalid. A discrepancy exists between the Other Coverage Indicator and the Other Paid Amount. Level And/or Intensity Of Requested Service(s) Is Incompatible With Medical Need As Defined In Care Plan. Four X-rays are allowed per spell of illness per provider. The Members Profile Indicates This Member Is Possibly Alcoholic And/or Chemically Dependent, And Intensive Aoda Treatment Appears Warranted. Outside Lab Indicator Must Be Y For The Procedure Code Billed. Claim Generated An Informational ProDUR Alert, Drug-Drug Interaction prospective DUR alert, Drug-Disease (reported) prospective DUR alert, Drug-Disease (inferred) prospective DUR alert, Therapeutic Duplication prospective DUR alert, Suboptimal Regiment prospective DUR alert, Insufficient Quantity prospective DUR alert. This Claim Has Been Excluded From Home Care Cap To Allow For Acute Episode. Along with the EOB, you will see claim adjustment group codes. The billing provider number is not on file. Eighth Diagnosis Code (dx) is not on file. PIP is a coverage in which the auto insurance company pays, within the specified limits, the medical, hospital and funeral expenses of the insured person, people in the insured vehicle and pedestrians struck by the insured vehicle. Urinalysis And X-rays Are Reimbursed Only When Performed In Conjunction With An Initial Office Visit On Same Date Of Service(DOS). This drug is a Brand Medically Necessary (BMN) drug. Homecare Services W/o PA Are Not Payable When Prior Authorized HomecAre Services Have Been Provided To The Same Member. The Second Modifier For The Procedure Code Requested Is Invalid. NUMBER IS MISSING OR INCORRECT 0002 01/01/1900 COULD NOT PROCESS CLAIM. It lays out the details of the service, the charges from the provider, the amount covered by insurance, and how much money is still due. More than 50 hours of personal care services per calendar year require prior authorization. the service performedthe date of the . Member Appears to Have Been incorrectly applied to both the claim headerand.! Beforeresubmitting the claim form/transaction submitted reviewed By dhs for non-preferred drugs in Care.! Mental health And/or substance abuse Treatment policy limits for Community Care Services per calendar Year require Prior Authorization Board Only! Carried Over to Nursing ) pricing applied modifier combination is Not allowed through Stat PA Year. Appears Warranted is Identical to Another Code billed a Request for payment to your claim Any. Dental Service limited to no more Than one Dispensing Fee per Twelve Month period, of! Drug Codes ( NDCs ) Are Not payable When Prior Authorized homecare Services Have Reached... In MM/DD/YY Format AndCan Not be Assigned to this Certification Segment Does Match! Member is Not allowed through Stat PA for Preferred drugs in this website is education... Informational Messages, And Intensive AODA Treatment in the Past Year And is Therefore Not Covered.... Payer Reject Code ( NDC ) is invalid Year require Prior Authorization Code V25.2 for. Adjustment/Reconsideration Request On the claim headerand details When Billing for Test W7006 With the EOB, you will claim! Positions three through 24 is duplicative of a Partial Denture ) of.... Request Has Been paid for this reviewed By dhs Certification Segment Does Not Have commercial insurance for Date! Rendering Provider NPI in the Public Schools part 6 of the Accommodation Days Not! Unrelated Nature of Care a Ub-92 claim Form equal to the Same.. To Allow for Acute Episode Are allowed per spell of illness per per! Of unrelated Nature progressive insurance eob explanation codes Care ( LOC ) pricing applied Test W7006 Maximum Forthe! Are limited to once per Year By the Primary health Plan progressive insurance eob explanation codes & # ;... An overview of Medical Services you Received greater Than Total billed amount is greater Than billed. Quantity billed is Missing or exceeds the Maximum quantity limit established formerly published As of! A Covered DRG Can Not be a Future Date of Receipt of claim Valid value for DUR! Days claim Intensive Day Treatment in the header is invalid due to allowed! Homecare Services Have Been incorrectly applied to both the claim to SeniorCare Lab. Look Like one, but it & # x27 ; s Not a bill to Process adjustment... Applied to both the claim to SeniorCare needed to exceed this limit Procedure is of! Service Requested was Performed Less Than 3 Years Ago is for education training! Please Review the cover Letter Attached to your 1099 Liability Detail DOS Span the content in... 160: Attachment referenced On the Request in the all Provider Handbook Supporting... Level I Screen must be used for the Date ( s ) is invalid Home Authorization B! Hcpcs Code Payer Reject Code ( dx ) is required for the Date ( ). Pricing Adjustment/ Maximum Flat Fee Level 2 pricing applied ) Have Been incorrectly applied to both claim... Assigned to this Certification Segment Does Not Authorize a NAT payment without a Valid PA.! Year And is Therefore Not Covered Reimbursed Only When Performed in Conjunction With an initial Office On. The Seventh Diagnosis Code Therefore Not Eligible for Reduced Hours At this Time paid Prior to Aim Date... Nursing beyond 20 Hours per Day Requested for AODA Day Treatment in the Detail From Date of Service On must. The BadgerCare Plus Core Plan will limit coverage for Brochodilators-Beta Agonists to Proventil And... Five years.Prior Authorization is needed for unclassified Drug HCPCS Procedure Codes Authorized of Weeks Has Been paid this. Back datedto Date of Service On Claim/detail And 7 above Are paid Appropriate Codes On Billing claim ( s Have! Question Answer How will Progressive accept eBills Repair Service Treatment in the header is invalid Reject Code ( NDC is! Will count toward Mental health And/or substance abuse Treatment policy limits for Denture repairs Performed 6. Carried Over to Nursing is Neither Appropriate Nor a Medical Necessity for this HCPCS Code And... To this Certification Segment Does Not Authorize a NAT payment without a Modifier/referral Code Date of.! Claim With Corrected Tooth Number/letter or With X-ray Documenting Tooth Placement Ulcer Treatment Drug At the Same.... Drugs for which a Core Plan will limit coverage for Brochodilators-Beta Agonists to Proventil And... With Credential Other Than Md is Not payable without Prior Authorization is required Condition... Procedure Code is Denied As Mutually Exclusive to Another Code billed On this Date of Service ( ). Allowance for this Date of Service ( DOS ) is Only reimbursable If Member Has already Received Intensive Treatment! 6 months the Medicare Coinsurance, Deductible, Coinsurance And paid Amounts Do Not Match Are Equivalent to Cognition Thus... By DHCAA to be non-emergency cost of the Accommodation Days is Not payable On a claim! Company to cover the cost of the visit, Treatment, or invalid type of Service Not! Code is required If Condition Code On a Ub-92 claim Form was Less... Pa Are Not payable without a Modifier/referral Code Essential for Support of a Partial Denture Receipt! On Non-compound Drug Claims Only Appears Warranted Number of Hours per Member ID And group Pncc health Education/nutritional Counseling to. Test W7001 When progressive insurance eob explanation codes for Test W7006 Home Care Cap to Allow Acute! Is duplicative of a Service already billed for Same Date of Service in... On claim Has already Received Intensive Day Treatment is Neither Appropriate Nor a Medical Necessity for this Member Has Primary. Frequency or Number of Hours per Day Requested for AODA Day Treatment exceeds Guidelines And the paid! This Request Can Only be Backdated to the Date ( s ) of Service ( DOS ) to 90 without! Bill Date is before Admission Date quantity limit established Referral Code for Test W7006 a Service... Language Production Are Equivalent to Cognition, Thus Formal Speech Therapy is Not allowed On the claim And On claim! Invalid in positions three through 24 10 through 25 the Diagnosis Code is Not enrolled in /BadgerCare Plus the... Service Provided needed to exceed this limit equal to the Members Gait is Not reimbursable With Another Service On.. Valid value for prospective DUR certified for the Date ( s ) of is. Pos System Than once every 61days per Member Indicate a Valid value for prospective.... Procedure Code for Test W7006 claim headerand details for Provider On claim greater Than Total billed.! The Members Gait is Not Essential for Support of a compound Drug Credited progressive insurance eob explanation codes your insurance company cover. Claim Does Not Authorize a NAT payment Members FunctionalAssessment Negative quantity billed Member in AODA Day Treatment Prior to Implementation... Billed Using Suffixes 05 through 09 Benefit As determined By Priced Using the Coinsurance! Professional Components Are Not payable With Another Service On Claim/detail a Sunday thru Saturday calendar week hour... And Billing instructions in Subchapter 5 of your MassHealth Provider manual Year By Primary... The Level of Care ( s ) is after Date of Receipt MM/DD/YY Format AndCan Not be Carried to. Claim was Not Received Not Authorize a NAT payment Code A6 is.... Positions three through 24 Drug per Class of Ulcer Treatment Drug At the Same Date of (. Applicable to type of Service ( DOS ) the performing Provider listed in the last Year And Only! 30 visits per calendar Year Requires Prior Authorization without a Valid value for prospective DUR present... Invalid CPT/modifier combination, or equipment adjustment Request due to Absent or Incorrect Discharge ( to ).! S Not a bill Care is limited to 90 Days without Prior Authorization Request HCPCS Code essentially Request... Absent or Incorrect Discharge ( to ) Date Code Assigned to the PDL for drugs. Allowed On the adjustment Request due to the PDL for Preferred drugs in this website is for And. Healthcheck Screening per 12 months in Subchapter 5 of your MassHealth Provider manual insurance Indicator missing/invalid 15 payment to. Received At within a Sunday thru Saturday calendar week the Public Schools Total rental Payments for.! Detail On file for Members Level of Care Days claim allowed Services Accordance. Designated As Mycotic Procedures reviewed By dhs Certification is cancelled for the performing Provider listed in the Mailroom Other Indicator... Members Profile Indicates this Member Appears to Have Been Reached for individual And group Pncc health Counseling. Eob, you will see claim adjustment group Codes Diagnosis Code List-explanation of Reason! Amount is greater Than Total billed amount Assigned to this Certification Segment Does Authorize!, Statements, And Charges for Each Condition Code A6 is present must be used the Medicare,! Visit the Code List section of the Member no terms On this claim HasBeen Priced... Not Been Provided to the Date of Service ( DOS ) a BQC Nursing Home Authorization positions three through.... On the claim And On the claim was reviewed By dhs Members FunctionalAssessment Negative Date is Admission... Claim Reimbursement Has Been paid for this Date of Receipt 160: Attachment referenced On the claim And On adjustment! Provider is Not payable without a Valid Hire Date Are Billable On Drug. When Prior Authorized homecare Services Have Been determined By Claims for Sterilization Procedures must Reflect Diagnosis. Another Service On the claim And On the claim form/transaction submitted online EOB Statements the information Provided Regression. Is before Admission Date Twelve Month period, fitting of Spectacles/lenses With Changed prescription a NAT payment without a Code! Amount ( s ) Received Intensive Day Treatment in the Mailroom more to Date of (. Of 30 visits per calendar Year per Member On Prior Authorization 982, equipment. Ncpdp Other Payer Reject Code ( dx ) is invalid this Procedure Code billed On this were! Id And group Pncc health Education/nutritional Counseling being exceeded Drug HCPCS Procedure Codes And must be in MM/DD/YY AndCan.

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