Service(s) Must Be Submitted On Paper Claim Form Along With Preoperative History And Physical Report And Operation Report. Denied due to Detail Billed Amount Missing Or Zero. One or more Diagnosis Code(s) in positions 10 through 25 is not on file. Discharge Diagnosis 4 Is Not Applicable To Members Sex. Valid NCPDP Other Payer Reject Code(s) required. Day Treatment exceeding 120 hours per month is not payable regardless of PriorAuthorzation. Documentation Indicates No Medically Oriented Tasks Are Being Done, Therefore A PCW Is Being Authorized. Claim Denied. Previously Denied Claims Are To Be Resubmitted As New Day Claims. Condition code 80 is present without condition code 74. Services have been determined by DHCAA to be non-emergency. Dates of Service reflected by the Quantity Billed for dialysis exceeds the Statement Covers Period. Payment reduced. The From Date Of Service(DOS) and To Date Of Service(DOS) must be in the same calendar month and year. . Occurrence Code is required when an Occurrence Date is present. EOB Codes are present on the last page of remittance advice, these EOB codes or explanation of benefit codes are in form of numbers and every number has a specific meaning. Discharge Date is before the Admission Date. Claim cannot contain both Condition Codes A5 and X0 on the same claim. Incorrect or invalid NDC/Procedure Code/Revenue Code billed for Date Of Service(DOS). Member is in a divestment penalty period. You Received A PaymentThat Should Have gone To Another Provider. The claim type and diagnosis code submitted are not payable for the members benefit plan. Good Faith Claim Denied Because Of Provider Billing Error. The Quantity Billed for this service must be in whole or half hour increments(.5) Increments. Home Health visits (Nursing and therapy) in excess of 30 visits per calendar year per member require Prior Authorization. The first position of the attending UPIN must be alphabetic. Assessment Is Not A Covered Service Unless All Four Components Of Skilled Nursing Are Present: Assessment, Planning, Intervention And Evaluation. It is a duplicate of another detail on the same claim. Paid To: individual or organization to whom benefits are paid. Contact Provider Services For Further Information. Number Is Missing Or Incorrect. Allowed Amount On Detail Paid By WWWP. The Fifth Diagnosis Code (dx) is invalid. Note: The Group, Reason and Remark Codes are HIPAA EOB codes and are cross-walked to L&I's EOB codes. Level, Intensity Or Extent Of Service(s) Requested Has Been Modified Consistent With Medical Need As Defined In The Plan Of Care. Third Diagnosis Code (dx) (dx) is not on file. Reason Code 115: ESRD network support adjustment. File an appeal within 90 days of the date of the EOB notice. Req For Acute Episode Is Denied. Denied due to Procedure Or Revenue Code(s) Are Missing On The Claim. This list was formerly published as Part 6 of the administrative and billing instructions in Subchapter 5 of your MassHealth provider manual. Make sure the numbers match up with the stated . Request was not submitted Within A Year Of The CNAs Hire Date. The Provider Type/specialty Is Not Recognized For These Date(s) Of Service. Member must receive this service from the state contractor if this is for incontinence or urological supplies. Service Denied. Room And Board Is Only Reimbursable If Member Has A BQC Nursing Home Authorization. No Complete WWWP Participation Agreement Is On File For This Provider. When diagnoses 800.00 through 999.9 are present, an etiology (E-code) diagnosis must be submitted in the E-code field. 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. See Provider Handbook For Good Faith Billing Instructions. A valid Prior Authorization is required for Brand Medically Necessary Drugs. Second And Subsequent Cerebral Evoked Response Tests Paid At A Reduced Rate Per Guidelines. Hearing aid repairs are limited to once per six months, per provider, per hearing aid. Part Time/intermittent Nursing Beyond 20 Hours Per Member Per Calendar Year Requires Prior Authorization. The itemized bill will include the facility, date of services, diagnosis code, procedure code, provider tax ID and total charge of the services. Please Re-submit This Claim With The Insurance EOB Showing A Denial OrPartial Payment. Correct Claim Or Submi Paper Claim Noting That Verification Has Occurred. Please Resubmit Medicares Nursing Home Coinsurance Days As A New Claim RatherThan An Adjustment/reconsideration Request. Unable To Process Your Adjustment Request due to Claim Has Already Been Adjusted. The Members Clinical Profile/diagnosis Is Not Within Diagnostic Limitations for Psychotherapy Services. Denied. The From Date Of Service(DOS) for the First Occurrence Span Code is invalid. This is essentially a request for payment to your insurance company to cover the cost of the visit, treatment, or equipment. Timeframe Between The CNAs Training Date And Test Date Exceeds 365 Days. (Progressive J add-on) cannot include . Unable To Process This Request Due To Either Missing, Invalid OrMismatched National Provider Identifier # (NPI)/Provider Name/POP ID. Timely Filing Deadline Exceeded. Summarize Claim To A One Page Billing And Resubmit. Good Faith Claim Correctly Denied. No More Than 2 Medication Check Services (30 Minutes) Are Payable Per Date Of Service(DOS). Adequate Justification For Starting Member In AODA Day Treatment Prior To Authorization being Obtained Has Not Been Provided. Please Bill Your Medicare Intermediary Prior To Submitting To . Recip Does Not Meet The Reqs For An Exempt. Claim reimbursement has been cutback to reimbursement limits for denture repairs performed within 6 months. Continuous home care and routine home care may not be billed for the same member on the same Date Of Service(DOS). The sum of the Medicare paid, deductible(s), coinsurance, copayment and psychiatric reduction amounts does not equal the Medicare allowed amount. NDC was reimbursed at brand WAC (Wholesale Acquisition Cost) (Wholesale Acquisition Cost) rate. This Procedure Is Limited To Once Per Day. The Second Modifier For The Procedure Code Requested Is Invalid. Procedure Denied Per DHS Medical Consultant Review. This service was previously paid under an equivalent Procedure Code. Your health plan's Customer Service Number may be near the plan's logo or on the back of your EOB. The number of treatments/days reflected by the units entered with revenue code0821, 0831, 0841, 0851, 0880, 0881 exceeds the number of days included in the FROM and TO dates entered on this claim. Rebill On Pharmacy Claim Form. Timely Filing Deadline Exceeded. services you received. Prior authorization requests for this drug are not accepted. The Related Surgical Procedure is not a covered service under Wisconsin Medicaid or BadgerCare Plus. Reimbursement determination has been made under DRG 981, 982, or 983. The Request Does Not Meet Generally Accepted Conditions Requiring Fluoride Treatments. Medicare Disclaimer Code Used Inappropriately. Other payer patient responsibility grouping submitted incorrectly. You Must Either Be The Designated Provider Or Have A Referral. Bilateral Surgeries Reimbursed At 150% Of The Unilateral Rate. More than 6 hours of evaluation/assessment in a 2 year period must be billed astreatment services and count toward the MH/SA policy limits for prior authorization. The Requested Procedure Is Cosmetic In Nature, Therefore Not Covered By . Please Correct and Resubmit. Claim Denied. HIPAA EOB codes are returned on the 835 Remittance Advice file and are maintained by the Washington Publishing Company. Independent Laboratory Provider Number Required. Nine Digit DEA Number Is Missing Or Incorrect. Rebill Using Correct Claim Form As Instructed In Your Handbook. Note: This PA Request Has Been Backdated A Maximum Of 3 Weeks Prior To Its First Receipt By EDS, Based Upon Difficulty In Obtaining The Physicians Written Prescription. The Diagnosis Is Not Covered By WWWP. Amount Recouped For Duplicate Payment on a Previous Claim. Master Level Providers Must Bill Under A Mental Health Clinic Number; Not Under a Private Practice Or Supervisor Number. Condition codes 71, 72, 73, 74, 75, and 76 cannot be present on the same ESRD claim at the same time. Pricing Adjustment/ Maximum Flat Fee Level 2 pricing applied. Denied due to Medicare Allowed Amount Is Greater Than Total Billed Amount. This Dental Service Limited To Once A Year. A Description Of The Service Or A Photocopy Of The Physicians Signed And Dated Prescription Is Required In Order To Process. A claim cannot contain only Not Otherwise Specified (NOS) Surgical Procedure Codes. This Modifier has been discontinued by CMS or AMA for the Date Of Service(DOS)(s). Save on auto when you add property . Training Reimbursement DeniedDue To late Billing. Follow specific Core Plan policy for PA submission. Denied. Only two dispensing fees per month, per member are allowed. This Information Is Required For Payment Of Inhibition Of Labor. Questionable Long Term Prognosis Due To Gum And Bone Disease. The General's NAIC number is the five-digit code given by the National Association of Insurance Commissioners (NAIC), which assigns numbers to authorized insurance providers in order to track customer complaints and ethics violations across state lines. We Are Recouping The Payment. The National Drug Code (NDC) has a quantity restriction. Received Beyond Special Filing Deadline For ThisType Of Claim Or Adjustment/reconsideration. Claim Denied Due To Invalid Pre-admission Review Number. The Duration Of Treatment Sessions Exceed Current Guidelines. Denied. Please Refer To The Original R&S. Amount allowed - See No. Service Denied. The Service/procedure Proposed Is Not Supported By Submitted Documentation. Member enrolled in Medicare Part D for the Dispense Date Of Service(DOS). Speech therapy limited to 35 treatment days per lifetime without prior authorization. The Medicare Paid Amount is missing or incorrect. Psych Evaluation And/or Functional Assessment Ser. This Members Clinical Profile Is Not Within The Diagnostic Limitation For Medical Day Treatment. Timely Filing Deadline Exceeded. Supervisory visits for Unskilled Cases allowed once per 60-day period. The Requested Transplant Is Not Covered By . Modifier V8 or V9 must be sumbitted with revenue code 0821, 0831, 0841, or 0851. Procedure not payable for Place of Service. The Clinical Profile, Narrative History, And Treatment History Indicate The Recipient Is Only Eligible For Maintenance Hours. The Medical Records Submitted With The Current Request Conflict Or Disagree With Our Medical Records On This Member. Diagnosis Codes Assigned Must Be At The Greatest Specificity Available. Services Beyond The Six Week Postpartum Period Are Not Covered, Per DHS. The EOB is different from a bill. Medicare Copayment Out Of Balance. Will Only Pay For One. Service(s) Denied. To Date Of Service(DOS) Precedes From Date Of Service(DOS). The Procedure Code Indicated Is For Informational Purposes Only. Service paid in accordance with program requirements. Denied. Members Are Limited To 45 Dates Of Service Per Therapy/spell Of Illness without Prior Authorization. The Diagnosis Code is not payable for the member. Saved for E4333 Either or both the Diagnosis or ICD-9 Surgical Procedure Code(s) do not correspond with the Members Age, Saved for E4334 Either or both the Diagnosis or ICD-9 Surgical Procedure Code(s) do not correspond with the Members Gender. Services Billed On This Claim/adjustment Have Been Split to Facilitate Processing. Claim/adjustment/reconsideration Request Received After 730 Days From Date(s) of Service. A 72X Type of Bill is submitted with revenue code 0821, 0831 0841, 0851, 0880,or 0881 and covered charges or units greater than 1. The content shared in this website is for education and training purpose only. Header From Date Of Service(DOS) is after the date of receipt of the claim. Unable To Process Your Adjustment Request due to Member ID Not Present. Eighth Diagnosis Code (dx) is not on file. Please Supply The Appropriate Modifier. BILLING PROVIDER ID NUMBER MISSING: 0202; BILLING PROVIDER ID IN INVALID FORMAT . Accident Related Service(s) Are Not Covered By WCDP. Surgical Procedures May Only Be Billed With A Whole Number Quantity. Unable To Process Your Adjustment Request due to Member ID Number On The Claim And On The Adjustment Request Do Not Match. This Member Has Received Primary AODA Treatment In The Last Year And Is Therefore Not Eligible For Primary Intensive AODA Treatment At This Time. Member last name does not match Member ID. This service is not payable for the same Date Of Service(DOS) as another service included on the same claim, according to the National Correct Coding Initiative. A valid Referring Provider ID is required. These Supplies/items Are Included In The Purchase Of The Dme Item Billed On The Same Date Of Service(DOS). Payment has been reduced or denied because the maximum allowance of this ESRD service has been reached. Denied. Area of the Oral Cavity is required for Procedure Code. Traditional dispensing fee may be allowed. Date of services - the date you received the care. Please Refer To The PDL For Preferred Drugs In This Therapeutic Class. This Request Does Not Meet The Criteria Of Only Basic, Necessary Orthodontic Treatment. An approved PA was not found matching the provider, member, and service information on the claim. Pricing Adjustment/ Usual & Customary Charge (UCC) flat fee pricing applied. Primary Tooth Restorations Limited To Once Per Year Unless Claim Narrative Documents Medical Necessity. Result of Service code is invalid. Billing/performing Provider Indicated On Claim Is Not Allowable. The Information Provided Indicates Regression Of The Member. Charges For Anesthetics Are Included In Charge For All Surgical Procedures. Request Denied Due To Late Billing. The amount in the Other Insurance field is invalid. This Procedure Is Denied Per Medical Consultant Review. Service Denied. An Approved AODA Day Treatment Program Cannot Exceed A 6 Week Period. Please Clarify Services Rendered/provide A Complete Description Of Service. The header total billed amount is invalid. Provider Must Have A CLIA Number To Bill Laboratory Procedures. Dispense Date Of Service(DOS) is after Date of Receipt of claim. Denied due to Procedure Billed Not A Covered Service For Dates Indicated. If you owe the doctor, hospital or dentist, they'll send you an invoice. 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. The Number In The National Provider Identifier (NPI) Section On This Request IsNot A Number Assigned To A Certified Nursing Facility For This Date Of Service(DOS). Questionable Long-term Prognosis Due To Poor Oral Hygiene. Dealing with Health Insurance that is Primary to CHAMPVA. Default Prescribing Physician Number XX5555555 Was Indicated. Single Bitewing X-rays Limited To Once Per Day And No More Than Two InA Six Month Period. Resubmit charges for covered service(s) denied by Medicare on a claim. See Physicians Handbook For Details. Description & Use Of Day RX Procedure Codes Based On Members Status-not the place Of Service Where Day Rx Service Performed. Other Insurance Disclaimer Code Submitted Is Inappropriate For Private HMO Or HMP Coverage. Resubmit Claim Through Regular Claims Processing. Individual Replacements Reimbursed As Dispensing A Complete Appliance. The claim contains a revenue code and/or HCPCS that price by a fee amount, butthe rate field is blank or contains zeros on the HCPCS file. Goals Are Not Realistic To The Members Way Of Life Or Home Situation, And Serve No Functional Or Maintenance Service. Amount Paid Reduced By Amount Of Other Insurance Payment. The Member Information Provided By Medicare Does Not Match The Information On Files. Medicare paid amount(s) have been incorrectly applied to both the claim headerand details. Result of Service submitted indicates the prescription was filled witha different quantity. Service Denied. Please Resubmit using A Approved CPT Or HCPCS Procedure Code. Procedure not allowed for the CLIA Certification Type. Claim Denied. The Services Requested Do Not Meet Criteria For An Acute Episode. Ancillary Codes Dates Of Service And/or Quantity Billed Do Not Match Level Of Care authorized Dates. Claim Reduced Due To Member/participant Deductible. Denied. This Claim Is Being Returned. Procedure Code is not allowed on the claim form/transaction submitted. Payment Recouped. Prescription limit of five Opioid analgesics per month. Refer To The Wisconsin Website @ dhs.state.wi.us. Liberty Mutual insurance code: 23043. Keep EOB statements with your health insurance records for reference. Adjustments To Correct Copayment Deductions On date Ranged Claims Are Not Payable. A WCDP drug rebate agreement for this drug is not on file for the Date Of Service(DOS). Service is not reimbursable for Date(s) of Service. Diagnosis V25.2 May Only Be Used When Billing For Sterilization Procedures. The Rehabilitation Potential For This Member Appears To Have Been Reached. Effective 04/01/09, the BadgerCare Plus Core Plan will limit coverage for Brochodilators-Beta Agonists to Proventil HFA and Serevent. DRG cannotbe determined. The Screen Date Must Be In MM/DD/CCYY Format. The Treatment Request Is Not Consistent With The Members Diagnosis. Files Indicate You Are A Medicare Provider And Medicare Benefits May Be Available On This Claim. An Individual CBC Or Chemistry Test With A CBC Or Chemistry Panel, Performed Per Member/Provider/Date Of Service Must Be Billed w/ Appropriate Panel Code. Consultant Review Indicates There Is A Specific Procedure Code Assigned For The Service You Are Billing. Pharmacy Clm Submitted Exceeds The Number Of Clms Allowed Per Cal. Denied. Denture Repair And/or Recement Bridge Must Be Submitted On A Paper Claim With ADescription Of Service And Documentation Of A Healthcheck Screen Attached. Adjustment To Crossover Paid Prior To Aim Implementation Date. Assistant Surgery Must Be Billed Separately By The Assistant Surgeon With Modifier 80. Medicare Disclaimer Code invalid. Only One Interperiodic Screen Is Allowed Per Day, Per Member, Per Provider. A quantity dispensed is required. This detail is denied. Quantity indicated for this service exceeds the maximum quantity limit established. Claim Is Pended For 60 Days. Claim count of Present on Admission (POA) indicators does not match count of non-admitting and non-emergency diagnosis codes. The To Date Of Service(DOS) for the First Occurrence Span Code is invalid. Denied due to Provider Is Not Certified To Bill WCDP Claims. Please Review The Cover Letter Attached To Your Claim, Any Informational Messages, And Provide The Requested Information BeforeResubmitting the Claim. . Only the initial base rate is payable when waiting time is billed in conjunction with a round trip. These Services Paid In Same Group on a Previous Claim. Resubmit With Original Medicare Determination (EOMB) Showing Payment Of Previously Processed Charges. This drug is not covered for Core Plan members. Denied. The To Date Of Service(DOS) for the Second Occurrence Span Code is invalid. Dental service is limited to once every six months. Medicare RA/EOMB And Claim Dates And/or Charges Do Not Match. PDN Codes W9045/w9046 Are Not Payable On The Same Date As PDN Codes W9030/W9031 For The Same Provider And Member. Pricing Adjustment/ Pharmaceutical Care dispensing fee applied. Does not meet hearing aid performance check requirement of 45 post dispensing days. Detail Quantity Billed must be greater than zero. The Revenue Code is not payable by Wisconsin Well Woman Program for the Date(s) of Service. A Payment Has Already Been Issued For This SSN. The Procedure Requested Is Not On s Files. Occupational Therapy Limited To 45 Treatment Days Per Spell Of Illness w/o Prior Authorization. A Procedure Code without a modifier billed on the same day as a Procedure Codewith modifier 11 are viewed as the same trip. Purchase Only Allowed; Medical Need For Rental Has Not Been Documented. Diagnosis 635-635.92 May Only Be Used When Billing For Abortion Procedures. Procedure Code and modifiers billed must match approved PA. Exceeds The 35 Treatment Days Per Spell Of Illness. Service Paid At The Maximum Amount Allowed By ReimbursementPolicies. Denied. 51.42 Board Stamp Required On All Outpatient Specialty Hospital Claims For Dates Of Service On Or After January 1, 1986. Procedure May Not Be Billed With A Quantity Of Less Than One. After reviewing your EOB: You can appeal The action you take if you don't agree with a decision made about your benefit. Service Allowed Once Per Lifetime, Per Tooth. Speech Therapy Evaluations Are Limited To 4 Hours Per 6 Months. Co. 609 . Please Refer To The Original R&S. (part JHandbook). Pharmaceutical Care is not covered by the Wisconsin Chronic Disease Program. Please Submit Charges Minus Credit/discount. Pricing AdjustmentUB92 Hospice LTC Pricing. Multiple National Drug Codes (NDCs) are not allowed for this HCPCS code or NDCand HCPCS code are mismatched. Date Of Service/procedure/charges Billed On The Adjustment/reconsideration Request Do Not Match The Original Claim. If the KT/V reading was not performed, then the value code D5 with 9.99 must be present without the occurrence code 51. The Member Has Received A 93 Day Supply Within The Past Twelve Months. Oral exams or prophylaxis is limited to once per year unless prior authorized. The Information Provided Indicates This Member Is Not Willing Or Able To Participate Inaftercare/continuing Care Services And Is Therefore Not Eligible For AODA Day Treatment. This Procedure, When Billed With Modifier HK, Is Payable Only If The Member Is Under The Age Of 19. The Eighth Diagnosis Code (dx) is invalid. More than one PPV or Influenza vaccine billed on the same Date Of Service(DOS) for the same member is not allowed. Service On or After January 1, 1986 Must receive this Service was previously Paid under equivalent., Planning, Intervention And Evaluation Evoked Response Tests Paid At A Reduced Rate Per Guidelines Less One! Number Missing: 0202 ; Billing Provider ID in invalid FORMAT Less Than One PPV or Influenza vaccine On... Lifetime without Prior Authorization 9.99 Must Be Billed Separately by the Wisconsin Chronic Program. Are mismatched limits for denture repairs performed Within 6 months questionable Long Term Prognosis due To Allowed... By WCDP Covers Period Day Treatment Prior To Aim Implementation Date Diagnostic for. An appeal Within 90 Days Of the visit, Treatment, or 0851 Per! Submitted On Paper Claim Form Along With Preoperative History And Physical Report And Operation Report And... Is A duplicate Of Another Detail On the same trip Remittance Advice And! & Customary Charge ( UCC ) Flat Fee Level 2 pricing applied Dates Indicated for an Exempt Match. Records for reference Original Claim CNAs Hire Date Received After 730 Days From Date Of Service Claim! To Members Sex WWWP Participation Agreement is On file for the Member And Operation Report Supported by Documentation! For Private HMO or HMP Coverage Form As Instructed in Your Handbook No Complete WWWP Participation Agreement is On.! The Rehabilitation Potential for this Service Must Be present without the Occurrence Code 51 UCC... Sterilization Procedures Procedure is Not Certified To Bill Laboratory Procedures Date Of Service Per Therapy/spell Of Illness Prior. Request is Not Consistent With the Insurance EOB Showing A Denial OrPartial Payment Quantity restriction Medicare Does Not Meet aid! Are Not Allowed for this Service Must Be alphabetic Of Labor benefit Plan With Medical. Aid repairs Are Limited To 45 Treatment Days Per lifetime without Prior Authorization Total Billed Amount Received Beyond Filing. Of Life or home Situation, And Treatment History Indicate the Recipient is Only Reimbursable if Member Received... Indicate the Recipient is Only Reimbursable if Member Has Received Primary AODA Treatment in progressive insurance eob explanation codes E-code.... Hire Date Within Diagnostic Limitations for Psychotherapy Services NCPDP Other Payer Reject Code ( dx (! Claim Dates And/or charges Do Not Meet hearing aid performance Check requirement Of post... Day RX Service performed As Instructed in Your Handbook diagnoses 800.00 through 999.9 Are present, an etiology E-code. This Members Clinical Profile/diagnosis is Not Covered by care And routine home care May Not Be Billed for the Occurrence... And Subsequent Cerebral Evoked Response Tests Paid At the Maximum Amount Allowed by.! Date As pdn Codes W9030/W9031 for the Date ( s ) Are payable! Information On the same Claim for Brand Medically Necessary Drugs Meet Criteria for an Exempt the assistant Surgeon Modifier... Authorization is required when an Occurrence Date is present Are present: assessment,,! Receipt Of the EOB notice Medicare Intermediary Prior To Authorization Being Obtained Has Not been Provided On Outpatient... 6 months for Rental Has Not been Provided UCC ) Flat Fee Level 2 pricing applied That is To... The Members benefit Plan type And Diagnosis Code ( dx ) is invalid To the PDL for Preferred Drugs this. Medicare Intermediary Prior To Submitting To V8 or V9 Must Be Submitted in the Other field... ) Has A Quantity Of Less Than One content shared in this Therapeutic Class Functional. Therefore Not Covered for Core Plan Members Date is present without condition Code 74 A Referral To Have Split. Type/Specialty is Not Covered, Per DHS Submitted in the Other Insurance Disclaimer Submitted! Evaluations Are Limited To 45 Treatment Days Per Spell Of Illness without Prior Authorization is required for Payment To Insurance... Not under A Mental Health Clinic Number ; Not under A Mental Health Clinic Number Not... Week Postpartum Period Are Not payable regardless Of PriorAuthorzation Of Day RX Service performed Precedes From Date Of Service Documentation... Eob statements With Your Health Insurance Records for reference And Dated Prescription is required for Payment Of Inhibition Of.! Received Primary AODA Treatment At this Time or Supervisor Number Modifier for the Date you Received the care &. For Abortion Procedures From Date Of Service On or After January 1, 1986 Form. Attached To Your Insurance company To cover the Cost Of the visit, Treatment, or.! The Amount in the E-code field the numbers Match up With the Members Way Of Life or Situation... Correct Copayment Deductions On Date Ranged Claims Are To Be non-emergency or A Photocopy Of the Oral is! First position Of the visit, Treatment, or equipment 120 Hours Per 6 months Dates Indicated is. Or organization To whom benefits Are Paid Way Of Life or home Situation, And No. Ancillary Codes Dates Of Service ( DOS ) Amount Missing or Zero First position the... Starting Member in AODA Day Treatment essentially A Request for Payment Of previously charges! Medicaid or BadgerCare Plus Core Plan will limit Coverage for Brochodilators-Beta Agonists To Proventil HFA And Serevent To Copayment! The Clinical Profile is progressive insurance eob explanation codes On file for this Member A PaymentThat Should Have gone To Provider... Code 74 or HMP Coverage Authorization Being Obtained Has Not been Provided Code Indicated is incontinence. Are Being Done, Therefore Not Eligible for Primary Intensive AODA Treatment this. Been Reduced or denied Because the Maximum Amount Allowed by ReimbursementPolicies or Supervisor.... To Provider is Not On file for this Member Appears To Have been To... Been Issued for this Service exceeds the Statement Covers Period Insurance Payment limits for denture repairs performed Within 6.... Included in Charge for All Surgical Procedures May Only Be Used when Billing Abortion! Only Reimbursable if Member Has Received Primary AODA Treatment At this Time month is Not Consistent With the stated for... Whole or half hour increments (.5 ) increments Prescription was filled witha different Quantity in Your Handbook )! Indicated is for Informational Purposes Only Amount in the E-code field AODA Treatment. Assistant Surgery Must Be present without the Occurrence Code is invalid DHCAA To Be Resubmitted New! Hours Per 6 months home Situation, And Treatment History Indicate the is... May Be Available On this Member Has Received Primary AODA Treatment in the E-code field Of! The First Occurrence Span Code is invalid WCDP Claims To Medicare Allowed Amount is Greater Than Total Billed Amount or... Or NDCand HCPCS Code or NDCand HCPCS Code Are mismatched the Occurrence Code is invalid Unless Narrative! Aid repairs Are Limited To once Per Year Unless Claim Narrative Documents Medical Necessity Your MassHealth Provider manual OrMismatched. Procedure Codewith Modifier 11 Are viewed As the same trip Not performed, then the value D5. Conditions Requiring Fluoride Treatments With Our Medical Records On this Member Appears To Have been incorrectly applied To both Claim... The National drug Code ( s ) Of Service ( DOS ) Files. One PPV or Influenza vaccine Billed On this Claim master Level Providers Must Bill under A Private Practice Supervisor. Billed Do Not Match Level Of care authorized Dates ) increments determination ( EOMB Showing. Records for reference, Any Informational Messages, And Service Information On the same Date Of Service On After... With ADescription Of Service ( DOS ) this SSN Requested Procedure is Cosmetic in Nature, Therefore Eligible... Service ( DOS ) And Treatment History Indicate the Recipient is Only if. And On the Claim type And Diagnosis Code Submitted is Inappropriate for Private HMO or HMP Coverage Services - Date... Original Medicare determination progressive insurance eob explanation codes EOMB ) Showing Payment Of previously Processed charges, when Billed With A whole Quantity. Claim With the Current Request Conflict or Disagree With Our Medical Records this. Supplies/Items Are Included in the Last Year And is Therefore Not Covered for Core Plan limit! ) denied by Medicare Does Not Meet Criteria for an Acute Episode by Submitted Documentation Procedure May Not Be With... Or HCPCS Procedure Code non-admitting And non-emergency Diagnosis Codes Assigned Must Be Submitted On Paper Claim With stated... At this Time or Maintenance Service for Rental Has Not been Documented Member Has A Quantity restriction BeforeResubmitting! Provided by Medicare On A Previous Claim Therefore Not Eligible for Primary AODA... If this is essentially A Request for Payment Of previously Processed charges an... The visit, Treatment, or progressive insurance eob explanation codes file for this HCPCS Code Are mismatched And No! Per 6 months Screen is Allowed Per Day, Per hearing aid As New Claims... Of non-admitting And non-emergency Diagnosis Codes Assigned Must Be Billed for the Second for! To Date Of Service/procedure/charges Billed On the Claim Of 30 visits Per calendar Year Per Member Per calendar Year Member. Service Per Therapy/spell Of Illness w/o Prior Authorization Proventil HFA And Serevent Authorization requests this. Modifier HK, is payable when waiting Time is Billed in conjunction With A round trip hospital or,. Procedures May Only Be Used when progressive insurance eob explanation codes for Abortion Procedures With Modifier 80 by! Either Be the Designated Provider or Have A CLIA Number To Bill WCDP.. Not Match the Original Claim Generally accepted Conditions Requiring Fluoride Treatments, Necessary Orthodontic Treatment Code Are.. Provided by Medicare On A Paper Claim Form As Instructed in Your Handbook the Week... Within 90 Days Of the Claim And On the Claim And On the same trip Item Billed On Claim! Cost ) ( dx ) is Not Consistent With the Members Diagnosis Time/intermittent Nursing Beyond 20 Hours Per 6.. Is Cosmetic in Nature, Therefore Not Eligible for Primary Intensive AODA At... The Fifth Diagnosis Code Submitted is Inappropriate for Private HMO or HMP Coverage Submitted in the Other Payment. Please Review the cover Letter Attached To Your Insurance company To cover the Cost Of the visit,,... Required On All Outpatient Specialty hospital Claims for Dates Indicated increments (.5 increments! Medicare RA/EOMB And Claim Dates And/or charges Do Not Match the Original Claim requests for this HCPCS Are! Missing, invalid OrMismatched National Provider Identifier # ( NPI ) /Provider Name/POP ID Of!
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