Please Submit On The Cms 1500 Using The Correct Hcpcs Code. Denied. Crossover Claims/adjustments Must Be Received Within 180 Days Of The Medicare Paid Date. Condition code must be blank or alpha numeric A0-Z9. Newborn Care Must Be Billed Under Newborn Name And Number; Occurrence Codes 50& 51 Cannotbe Present if Billing Under Newborn Name. this Procedure Code Is Denied As Mutually Exclusive To Another Code Billed On This Claim. Consistent With Documented Medical Need, The Number Of Services Requested HaveBeen Reduced. Denied. This Claim Is Being Returned. Claim Denied For No Client Enrollment Form On File. Ancillary Codes Dates Of Service And/or Quantity Billed Do Not Match Level Of Care authorized Dates. Purchase of a blood glucose monitor includes the first 30 days of supplies for the monitor. The Request Can Only Be Backdated Up To 5 Working Days Prior To The Date Eds Receives The Request In Eds Mailroom If Adequate Justification Is Provided. Denied due to Prescription Number Is Missing Or Invalid. Payment may be reduced due to submitted Present on Admission (POA) indicator. Quantity Billed is restricted for this Procedure Code. Submit Claim To Other Insurance Carrier. Please Correct And Resubmit. This Payment Is To Satisfy The Amount Owed For OBRA Nurse Aid Training. Drug Dispensed Under Another Prescription Number. READING YOUR EXPLANATION OF BENEFITS (EOB) go.cms . Has Processed This Claim With A Medicare Part D Attestation Form. Verify billed amount and quantity billed. Combine Like Details And Resubmit. 10. Ninth Diagnosis Code (dx) is not on file. Healthcheck screenings or outreach limited to three per year for members between the age of one and two years. Denied due to The Members First Name Is Missing Or Incorrect. A Training Payment Has Already Been Issued To A Different NF For This CNA. It Corrects Claim Information Found During Research Of An OBRA Drug Rebate Dispute. 93000: Electrocardiogram . The Medical Need For This Service Is Not Supported By The Submitted Documentation. Pharmaceutical care indicates the prescription was not filled. Pharmaceutical care code must be billed with a valid Level of Effort. Services Billed Denied As Being Covered In The Payment For Day Rx Per Medical Day Treatment Guidelines. Area of the Oral Cavity is required for Procedure Code. This Claim HasBeen Manually Priced Using The Medicare Coinsurance, Deductible, And Psyche RedUction Amounts As Basis For Reimbursement. Individual Replacements Reimbursed As Dispensing A Complete Appliance. The From Date Of Service(DOS) for the First Occurrence Span Code is invalid. The Type Of Psychotherapy Service Requested For This Member Is Considered To be Professionally Unacceptable, Unproven And/or Experimental. It Must Be In MM/DD/YY FormatAnd Can Not Be A Future Date. Paid In Accordance With Dental Policy Guide Determined By DHS. Other Insurance Disclaimer Code Invalid. Service Denied A Physician Statement (including Physical Condition/diagnosis) Must Be Affixed To Claims For Abortion Services Refer To Physician Handbook. This Claim Has Been Denied Due To A POS Reversal Transaction. Speech therapy limited to 35 treatment days per lifetime without prior authorization. One Visit Allowed Per Day, Service Denied As Duplicate. Denied due to Medicare Allowed, Deductible, Coinsurance And Paid Amounts Do Not Balance. 0395 HEADER STATEMENT COVERS PERIOD "FROM" DATE MISSING. Good Faith Claim Has Previously Been Denied By Certifying Agency. Resubmit Private Duty Nursing Services For Complex Children With Documentation Supporting The Level Of Care. Birth to 3 enhancement is not reimbursable for place of service billed. Normal delivery reimbursement includes anesthesia services. Or, if you'd like, you can seek care from a network of medical providers that may offer reduced rates to Progressive customers. 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. The billing provider number is not on file. The Provider Type/specialty Is Not Recognized For These Date(s) Of Service. The Surgical Procedure Code is not payable for /BadgerCare Plus for the Date Of Service(DOS). Pricing Adjustment/ Maximum Allowable Fee pricing used. Other Medicare Part A Response not received within 120 days for provider basedbill. An NCCI-associated modifier was appended to one or both procedure codes. Inpatient mental health services performed by masters level psychotherapists or substance abuse counselors are not covered. Denied. Understanding Insurance Codes To Avoid Billing Errors - Verywell . Case Planning And/or On-going Monitoring For Both Targeted Case Managementand Child Care Coordination Are Not Allowed In The Same Month. Member Successfully Outreached/referred During Current Periodicity Schedule. See Physicians Handbook For Details. Timely Filing Deadline Exceeded. Please Supply Modifier Code(s) Corresponding To The Procedure Code Description. Third Other Surgical Code Date is invalid. The Maximum Allowable Was Previously Approved/authorized. Eyeglasses limited to original plus 1 replacement pair, lens or frame in 12 wit hout Prior Authorization. Explanation Examples; ADJINV0001. The Functional Assessment And/or Progress Status Report Does Not Indicate Any Change, and/or Positive Rehabilitation Potential. Competency Test Date Is Not A Valid Date. Claim count of Present on Admission (POA) indicators does not match count of non-admitting and non-emergency diagnosis codes. Medicare Deductible Amount Was Incorrect Or Not Provided On Crossover Claim. Complex Care Services Are Limited To One Per Date Of Service(DOS) Per Member. No policy override available for BadgerCare Plus Benchmark Plan, Core Plan or Basic Plan. The From Date Of Service(DOS) and To Date Of Service(DOS) must be in the same calendar month and year. Service Denied. The Billing Providers taxonomy code is invalid. A National Provider Identifier (NPI) is required for the Rendering Provider listed in the header. Training CompletionDate Exceeds The Current Eligibility Timeline. Four X-rays are allowed per spell of illness per provider. The Revenue Code requires an appropriate corresponding Procedure Code. Please Resubmit Using Newborns Name And Number. This claim did not include the Plan ID, therefore we assigned TXIX as the Plan ID for this claim. This Service Is Included In The Hospital Ancillary Reimbursement. Dental X-rays Indicate A Dental Cleaning, Followed By Good Dental Care At Home, Would Be Sufficient To Maintain Healthy Gums. Continuous home care and routine home care may not be billed for the same member on the same Date Of Service(DOS). Billing Provider Name Does Not Match The Billing Provider Number. Dispensing fee denied. Denied due to Claim Exceeds Detail Limit. Please submit claim to BadgerRX Gold. To Continue Treatment With Two Anti-ulcer Drugs Beyond Authorized Limit Please Submit Request On Paper With Clinical Documentation Clearly Indicating medical necessity. Denied due to Procedure/Revenue Code Is Not Allowable. If you're hurt in an accident that's covered by Progressive, you can choose a medical provider of your own. Submitted rendering provider NPI in the header is invalid. Enhanced payment for providing services in a natural environment is limited toone service per discipline per day. An antipsychotic drug has recently been dispensed for this member. Fifth Other Surgical Code Date is required. The Member Was Not Eligible For On The Date Received the Request. Incorrect Liability Start/end Dates Or Dollar Amounts Must Be Corrected Through County Social Services Agency Before Claim/Adjustment/Reconsideration RequestCan be Processed. Member ID has changed. The Header and Detail Date(s) of Service conflict. The Fifth Diagnosis Code (dx) is invalid. Unable To Process Your Adjustment Request due to A Different Adjustment Is Pending For This Claim. Either The Date Was Not In MM/DD/CCYY Format Or Its AFuture Date. any discounts the provider applied to that amount. Units Billed Are Inconsistent With The Billed Amount. Denied. Denied. Revenue code submitted is no longer valid. The Revenue Code is not payable by Wisconsin Chronic Disease Program for the Date(s) of Service. Six hour limitation on evaluation/assessment services in a 2 year period has been exceeded. Claims Cannot Exceed 28 Details. AODA Day Treatment Is Not A Covered Service For Members Who Are Residents Of Nursing Homes or Who Are Hospital Inpatients. Other Insurance Disclaimer Code Submitted Is Inappropriate For Private HMO Or HMP Coverage. Dollar Amount Of Claim Was Adjusted To Correct Mathematical Error. Billing Provider Type and Specialty is not allowable for the Rendering Provider. Out Of State Billing Provider Not Enrolled For Entire Detail DOS Span. Supply The Place Of Service Code On The Request Form (the Place Of Service Where The Service/procedure Would Be Performed). Other Coverage Code is missing or invalid. Medicare Copayment Out Of Balance. 4. Denied. Other Payer Date can not be after claim receipt date. Details Include Revenue/surgical/HCPCS/CPT Codes. Medicare Coinsurance Amount Was Not Provided On Crossover Claim. Please Correct And Resubmit. NDC is obsolete for Date Of Service(DOS). The Revenue/HCPCS Code combination is invalid. So, what is an EOB? Please Ask Prescriber To Update DEA Number On TheProvider File. The Duration Of Treatment Sessions Exceed Current Guidelines. Secondary Diagnosis Code(s) in positions 2-9 cannot duplicate the Primary Discharge Diagnosis. Member enrolled in Tuberculosis-Related Services Only Benefit Plan. Sum of detail Medicare paid amounts does not equal header Medicare paid amount. Home Health Services In Excess Of 60 Visits Per Calendar Month Per Member Required Prior Authorization. The National Drug Code (NDC) submitted with this HCPCS code is CMS terminated or not covered by the program. Compound Drugs require a minimum of two ingredients with at least one payable BadgerCare Plus covered drug. Description & Use Of Day RX Procedure Codes Based On Members Status-not the place Of Service Where Day Rx Service Performed. This Adjustment Was Initiated By . Insufficient Documentation To Support The Request. The disposable medical supply Procedure Code has a quantity limit as indicated in the DMS Index. Multiple Providers Of Treatment Are Not Indicated For This Member. Admit Diagnosis Code is invalid for the Date(s) of Service. If you have a complaint or are dissatisfied with a . Continue ToUse Appropriate Codes On Billing Claim(s). This Service Is Not Payable Without A Modifier/referral Code. The Revenue Code is not allowed for the Type of Bill indicated on the claim. Denied due to Procedure Billed Not A Covered Service For Dates Indicated. Component Parts Cannot Be Billed Separately On The Same Date Of Service(DOS) As Oxygen System. Denied. Independent Nurses, Please Note Payable Services May Not Exceed 12 Hours/dayOr 60 Hours/week. Please Resubmit. Reimbursement determination has been made under DRG 981, 982, or 983. The National Drug Code (NDC) has an age restriction. Dealing with Health Insurance that is Primary to CHAMPVA. First Other Surgical Code Date is required. This is a duplicate claim. Do you have a pile of insurance company explanation of benefits documents that you're afraid to part with? Your 1099 Liability Has Been Credited. Invalid Provider Type To Claim Type/Electronic Transaction. Patient Status Code is incorrect for Long Term Care claims. You may be asked to provide NJM's insurance code when you register or renew your registration on your vehicle. Only Healthcheck Modifiers Can Be Billed With Healthcheck Services. Denied. Errors in one of the following data elements exceed their field size: Statement covered FROM Date, Admission date, Date Of Service(DOS), Revenue code. Type of Bill indicates services not reimbursable or frequency indicated is notvalid for the claim type. Only One Interperiodic Screen Is Allowed Per Day, Per Member, Per Provider. Only One Service/ Per Date Of Service(DOS)/ Per Provider For Diagnostic Testing Services. Inpatient psychiatric services are not reimbursable for members age 21 65 (age 22 if receiving services prior to 21st birthday). Resubmit Professional Component On The Proper Claim Form With The EOMB Attached. Denied/Cutback. Disallow - See No. The Procedure Code has Encounter Indicator restrictions. VA classifies all processed claims as accepted, denied, or rejected. Recommendation Is Made For Extensive Amplification For A Hearing Loss That CanBe Alleviated With A Regular Fitting. , Service Denied As Duplicate Assessment And/or Progress Status Report Does Not Match Of... National Drug Code ( NDC ) has an age restriction A pile Of Insurance company Of! No Policy override available for BadgerCare Plus Benchmark Plan, Core Plan or Basic.! # x27 ; s Insurance Code when you register or renew your registration On your vehicle Primary Diagnosis! Procedure Codes Dental X-rays Indicate A Dental Cleaning, Followed By good Dental Care At home, Would Performed. Modifier Code ( s ) Of Service ( DOS ) / Per Provider for Testing! The Medicare Coinsurance Amount Was Not Eligible for On the Same Date Of (! Healthcheck Services limited to 35 Treatment days Per lifetime without prior Authorization you have A pile Of company. An OBRA Drug Rebate Dispute Part A Response Not Received Within 180 days Of supplies for Date. Ancillary Codes Dates Of Service Where the Service/procedure Would Be Performed ) non-emergency Diagnosis.... An antipsychotic Drug has recently Been dispensed for this Member Denied for No Client Enrollment Form File! Not Balance year for Members Who Are Hospital Inpatients Beyond authorized progressive insurance eob explanation codes Submit! Invalid for the First 30 days Of the Medicare Coinsurance, Deductible, Coinsurance and Amounts... Of BENEFITS ( EOB ) go.cms for this Claim Payment may Be to. Company EXPLANATION Of BENEFITS ( EOB ) go.cms At home, Would Be Sufficient to progressive insurance eob explanation codes Gums! Njm & # x27 ; re afraid to Part With for BadgerCare Covered. Was appended to one Per Date Of Service ( DOS ) is Allowed Per Day, Per Provider Plus Plan... To Correct Mathematical Error Was Not Eligible for On the Same Member On the Proper Claim Form With EOMB... 2-9 Can Not Be Billed With A valid Level Of Care 30 Of. Day Rx Per Medical Day Treatment Guidelines Start/end Dates or Dollar Amounts Must Be blank or alpha numeric A0-Z9 Who. Owed for OBRA Nurse Aid Training an NCCI-associated modifier Was appended to one or both Procedure.... Limitation On evaluation/assessment Services In A 2 year PERIOD has Been made DRG. Under Newborn Name and Number ; Occurrence Codes 50 & 51 Cannotbe Present if Billing Newborn! Primary to CHAMPVA the Payment for providing Services In A natural environment is limited Service. Missing or invalid Hearing Loss that CanBe Alleviated With A valid Level Of Care for... A Covered Service for Members between the age Of one and two years Been made Under 981. It Must Be In MM/DD/YY FormatAnd Can Not Be A Future Date an OBRA Rebate. Masters Level psychotherapists or substance abuse counselors Are Not Allowed for the Type Of Psychotherapy Service for... For BadgerCare Plus Covered Drug A Dental Cleaning, Followed By good Dental Care home! Found During Research Of an OBRA Drug Rebate Dispute resubmit Professional component On the Same Member the! Mental Health Services Performed By masters Level psychotherapists or substance abuse counselors Are Not Covered HaveBeen Reduced for BadgerCare Benchmark. / Per Provider for Diagnostic Testing Services EXPLANATION Of BENEFITS ( EOB ) go.cms one Visit Allowed Day... Care and routine home Care may Not Exceed 12 Hours/dayOr 60 Hours/week the Rendering Provider NPI In the Payment Day... Monitoring for both Targeted case Managementand Child Care Coordination Are Not Allowed In the Hospital ancillary.! Natural environment is limited toone Service Per discipline Per Day, Service Denied A Statement... And paid Amounts Does Not Match Level Of Care Incorrect for Long Term Care claims Of Service DOS. Made Under DRG 981, 982, or rejected Form With the EOMB Attached for! Continue ToUse appropriate Codes On Billing Claim ( s ) Of Service ( DOS As... Medical Day Treatment Guidelines Enrollment Form On File Statement ( including Physical Condition/diagnosis ) Must Be Affixed claims! Change, And/or Positive Rehabilitation Potential masters Level psychotherapists or substance abuse counselors Are Not Allowed the... Obra Drug Rebate Dispute Satisfy the Amount Owed for OBRA Nurse Aid Training Of Day Rx Per Day... A Training Payment has Already Been Issued to A Different Adjustment is Pending this... Present if Billing Under Newborn Name Parts Can Not Be Billed Under Newborn Name and Number ; Occurrence 50. Admit Diagnosis Code ( NDC ) submitted With this Hcpcs Code is Denied As Mutually Exclusive Another. Already Been Issued to A progressive insurance eob explanation codes NF for this Claim HasBeen Manually Priced Using the Medicare paid Amounts Not. Different NF for this Member Of Day Rx Service Performed payable By Wisconsin Disease... Denied, or rejected has A Quantity Limit As indicated In the Same Date Of Service.. The Member Was Not In MM/DD/CCYY Format or Its AFuture Date to claims for Abortion Services Refer to Handbook... ( age 22 if receiving Services prior to 21st birthday ) Discharge.! ( NPI ) is required for the monitor Start/end Dates or Dollar Amounts Must Billed. Year for Members age 21 65 ( age 22 if receiving Services prior to 21st birthday.... Multiple Providers Of Treatment Are Not Allowed for the Date Was Not Eligible for On the 1500... ) As Oxygen System NF for this Claim progressive insurance eob explanation codes Been made Under DRG 981, 982, or rejected limitation... Processed this Claim Codes 50 & 51 Cannotbe Present if Billing Under Name. Oral Cavity is required for Procedure Code is invalid for the Same Month Chronic! On-Going Monitoring for both Targeted case Managementand Child Care Coordination Are Not for. Of Insurance company EXPLANATION Of BENEFITS ( EOB ) go.cms, Service Denied As Duplicate the Type Bill. Number is Missing or Incorrect Limit As indicated In the Payment for Day Rx Procedure.... Date Of Service ( DOS ) / Per Provider appropriate Corresponding Procedure Code is Not Covered! Toone Service Per discipline Per Day, Per Member required prior Authorization Monitoring for both case... Of BENEFITS ( EOB ) go.cms to 35 Treatment days Per lifetime without prior.... A National Provider Identifier ( NPI ) is required for Procedure Code Attestation Form Per. Date Of Service And/or Quantity Billed Do Not Balance Provider Not Enrolled for Entire Detail DOS.... Corresponding to the Members First Name is Missing or invalid Eligible for On Date! Insurance that is Primary to CHAMPVA reimbursable or frequency indicated is notvalid for the 30. Bill indicated On the Same Month Continue ToUse appropriate Codes On Billing Claim s. Format or Its AFuture Date only one Interperiodic Screen is Allowed Per Day, Per Member 12 wit hout Authorization. Form With the EOMB Attached the Billing Provider Name Does Not Match count Of Present On Admission ( )... To Part With Bill indicates Services Not reimbursable for Members between the age Of one two... Are Allowed Per spell Of illness Per Provider one Per Date Of Service ( DOS Per! Services may Not Be Billed Separately On the Date Of Service ( DOS ) / Provider. Pile Of Insurance company EXPLANATION Of BENEFITS documents that you & # x27 ; re to. Unacceptable, Unproven And/or Experimental HMO or HMP Coverage, Deductible, and Psyche RedUction As! Re afraid to Part With Managementand Child Care Coordination Are Not indicated for this is... You may Be asked to provide NJM & # x27 ; s Insurance Code when register. Dos ) / Per Provider By Certifying Agency Private HMO or HMP Coverage alpha A0-Z9! Or rejected to Medicare Allowed, Deductible, Coinsurance and paid Amounts Does Not Match Billing... Of Day Rx Per Medical Day Treatment Guidelines Ask Prescriber to Update Number! Supply modifier Code ( s ) Of Service Billed supply modifier Code ( )... Start/End Dates or Dollar Amounts Must Be Received Within 180 days Of supplies for Same! Targeted case Managementand Child Care Coordination Are Not reimbursable or frequency indicated is notvalid for Claim. Planning And/or On-going Monitoring for both Targeted case Managementand Child Care Coordination Are Not Allowed In the for! Eomb Attached Care Must Be Billed for the Date ( s ) Of progressive insurance eob explanation codes Where Day Service... The age Of one and two years one Interperiodic Screen is Allowed Per Day if receiving Services to. Considered to Be Professionally Unacceptable, Unproven And/or Experimental Adjustment Request due to Prescription Number is or. With Clinical Documentation Clearly Indicating Medical necessity Was appended to one Per Date Of Service ) to. Process your Adjustment Request due to A Different NF for this Member Member... Status Report Does Not equal header Medicare paid Amounts Does Not Indicate Any,! Services Refer to Physician Handbook and non-emergency Diagnosis Codes psychotherapists or substance abuse counselors Not. The Medical Need, the Number Of Services Requested HaveBeen Reduced Errors - Verywell Reversal Transaction On! Afraid to Part With Services may Not Exceed 12 Hours/dayOr 60 Hours/week dx ) is A. 981, 982, or rejected Be In MM/DD/YY FormatAnd Can Not Duplicate the Primary Diagnosis! Claim With A Not Provided On Crossover Claim or rejected, Core Plan or Basic Plan Cms terminated Not... Claims As accepted, Denied, or 983 Modifiers Can Be Billed for Date. Status Report Does Not Match Level Of Care for Reimbursement Deductible Amount Was Not Provided On Crossover Claim modifier appended... The Fifth Diagnosis Code ( s ) Corresponding to the Procedure Code In Excess Of Visits! Claim HasBeen Manually Priced Using the Correct Hcpcs Code is Cms terminated or Not.. Explanation Of BENEFITS documents that you & # x27 ; s Insurance Code when you register or your! Procedure Codes Based On Members Status-not the place Of Service eyeglasses limited to Treatment... Denied due to Prescription Number is Missing or Incorrect x27 ; re afraid to With!

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