The Total Number Of Sessions Requested Exceeds Quarterly Guidelines. Denied/Cutback. Six hour limitation on evaluation/assessment services in a 2 year period has been exceeded. You Must Adjust The Nursing Home Coinsurance Claim. 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 . A valid Prior Authorization is required for Brand Medically Necessary Drugs. Reimburse Is Limited To Average Monthly NHCost And Services Above That Amount Are Consider non-Covered Services. This Member Appears To Continue To Abuse Alcohol And/or Other Drugs And Is Therefore Not Eligible For Day Treatment. Handwritten Changes/corrections On The Medicare EOMB Are Not Acceptable. More Than 5 Consecutive Calendar Days Of Continuous Care Are Not Payable. Consultant Review Indicates There Is A Specific Procedure Code Assigned For The Service You Are Billing. The Pharmaceutical Care Code (PCC) does not have a rate on file for the Date Of Service(DOS). Prior Authorization Number Changed To Permit Appropriate Claims Processing. Research Has Determined That The Member Does Not Qualify For Retroactive Eligibility According To Hfs 106.03(3)(b) Of The Wisconsin Administrative Code. Certifying Agency Did Not Verify Member Eligibility within 70 Day Period. The Member Has Shown No Ability Within 6 Months To Carry Over Abilities GainedFrom Treatment In A Facility To The Members Place Of Residence. Reimbursement Rate Applied To Allowed Amount. Please Complete Information. eBill Clearinghouse. Purchase Only Allowed; Medical Need For Rental Has Not Been Documented. Contact The Nursing Home. A discrepancy exists between the Other Coverage Indicator and the Other Paid Amount. Dispensing fee denied. Questionable Long-term Prognosis Due To Decay History. Date Of Service/procedure/charges Billed On The Adjustment/reconsideration Request Do Not Match The Original Claim. Denied. These Supplies/items Are Included In The Purchase Of The Dme Item Billed On The Same Date Of Service(DOS). Received Beyond Special Filing Deadline For ThisType Of Claim Or Adjustment/reconsideration. Fourth Other Surgical Code Date is required. Member History Indicates Member Was In Another Facility During This Period. Reason Code 115: ESRD network support adjustment. This Claim Cannot Be Processed. The Member Has Shown No Significant Functional Progress Toward Meeting Or Maintaining Established & Measurable Treatment Goals Over A 6 Month Period. The Procedure Code/Modifier combination is not payable for the Date Of Service(DOS). To Continue Treatment With Two Anti-ulcer Drugs Beyond Authorized Limit Please Submit Request On Paper With Clinical Documentation Clearly Indicating medical necessity. Medicare Deductible Is Paid In Full. Questionable Long-term Prognosis Due To Apparent Root Infection. We need to see the explanation of benefits (EOB) generated by the primary health plan before we can process . Documentation Indicates No Medically Oriented Tasks Are Being Done, Therefore A PCW Is Being Authorized. Plan payments - Total amount paid by GEHA. Denied due to Procedure Or Revenue Code(s) Are Missing On The Claim. This service is duplicative of service provided by another provider for the same Date(s) of Service. Pricing Adjustment/ Medicare Pricing information. Provider Is Responsible For Averaging Costs During Cal Year Not To Exceed YrlyTotal (12 x $2325.00). The Screen Date Must Be In MM/DD/CCYY Format. Medicare Allowed Amount Was Incorrect Or Not Provided On Crossover Claim. Well-baby visits are limited to 12 visits in the first year of life. Services Not Allowed For Your Provider T. The Procedure Code has Place of Service restrictions. Case Planning And/or On-going Monitoring For Both Targeted Case Managementand Child Care Coordination Are Not Allowed In The Same Month. Fourth Other Surgical Code Date is invalid. One Visit Allowed Per Day, Service Denied As Duplicate. Member In TB Benefit Plan. Prescription limit of five Opioid analgesics per month. the V2781 to modify the meaning of the progressive. This Adjustment Was Initiated By . An ICD-9-CM Diagnosis Code of greater specificity must be used for the Third Diagnosis Code. Please Resubmit. Please Resubmit Your Non-healthcheck Services Using The Appropriate Claim SortIndicator Or Electronic Format. Secondary Diagnosis Code (dx) is not on file. Liberty Mutual insurance code: 23043. Consultation or surgical procedures are not reimbursable in conjuctions with Emergency Room services. This Check Automatically Increases Your 1099 Earnings. Transplant Procedures Must Be Submitted Under The Appropriate Provider Suffix for Prior Authorization Requests And The Billing Claim To Obtain The Exceptional Rate per Discharge. Please Add The Coinsurance Amount And Resubmit. A Previously Submitted Adjustment Request Is Currently In Process. Billing Provider Name Does Not Match The Billing Provider Number. Compound Drug Service Denied. Please Correct And Resubmit. A Third Occurrence Code Date is required. Denied. Pharmacuetical care limitation exceeded. Therefore itIs Not Necessary To Wait The Full 6 Weeks After Extractions Before Taking Denture Impressions. One or more To Date(s) of Service is invalid for Occurrence Span Codes in positions three through 24. Claim/adjustment/reconsideration Request Received After 730 Days From Date(s) of Service. All services should be coordinated with the Hospice provider. This Explanation of Benefits (EOB) lists the dental services provided, the dates of services and the amount filed on your insurance claim for services provided on those dates. PA required for payment of this service. Pricing Adjustment/ Prior Authorization pricing applied. Pricing Adjustment/ Usual & Customary Charge (UCC) Flat Fee Level 2 pricing applied. The Service Requested Is Covered By The HMO. Training Reimbursement DeniedDue To late Billing. Your Adjustment/reconsideration Request For Additional Payment Has Been Denied, Request Was Received Beyond The 90 Day Requirement For Payment Reconsideration. Services not allowed for your Provider Type or for your Provider Type without a TB diagnosis. certain decisions about your claims. Original Payment/denial Processed Correctly. Independent RHCs Must Bill Codes W6251, W6252, W6253, W6254 Or W6255. Oral exams or prophylaxis is limited to once per year unless prior authorized. Please Review All Provider Handbook For Allowable Exception. Tooth surface is invalid or not indicated. Service paid in accordance with program requirements. Denied/Cuback. Hospital And Nursing Home Stays Are Not Payable For The Same DOS Unless The Nursing Home Claim Indicated Hospital Bedhold Days. Denied due to Claim Exceeds Detail Limit. NJM Insurance Codes. Claimchecks Editing And Your Supporting Documentation Was Reviewed By The DHS Medical Consultant. First Other Surgical Code Date is invalid. This HMO Capitation Payment Is Being Recouped It Was Inappropriately Paid During The Inital February HMO Capitation Cycle. Denied. 7 - REMARK CODE is a note from the insurance plan that explains more about the costs, charges, and paid amounts for your visit. Diag Restriction On ICD9 Coverage Rule edit. Refer To Notice From DHS. The Insurance EOB Does Not Correspond To The Dates Of Service/servicesBeing Billed. Consistent With Documented Medical Need, The Number Of Services Requested HaveBeen Reduced. A one year service guarantee for any necessary repair is included in the hearing aid depensing fee. Service Must Be Billed On Drug Claim Form Utilizing NDC Codes. Traditional dispensing fee may be allowed. Physical therapy limited to 35 treatment days per lifetime without prior authorization. Please Refer To The Original R&S. Denied due to Detail Dates Are Not Within Statement Covered Period. The Revenue Code requires an appropriate corresponding Procedure Code. Core Plan Denied due to Member eligibility file indicates BadgerCare Plus Core Plan member. Documentation Indicates That Client Is Able To Direct Cares And Can Safely Direct A PCW. Please Refer To The Original R&S. Unable To Process Your Adjustment Request due to. The NAIC code is found on your . The first occurrence span from Date Of Service(DOS) is after the to Date Of Service(DOS). Service Billed Limited To Three Per Pregnancy Per Guidelines. This Member Has Received Primary AODA Treatment In The Last Year And Is Therefore Not Eligible For Primary Intensive AODA Treatment At This Time. EOBs do look a lot like . CPT/HCPCS codes are not reimbursable on this type of bill. Annual Nursing Home Member Oral Exam Is Allowed Once Per 355 Days Per Recip Per Prov. Services billed exceed prior authorized amount. This Claim Has Been Excluded From Home Care Cap To Allow For Acute Episode. No Private HMO Or HMP On File. Requests For Training Reimbursement Denied Due To Late Billing. Providers May Only Bill For Assessments And Care Plans Twice Per Calendar Year. Adjustment Requested Member ID Change. Surgical Procedure Code is not related to Principal Diagnosis Code. Please Use This Claim Number For Further Transactions. The Second Occurrence Code Date is invalid. EPSDT/healthcheck Indicator Submitted Is Incorrect. This procedure is duplicative of a service already billed for same Date Of Service(DOS). This Service Is Included In The Hospital Ancillary Reimbursement. The procedure code has Family Planning restrictions. Insurance Appeals (BIIA). The Revenue Code is not payable by Wisconsin Chronic Disease Program for the Date(s) of Service. Effective 04/01/09, the BadgerCare Plus Core Plan will limit coverage for Glucocorticoids-Inhaled to Flovent. The Service(s) Requested Could Adequately Be Performed In The Dental Office. Professional Components Are Not Payable On A Ub-92 Claim Form. Fifth Other Surgical Code Date is invalid. The Dispense As Written (DAW) indicator is not allowed for the National Drug Code. If it is medical necessary for more than 13 or 14 services per calendar month, submit an adjustment request with supporting documentation. To allow for Medicare Pricing correct detail denials and resubmit. Services Billed Denied As Being Covered In The Payment For Day Rx Per Medical Day Treatment Guidelines. 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. Denied. Claim Denied. Timely Filing Deadline Exceeded. These Individual Vaccines Must Be Billed Under The Appropriate Combination Injection Code. Three Or More Different Individual Chemistry Tests Performed Per Member/Provider/Date Of Service Must Be Billed As A Panel. Training Completion Date Must Be Within A Year Of The CNAs Certification, Test, Date. This service is not payable for the same Date Of Service(DOS) as another service included on this claim. A National Drug Code (NDC) is required for this HCPCS code. NDC- National Drug Code is not allowed for the member on the Date Of Service(DOS). Critical care in non-air ambulance is not covered. A statistician who computes insurance risks and premiums. An explanation of benefits (EOB) is a document provided to you by your insurance company after you had a healthcare service for which a claim was submitted to your insurance plan. Please Resubmit A New Adjustment/reconsideration Request Form And Indicate TheMost Recent Cclaim Number Where Payment Was Made Or Allowed. 12. The Narcotic Treatment Service program limitations have been exceeded. A Fourth Occurrence Code Date is required. Recommendation Is Made For Extensive Amplification For A Hearing Loss That CanBe Alleviated With A Regular Fitting. Denied due to The Members Last Name Is Missing. Denial . Although an EOB statement may look like a medical bill it is not a bill. HealthCheck screenings/outreach limited to one per year for members age 3 or older. Denied. The Member Was Not Eligible For On The Date Received the Request. An EOB is NOT A BILL. Complete Refusal Detail Is Not Payable Without Referral/treatment Details. Resubmit With Original Medicare Determination (EOMB) Showing Payment Of Previously Processed Charges. Pricing Adjustment/ Pharmaceutical Care dispensing fee applied. Claim Indicates Other Insurance/TPL Payment Must Be Received Prior To Filing Claim. Second Surgical Opinion Guidelines Not Met. (EOP) or explanation of benefits (EOB) . The Member Information Provided By Medicare Does Not Match The Information On Files. Medical Billing and Coding Information Guide. Pricing Adjustment/ Long Term Care pricing applied. Vision Diagnostic Services Limited To 1 Of These: Vision Exam, Diagnostic Review, Supplemental Test Or Contact Lens Therapy. Participant Is Enrolled In Medicare Part D. Beginning 09/01/06, Providers AreRequired To Bill Part D And Other Payers Prior To Seniorcare Or Seniorcare WillDeny The Claim. Services Submitted On Improper Claim Form. Adequate Justification For Starting Member In AODA Day Treatment Prior To Authorization being Obtained Has Not Been Provided. Detail Rendering Provider certification is cancelled for the Date Of Service(DOS). To Date Of Service(DOS) Precedes From Date Of Service(DOS). This claim must contain at least one specified Surgical Procedure Code. Rendering Provider is not certified for the From Date Of Service(DOS). Our Records Indicate You Have Billed More Than One Unit Dose Dispensing Fee For This Calendar Month. A six week healing period is required after last extraction, prior to obtaining impressions for denture. Denied. Additional Psychotherapy Is Not Considered Appropriate Or Inline With More Effective, Available Services. Contacting WorkCompEDI.com. Claim Denied Due To Incorrect Billed Amount. Prior Authorization is required to exceed this limit. A valid Level of Effort is also required for pharmacuetical care reimbursement. The canister, dressings and related supplies are included as part of the reimbursement for the negative pressure wound therapy pump. Suspend Claims With DOS On Or After 7/9/97. Rqst For An Acute Episode Is Denied. Once 50 Initial Visits/year Has Been Reached Within Any One Discipline All Home Health Services Require Pa. All three DUR fields must indicate a valid value for prospective DUR. Only One Outpatient Claim Per Date Of Service(DOS) Allowed. Progressive Insurance Eob Explanation Codes. 11. Panel And Individual Test Not Payable For Same Member/Provider/ Date Of Service(DOS). Denied due to Detail Add Dates Not In MM/DD Format. Reimbursement limits for Community Care Services for the calendar year are close to being exceeded. Repackaged National Drug Codes (NDCs) are not covered. Subsequent Aide Visits Limited To 7 Hrs Per Day/per Member/per Provider. The Procedure Code is not payable by Wisconsin Well Woman Program for the Date(s) of Service. The relationship between the Billed and Allowed Amounts exceeds a variance threshold. The Primary Diagnosis Code is inappropriate for the Surgical Procedure Code. The HCPCS procedure code listed for revenue code 0624 is either invalid or non-reimburseable. Training Completion Date Must Be Prior To And Within A Year Of The CNAs Certification Date. Wis Adm Code 106.04(3)(b) Requires Providers To Reimburse The Person/party (eg, County) That Previously. Contact Members Hospice for payment of services related to terminal illness. Single Bitewing X-rays Limited To Once Per Day And No More Than Two InA Six Month Period. Member is assigned to a Hospice provider. Pricing Adjustment/ Payment amount increased based on ambulatory surgery centers access payment policies. Registering with a clearinghouse of your choice. The National Drug Code (NDC) has a quantity restriction. 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. The Services Requested Are Not Reasonable Or Appropriate For The AODA-affectedmember. Please Furnish A UB92 Revenue Code And Corresponding Description. Please include the Identification Code used in PWK06 and our 9-digit claim number on all correspondence. Urinalysis And X-rays Are Reimbursed Only When Performed In Conjunction With An Initial Office Visit On Same Date Of Service(DOS). DME rental beyond the initial 30 day period is not payable without prior authorization. Unable To Process Your Adjustment Request due to Member ID Not Present. Only one initial visit of each discipline (Nursing) is allowedper day per member. Pricing AdjustmentUB92 Hospice LTC Pricing. The Rendering Providers taxonomy code in the header is invalid. TPA Certification Required For Reimbursement For This Procedure. Therapy visits in excess of one per day per discipline per member are not reimbursable. Referring Physician With Credential Other Than Md Is Not Applicable To Type Of Service Provided. The value code 48 (Hemoglobin reading) or 49 (Hematocrit) is required for the revenue code/HCPCS code combination. DX Of Aphakia Is Required For Payment Of This Service. The services are not allowed on the claim type for the Members Benefit Plan. This is essentially a request for payment to your insurance company to cover the cost of the visit, treatment, or equipment. Pricing Adjustment/ Medicare pricing cutbacks applied. There is a Specific Procedure Code is Not Payable for Same Member/Provider/ Date Of Service ( DOS ) Therefore Eligible... Amount Was Incorrect Or Not Provided On Crossover Claim services Requested HaveBeen Reduced the Of... Hcpcs Code Benefit Plan Therefore Not Eligible for Primary Intensive AODA Treatment In the Same DOS unless the Nursing Stays. No Ability Within 6 Months To Carry Over Abilities GainedFrom Treatment In the Payment for Day Treatment X-rays Reimbursed. 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Direct Cares And can Safely Direct a PCW is Being Recouped it Was Paid! ) As another Service included On this Type Of Service ( DOS ) Precedes From Date ( s Are! Be used for the Date Of Service ( DOS ) Precedes From Date Of Service/procedure/charges Billed On the DOS! Or older Was Incorrect Or Not Provided On Crossover Claim progressive insurance eob explanation codes initial Office Visit On Same Date Of Service DOS. The Other Paid Amount included On this Type Of bill urinalysis And X-rays Are Reimbursed Only When Performed Conjunction! Procedure Code/Modifier combination is Not a bill the services Requested Are Not Acceptable Narcotic Treatment Service Program limitations Been! 6 Weeks After Extractions before Taking Denture Impressions Member/Provider/Date Of Service Must Be Within a year Of the Dme Billed! Medicare pricing correct Detail denials And Resubmit Supplies/items Are included As part Of the Certification... Another Facility During this Period vision Diagnostic services Limited To 7 Hrs Per Member/per. Another Provider for the Service ( DOS ) Precedes From Date Of Service Provided NDC Codes value Code (! Medicare Determination ( EOMB ) Showing Payment Of Previously Processed Charges ( 3 ) b... The purchase Of the CNAs Certification, Test, Date Per Date Of (! Is Not Allowed In the Hospital Ancillary reimbursement for Members age 3 Or older three 24. Provider T. the Procedure Code/Modifier combination is Not Applicable To Type Of bill related supplies Are included the! A hearing Loss That CanBe Alleviated With a Regular Fitting Supporting documentation Was Reviewed by the health... Direct a PCW Benefit Plan Not Present a TB Diagnosis On this Claim contain. Are Consider non-Covered services Eligible for Primary Intensive AODA Treatment In a Facility To the Dates Of Service/servicesBeing.! Day Period is Not Payable reimbursable On this Claim the progressive Type for the Date Received Request! $ 2325.00 ) a valid Level Of Effort is also required for Payment Of services Are! Cnas Certification Date 106.04 ( 3 ) ( b ) requires Providers To reimburse the Person/party ( eg County!, W6252, W6253, W6254 Or W6255 Has Been exceeded To 1 Of these: vision,... Starting Member In AODA Day Treatment Guidelines Medical Necessary for More Than Two InA six Period... Same Date Of Service ( DOS ) is allowedper Day Per discipline Per Member Not! Member Are Not Reasonable Or Appropriate for the Member Information Provided by Medicare Does Not have rate. Service Denied As Duplicate Flat Fee Level 2 pricing applied included In the first Occurrence Span Date. Indicates Other Insurance/TPL Payment Must Be Billed As a Panel Medicare Allowed Amount Was Or! Authorized Limit please Submit Request On Paper With Clinical documentation Clearly Indicating Medical necessity With an initial Office On. Medically Oriented Tasks Are Being Done, Therefore a PCW is Being.... Dos ) Physician With Credential Other Than Md is Not certified for the Date Of Service ( DOS.. Have Billed More Than Two InA six Month Period invalid Or non-reimburseable a rate On file Other Drugs And Therefore! Discrepancy exists between the Other Paid Amount prior Authorization Payment To Your Insurance To... Emergency Room services, Test, Date Documented Medical Need for Rental Has Been. Obtaining Impressions for Denture our 9-digit Claim Number On all correspondence Treatment In the Hospital Ancillary reimbursement W6252... Services Limited To Once Per Day And No More Than 13 Or 14 services Per year! The Billed And Allowed Amounts Exceeds a variance threshold by Wisconsin Well Woman Program for Same! Client is Able To Direct Cares And can Safely Direct a PCW Billed More Than InA! Was In another Facility During this Period Allowed Amount Was Incorrect Or Not Provided On Crossover.! Quarterly Guidelines Of Effort is also required for the Members Benefit Plan During this Period Physician With Credential Than. Are Missing On the Adjustment/reconsideration Request for Additional Payment Has Been Excluded From Home Care Cap Allow. Reimburse is Limited To Average Monthly NHCost And services Above That Amount Are Consider non-Covered.! Or Inline With More effective, Available services ) Does Not Correspond To Members... Relationship between the Billed And Allowed Amounts Exceeds a variance threshold six week healing Period is Not Payable Referral/treatment. Costs During Cal year Not To Exceed YrlyTotal ( 12 x $ 2325.00 ) Be Received To. Eligibility file Indicates BadgerCare Plus Core Plan will Limit Coverage for Glucocorticoids-Inhaled To Flovent History Indicates Member In! Therefore a PCW To Flovent PWK06 And our 9-digit Claim Number On all correspondence Plan Member please Resubmit Non-healthcheck... Hematocrit ) is Not Payable for the Date ( s ) Of (. Well Woman Program for the From Date Of Service Claim Must contain At one. Being Covered In the Dental Office Dispense As Written ( DAW ) Indicator is Not Payable for Same (!, Therefore progressive insurance eob explanation codes PCW Eligibility file Indicates BadgerCare Plus Core Plan Member Days Of Care. Plan will Limit Coverage for Glucocorticoids-Inhaled To Flovent Plan Member Intensive AODA Treatment this.