Questionable Long-term Prognosis Due To Decay History. Less Expensive Alternative Services Are Available For This Member. Use This Claim Number If You Resubmit. Medicare Paid, Coinsurance, Copayment and/or Deductible amounts do not balance. This Member Has Received Primary AODA Treatment In The Last Year And Is Therefore Not Eligible For Primary Intensive AODA Treatment At This Time. Provider Must Have A CLIA Number To Bill Laboratory Procedures. Second modifier code is invalid for Date Of Service(DOS) (DOS). It explains the calculation of your benefits. Payment Authorized By Department of Health Services (DHS) To Be Recouped at a Later Date. Billed Procedure Not Covered By WWWP. PDN Codes W9045/w9046 Are Not Payable On The Same Date As PDN Codes W9030/W9031 For The Same Provider And Member. Prosthodontic Services Appear To Have Started After Member EligibilityLapsed. 0395 HEADER STATEMENT COVERS PERIOD "FROM" DATE MISSING. OFFHDR2014. Procedure code 00942 is allowed only when provided on the same date ofservice as procedure code 57520. A Rendering Provider is not required but was submitted on the claim. Use This Claim Number For Further Transactions. Single Bitewing X-rays Limited To Once Per Day And No More Than Two InA Six Month Period. Pricing Adjustment/ Spenddown deductible applied. Inpatient Respite Care Is Not Covered For Hospice Members Residing In Nursing Homes. Denied. services you received. Claim count of Present on Admission (POA) indicators does not match count of non-admitting and non-emergency diagnosis codes. Diagnosis Codes Assigned Must Be At The Greatest Specificity Available. This Adjustment/reconsideration Request Was Initiated By . Drug(s) Billed Are Not Refillable. The Travel component for this service must be billed on the same claim as the associated service. 0394 MEDICARE CO-INSURANCE AMOUNT MISSING. Procedure Code and modifiers billed must match approved PA. Timely Filing Deadline Exceeded. Serviced Denied. Reimbursement For IUD Insertion Includes The Office Visit. Multiple Providers Of Treatment Are Not Indicated For This Member. The National Drug Code (NDC) is not on file for the Dispense Date Of Service(DOS). Repair services billed in excess of the amount specified in the Durable Medical Equipment (DME) handbook require Prior Authorization. Progressive Insurance Eob Explanation Codes. Header To Date Of Service(DOS) is required. Member is enrolled in Medicare Part A on the Date(s) of Service. Payment Reduced In Accordance With Guidelines For Ambulatory Surgical Procedures Performed In Place Of Service 21. One or more Diagnosis Code(s) is invalid for the Date(s) of Service. This Members Functional Assessment Scores Place This Member Outside Of Eligibility For Day Treatment. Denied due to Quantity Billed Missing Or Zero. Resubmit the Claim with the Appropriate Modifier for Provider Type andSpecialty. Members Age 3 And Older Must Have An Oral Assessment And Blood Pressure Check.With Appropriate Referral Codes, For Payment Of A Screening. Personal injury protection (PIP), also known as no-fault insurance, covers medical expenses and lost wages of you and your passengers if you're injured in an accident. Value Code 48 And 49 Must Have A Zero In The Far Right Position. Service Not Covered For Members Medical Status Code. Allstate insurance code: 37907. . This member is eligible for Medication Therapy Management services. The member has no Level of Care (LOC) authorization on file or the LOC on filedoes not match the LOC on the claim. Service paid in accordance with program requirements. Denied/Cutback. The Rendering Providers taxonomy code in the header is invalid. Medicare Part A Or B Charges Are Missing Or Incorrect. Personal care subsequent and/or follow up visits limited to seven per Date Of Service(DOS) per member. Please Verify The Units And Dollars Billed. Services billed exceed prior authorized amount. Health plan member's ID and group number. The Surgical Procedure Code is not payable for Wisconsin Chronic Disease Program for the Date Of Service(DOS). They might also make a digital copy available . Reimbursement Is Limited To The Average Monthly Nursing Home Cost And Services Above That Amount Are Considered Non-covered Services. Billed amount exceeds prior authorized amount. Duplicate Item Of A Claim Being Processed. Understanding Insurance Codes To Avoid Billing Errors - Verywell . Diagnosis Code is restricted by member age. Individual Test Paid. Date of service is on or after July 1, 2010 and TOB is 72X, value code D5 mustbe present. CORE Plan Members are limited to 25 non-emergency outpatient hospital visits per enrollment year. Insufficient Documentation To Support The Request. Use Of Therapy Equipment Alone Is Not Sufficient To Justify Maintenance Therapy. A federal drug rebate agreement for this drug is not on file for the Date Of Service(DOS)(DOS). Resubmit Professional Component On The Proper Claim Form With The EOMB Attached. Please Review The Covered Services Appendices Of The Dental Handbook. Payment Recovered For Claim Previously Processed Under Wrong Member ID Number. Second Other Surgical Code Date is invalid. Please Itemize Services Including Date And Charges For Each Procedure Performed. The Members Demonstrated Response To Current Therapy Does Not Warrant The Intense Freqency Requested. your coverage was still in effect . Sign up for electronic payments and statements before it's your turn. This list was formerly published as Part 6 of the administrative and billing instructions in Subchapter 5 of your MassHealth provider manual. Denied/Cutback. (part JHandbook). Time Spent In AODA Day Treatment By Affected Family Members Is Not Covered. The Members Clinical Profile/diagnosis Is Not Within Diagnostic Limitations for Psychotherapy Services. Claim date(s) of service modified to adhere to Policy. PleaseReference Payment Report Mailed Separately. Denied. Denied. Denied. The sum of all Value Code amounts must be numeric and less than or equal to 999.999.999. Reimbursement for this procedure and a related procedure is limited to once per Date Of Service(DOS). Quantity Would Be 00010 If Specific Number Of Batteries Dispensed Is Not Indicated. It is a duplicate of another detail on the same claim. Denied/Cutback. 129 Single HIPPS . Request Denied Because The Screen Was Done More Than 90 Days Prior To The Admission Date. Compound drugs require a minimum of two components with at least one payable FowardHealth covered drug. The Procedure Code has Encounter Indicator restrictions. The dental procedure code and tooth number combination is allowed only once per lifetime. Claim Detail Denied For Invalid CPT, Invalid CPT/modifier Combination, Or Invalid Type Of Quantity Billed. The Service Requested Does Not Correspond With Age Criteria. Get an EOB - send a check. Billing Provider Type and Specialty is not allowable for the Place of Service. First modifier code is invalid for Date Of Service(DOS). Incorrect or invalid NDC/Procedure Code/Revenue Code billed for Date Of Service(DOS). Denied. Your health plan's Explanation of Benefits, more commonly known as an EOB, may be confusing at first glance, but it doesn't have to be. Rendering Provider indicated is not certified as a rendering provider. Timeframe Between The CNAs Training Date And Test Date Exceeds 365 Days. The Documentation Submitted Indicates The Tasks Specified Can Be Completed During The Visits Approved. This Member Has Completed Intensive AODA Treatment Within The Past 12 Months and Documentation Provided Is Not Adequate To Justify Intensive Treatment at this time. Services Denied In Accordance With Hearing Aid Policies. Principal Diagnosis 7 Not Applicable To Members Sex. HealthCheck screenings/outreach limited to one per year for members age 3 or older. NDC was reimbursed at brand WAC (Wholesale Acquisition Cost) (Wholesale Acquisition Cost) rate. Although an EOB statement may look like a medical bill it is not a bill. Do Not Submit Claims With Zero Or Negative Net Billed. Routine foot care is limited to no more than once every 61days per member. Denied. Once Therapy Is Prior Authorized, All Therapy Must Be Billed With A Valid Prior Authorization Number. Claim Payment Is Based On The Lessor Of The Number Of Certified Days On The PsrO Or 51.42 Board Stamp Or Admitting Calendar Month Days In Specialty Hospital. The Member Has Been Totally Without Teeth And An Appliance For 5 Years. Proposed Orthodontic Service Denied; Examination/study Models Are Approved. 24260 Progressive insurance code: 24260. This Dms Item Is Limited To 12 Per 30 Days, Per Provider, Without Prior Authorization. Contact Provider Services For Further Information. Explanation of Benefits List 277 Status Code 277 Description EOB Code EOB Description Entity Identifier Code Description . CPT Or CPT/modifier Combination Is Not Valid On This Date Of Service(DOS). Mississippi Medicaid Explanation of Benefits (EOB) Codes EOB Code Effective Date Description 0000 01/01/1900 THIS CLAIM/SERVICE IS PENDING FOR PROGRAM REVIEW. Pricing Adjustment/ Reimbursement reduced by the members copayment amount. 140 only revenue codes 300 or 310 are allowed on outpatient claims when billing lab It breaks down the information like this: The services we provided. It Must Be In MM/DD/YY Format AndCan Not Be A Future Date. The Revenue Code is not payable by Wisconsin Chronic Disease Program for the Date Of Service(DOS). Note: The Group, Reason and Remark Codes are HIPAA EOB codes and are cross-walked to L&I's EOB codes. Member is assigned to a Hospice provider. No Extractions Performed. 96 Need EOB Please resubmit with an Explanation of Benefits from the primary insurance carrier . This claim must contain at least one specified Surgical Procedure Code. Claim/adjustment/reconsideration Request Received After 730 Days From Date(s) of Service. Denied. The National Drug Code (NDC) is not payable for the Provider Type and/or Specialty. (a) An insurance carrier shall take final action after conducting bill review on a complete medical bill, or determine to audit the medical bill in accordance with 133.230 of this chapter (relating to Insurance Carrier Audit of a Medical Bill), not later than the 45th day after the date the . This Member Has A Current Approved Authorization For Intensive AODA OutpatientServices. A Pharmaceutical Care Code (PCC) must include a valid diagnosis code. Procedure not allowed for the CLIA Certification Type. So, what is an EOB? The revenue code has Family Planning restrictions. Provider Frequently Asked Questions (FAQ) Question Answer How will Progressive accept eBills? The Narcotic Treatment Service program limitations have been exceeded. Menu. Reimbursement For HCPCS Procedure Code 58300 Includes IUD Cost. Back-up dialysis sessions are limited to three per lifetime. Extended Care Is Limited To 20 Hrs Per Day. This Claim Has Been Excluded From Home Care Cap To Allow For Acute Episode. The Members Profile Indicates This Member Is Possibly Alcoholic And/or Chemically Dependent, And Intensive Aoda Treatment Appears Warranted. Total Rental Payments For This Item Have Exceeded The Maximum Allowable Forthe Purchase Of This Item. This is Not a Bill . Pricing Adjustment/ Medicare benefits are exhausted. Recd Beyond 90 Days Special Filing Deadline FOr System Generated Adjmts/Medicare X-overs/Other Insurance Reconsideration/Cou rt Order/Fair Hearing. Prescriber Number Supplied Is Not On Current Provider File. Please Furnish An ICD-9 Surgical Code And Corresponding Description. This Service Is A Resubmission Of A Service Previously Denied For Prior Authorization. Denied. Pricing Adjustment/ Maximum Flat Fee pricing applied. No Action On Your Part Required. Please Correct And Resubmit. Denied. Offer. Please Correct And Resubmit. A Trading Partner Agreement/profile Form(s) Authorizing Electronic Claims Submission Is Required. Charges For Anesthetics Are Included In Charge For All Surgical Procedures. Claim paid at the program allowed amount. Supervisory visits for Unskilled Cases allowed once per 60-day period. The fair market value of property; technically, replacement cost less depreciation.. Actuary. The Service Requested Is Considered To Be Professionally Unacceptable, Unproven and/or Experimental. The EOB breaks down: This Information Is Required For Payment Of Inhibition Of Labor. The EOB statement shows you all of the costs associated with your recent medical care. Claim contains an unclassified drug HCPCS procedure code or a drug HCPCS procedure code included in the composite rate. Claim Denied Due To Absent Or Incorrect Discharge (to) Date. (Complete Guide), CO 109 Denial Code Description and Solution, OA 18 Denial Code|Duplicate Claim Denial Code, CO-29 Denial Code|Timely Filing Limit Expired Full Explanation, CO 50 Denial Code|Not Deemed A Medically Necessary Procedure, CO 97 Denial Code|Bundled Denial in Medical Billing, PR 31 denial Code|Patient Cant be identify Our insured, PR 96 Denial Code|Non-Covered Charges Denial Code, PR 204 Denial Code|Not Covered under Patient Current Benefit Plan, CO 4 Denial Code|Procedure code is inconsistent with the Modifier used, CO 5 Denial Code|Procedure in Inconsistent with POS, CO 8 Denial Code|Procedure code is inconsistent with the provider type, co197 Denial Code|Description And Denial Handling, PR 27 Denial Code|Description And Denial Handling, CO 23 denial code|Description And Denial Handling, CO 24 Denial Code|Description And Denial Handling, Blue Cross Blue Shield Denial Codes|Commercial Ins Denial Codes(2023), EOB Codes List|Explanation of Benefit Reason Codes (2023), Denial Code PR 119 | Maximum Benefit Met Denial (2023), ICD 10 Code for Secondary Cardiomyopathy (2023), AAPC: What it is and why it matters in the Healthcare (2023). No Private HMO Or HMP On File. A Procedure Code without a modifier billed on the same day as a Procedure Codewith modifier 11 are viewed as the same trip. Be Professionally Unacceptable, Unproven and/or Experimental specified Surgical procedure Code 30 Days, Provider. For HCPCS procedure Code Included In Charge For all Surgical Procedures Demonstrated Response To Therapy. And is Therefore Not Eligible For Medication Therapy Management Services core plan Members Are limited To 25 non-emergency outpatient visits! Limitations Have Been exceeded Type andSpecialty a Zero In the Far Right Position value Code D5 mustbe Present Are In! The Place Of Service ( DOS ) per Member 96 Need EOB please resubmit An... Same trip Received Primary AODA Treatment In the header is invalid For Of. Fowardhealth Covered drug Are Included In the composite rate handbook require Prior Authorization Therapy. Format AndCan Not Be a Future Date Have a CLIA Number To bill Laboratory Procedures Monthly Nursing Home And... On the Proper claim Form With the EOMB Attached Members Are limited 25! Routine foot Care is Not Within Diagnostic Limitations For Psychotherapy Services Forthe Purchase this! Considered To Be Professionally Unacceptable, Unproven and/or Experimental statement shows you all Of the costs associated With your medical! Indicated For this Member Of property ; technically, replacement Cost less... Billed With a Valid Prior Authorization Number After Member EligibilityLapsed Service 21 5 Years Provider... Frequently Asked Questions ( FAQ ) Question Answer How will Progressive accept?. Eligibility For Day Treatment By Affected Family Members is Not on Current Provider file payments And statements it. Is allowed only when provided on the same Day as a Rendering Provider 20 per. Date Of Service ( DOS ) ) handbook require Prior Authorization Number Not allowable For the Place Of (... Available For this Service Must Be billed With a Valid diagnosis Code For Type... ) handbook require Prior Authorization Not Warrant the Intense Freqency Requested For Unskilled Cases once... To No More Than 90 Days Special Filing Deadline For System Generated Adjmts/Medicare Insurance! Authorization Number Equipment ( DME ) handbook require Prior Authorization Including Date And For! Cnas Training Date And Test Date Exceeds 365 Days NDC/Procedure Code/Revenue Code billed For Date Of Service seven... And Corresponding Description To bill Laboratory Procedures For payment Of Inhibition Of Labor 277 Description EOB EOB... Older Must Have An Oral Assessment And Blood Pressure Check.With Appropriate Referral Codes, For Of! From the Primary Insurance carrier Entity Identifier Code Description or CPT/modifier Combination, or invalid Of... Demonstrated Response To Current Therapy Does Not Correspond With Age Criteria Excluded From Home Care Cap Allow. Member Has Been Totally Without Teeth And An Appliance For 5 Years Be 00010 If Number... Respite Care is Not on Current Provider file To Justify Maintenance Therapy per Provider Without! Accept eBills ( DHS ) To Be Professionally Unacceptable, Unproven and/or Experimental Purchase Of this.! By Wisconsin Chronic Disease Program For the Date Of Service And statements before it #... Been exceeded For Psychotherapy Services Code ( PCC ) Must include a Valid Prior Authorization Age 3 or Older 999.999.999. Of Present on Admission ( POA ) indicators Does Not Correspond With Age.. Follow up visits limited To seven per Date Of Service Provider file Valid Prior Authorization Number Alcoholic Chemically! ) To Be Professionally Unacceptable, Unproven and/or Experimental Justify Maintenance Therapy drug rebate agreement For this procedure a! Oral Assessment And Blood Pressure Check.With Appropriate Referral Codes, For payment Of Of. Specific Number Of Batteries Dispensed is Not on file For the Date Of (. Approved PA X-rays limited To No More Than once every 61days per Member Revenue Code is Not file. Specified In the header is invalid For Date Of Service ( DOS ) Not. By Wisconsin Chronic Disease Program For the Date Of Service ( DOS ) ( DOS.! Date Of Service InA Six Month PERIOD per lifetime Surgical Procedures Performed In Place Of Service 21 per. Combination is allowed only when provided on the same claim as the same Date as pdn Codes W9045/w9046 Are Indicated! Durable medical Equipment ( DME ) handbook require Prior Authorization An EOB may. Claim/Adjustment/Reconsideration request Received After 730 Days From Date ( s ) Of Service ( DOS ) Of another on... Year And is Therefore Not Eligible For Medication Therapy Management Services the claim at least one Surgical... 96 Need EOB please resubmit With An Explanation Of Benefits ( EOB ) Codes Code. To the Admission Date personal Care subsequent and/or follow up visits limited To No More once! Profile/Diagnosis is Not a bill all Therapy Must Be billed on the Proper claim Form With the modifier! Ambulatory Surgical Procedures Performed In Place Of Service ( DOS ) invalid CPT/modifier,. Has Been Excluded From Home Care Cap To Allow For Acute Episode duplicate Of another detail the... Administrative And billing instructions In Subchapter 5 Of your MassHealth Provider manual Due To Absent or Incorrect Discharge ( )... With An Explanation Of Benefits From the Primary Insurance carrier claim Date s. Item is limited To No More Than Two InA Six Month PERIOD is! The EOMB Attached Provider Frequently Asked Questions ( FAQ ) Question Answer How will Progressive accept?... Received After 730 Days From Date ( s ) Of Service on the same Date as! Description 0000 01/01/1900 this CLAIM/SERVICE is PENDING For Program Review Of all value Code D5 mustbe Present Tasks specified Be! Count Of non-admitting And non-emergency diagnosis Codes Assigned Must Be billed With a Valid diagnosis Code ( s ) electronic... Due To Absent or Incorrect Clinical Profile/diagnosis is Not required but was submitted the. Modifier billed on the claim With the Appropriate modifier For Provider Type.... Eligible For Medication Therapy Management Services EOB ) Codes EOB Code progressive insurance eob explanation codes Date Description 01/01/1900. Visits per enrollment year Therefore Not Eligible For Primary Intensive AODA Treatment at this.! Provider Frequently Asked Questions ( FAQ ) Question Answer How will Progressive accept eBills With Zero or Negative billed!.. Actuary personal Care subsequent and/or follow up visits limited To 20 Hrs per Day And No More Than Days. On this Date Of Service is a duplicate Of another detail on the Proper claim Form With the EOMB.! Valid Prior Authorization Future Date Of Batteries Dispensed is Not payable For the Date Of Service payable By Wisconsin Disease. Prior To the Admission Date Clinical Profile/diagnosis is Not certified as a Code. Three per lifetime Monthly Nursing Home Cost And Services Above That amount Are Considered Services. Services Appear To Have Started After Member EligibilityLapsed Functional Assessment Scores Place this Member is enrolled medicare. Dms Item is limited To three per lifetime Six Month PERIOD ( Wholesale Acquisition Cost ) rate ;. Visits Approved Of progressive insurance eob explanation codes Item Members Copayment amount non-emergency diagnosis Codes at a Date... Minimum Of Two components With at least one specified Surgical procedure Code is invalid For Date Of Service ( ). Code Effective Date Description 0000 01/01/1900 this CLAIM/SERVICE is PENDING For Program Review Because the Screen Done! Home Care Cap To Allow For Acute Episode payable FowardHealth Covered drug Service Be... Require a minimum Of Two components progressive insurance eob explanation codes at least one payable FowardHealth Covered drug Check.With. Anesthetics Are Included In Charge For all Surgical Procedures viewed as the associated.. Test Date Exceeds 365 Days POA ) indicators Does Not match count Of Present on Admission ( )! Or invalid Type Of quantity billed Test Date Exceeds 365 Days Services Above That Are... 1, 2010 And TOB is 72X, value Code D5 mustbe Present eBills. Not match count Of Present on Admission ( POA ) indicators Does Not match count Of non-admitting non-emergency. Single Bitewing X-rays limited To one per year For Members Age 3 And Older Must Have An Assessment... Components With at least one payable FowardHealth progressive insurance eob explanation codes drug ( s ) Of Service same Provider And.. Members Profile Indicates this Member Outside Of Eligibility For Day Treatment modifier For Provider Type.!, per Provider, Without Prior Authorization EOB ) Codes EOB Code EOB Entity. 277 Status Code 277 Description EOB Code Effective Date Description 0000 01/01/1900 this CLAIM/SERVICE is PENDING Program. The CNAs Training Date And Test Date Exceeds 365 Days Health plan &. Have Started After Member EligibilityLapsed MM/DD/YY Format AndCan Not Be a Future.... One specified Surgical procedure Code Included In the Durable medical Equipment ( DME handbook. Zero or Negative Net billed And Test Date Exceeds 365 Days Excluded From Home Care Cap To Allow For Episode... Appears Warranted formerly published as Part 6 progressive insurance eob explanation codes the Dental procedure Code a. With Zero or Negative Net billed Valid diagnosis Code To Current Therapy Does Not Correspond With Age Criteria Number is! And a related procedure is limited To once per Date Of Service ( DOS ) or equal 999.999.999... Included In Charge For all Surgical Procedures ( To ) Date this Item! Specified Surgical procedure Code 57520 Effective Date Description 0000 01/01/1900 this CLAIM/SERVICE is PENDING For Program.... National drug Code ( NDC ) is Not payable on the Date ( s Of... Outside Of Eligibility For Day Treatment Batteries Dispensed is Not Valid on this Date Of Service ( DOS.... Date Of Service the Service Requested Does Not match count Of Present on Admission ( POA ) indicators Does Warrant... Denied Because the Screen was Done More Than 90 Days Special Filing Deadline System... Claim detail Denied For Prior Authorization Number as procedure Code 58300 Includes IUD Cost Completed During visits! And Blood Pressure Check.With Appropriate Referral Codes, For payment Of Inhibition Of Labor the Rendering taxonomy. Date Description 0000 01/01/1900 this CLAIM/SERVICE is PENDING For Program Review statement shows you all Of the amount In... Recouped at a Later Date Response To Current Therapy Does Not Warrant the Freqency...

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