Non-scheduled drugs are limited to the original dispensing plus 11 refills or 12 months. Billing Provider is not certified for the Date(s) of Service. Principal Diagnosis 8 Not Applicable To Members Sex. Incorrect Or Invalid National Drug Code Billed. Modifiers submitted are invalid for the Date Of Service(DOS) or are missing.. An ICD-9-CM Diagnosis Code of greater specificity must be used for the Sixth Diagnosis Code. Referral Codes Must Be Indicated For W7001, W7002, W7003, W7006, W7008 And W7013. Core Plan Denied due to Member eligibility file indicates BadgerCare Plus Core Plan member. The Service Requested Is Not Medically Necessary. A National Drug Code (NDC) is required for this HCPCS code. The Other Payer Amount Paid qualifier is invalid for . Questions, complaints, appeals, and grievances. The EOB is different from a bill. When diagnoses 800.00 through 999.9 are present, an etiology (E-code) diagnosis must be submitted in the E-code field. The Use Of This Drug For The Intended Purpose Is Not Covered By ,Consistent With Wisconsin Administrative Code Hfs 107.10(4) And 1396r-8(d). Files Indicate You Are A Medicare Provider And Medicare Benefits May Be Available On This Claim. Access payment not available for Date Of Service(DOS) on this date of process. Discharge Diagnosis 5 Is Not Applicable To Members Sex. Complex Evaluation and Management procedures require history and physical or medical progress report to be submitted with the claim. Eight hour limitation on evaluation/assessment services in a 1 year period has been exceeded. One or more From Date(s) of Service is missing for Occurrence Span Codes in positions three through 24. Second And Subsequent Cerebral Evoked Response Tests Paid At A Reduced Rate Per Guidelines. This Member Does Not Appear To Be Suffering From A Chronic Or Acute Mental Illness And Is Therefore Not Eligible For Day Treatment. The Second Other Provider ID is missing or invalid. Learn more. Revenue code submitted with the total charge not equal to the rate times number of units. The Service/procedure Proposed Is Not Supported By Submitted Documentation. Compound Ingredient Quantity must be greater than zero. Traditional dispensing fee may be allowed. CO 9 and CO 10 Denial Code. The Revenue Code is not payable by Wisconsin Well Woman Program for the Date Of Service(DOS). Payment Subject To Pharmacy Consultant Review. Independent RHCs Must Bill Codes W6251, W6252, W6253, W6254 Or W6255. Third Diagnosis Code (dx) (dx) is not on file. Third Other Surgical Code Date is invalid. The Rendering Providers taxonomy code in the header is not valid. Reimbursement For This Service Has Been Approved. No Separate Payment For IUD. Please Correct Claim And Resubmit. The Related Surgical Procedure is not a covered service under Wisconsin Medicaid or BadgerCare Plus. Denied. The Hearing Aid Recommended Is Not Necessary; The Member Could Be Adequately Fitted With A Conventional Aid. Rendering Provider may not submit claims for reimbursement as both the Surgeonand Assistant Surgeon For The Same Member On The Same DOS. Please Supply Modifier Code(s) Corresponding To The Procedure Code Description. This Procedure Is Denied Per Medical Consultant Review. Incidental modifier was added to the secondary procedure code. Learn more about Ezoic here. EOB meaning: 1. abbreviation for explanation of benefits: a document sent by a health insurance company to a. This Information Is Required For Payment Of Inhibition Of Labor. Denied. Denied. Please submit claim to BadgerRX Gold. This diabetic supply has been paid under an equivalent code on this Date Of Service(DOS). A Rendering Provider is not required but was submitted on the claim. The Member Was Not Eligible For On The Date Received the Request. Only Medicare Crossover claims are reimbursed for coinsurance, copayment, and deductible. Correction Made Per Medical Consultant Review. Questionable Long Term Prognosis Due To Gum And Bone Disease. (National Drug Code). Reimb Is Limited To The Average Montly NH Cost And Services Above that Amount Are Considered non-Covered Services. The Clinical Profile/Diagnosis Makes This Member Ineligible For AODA Services. Separate reimbursement for drugs included in the composite rate is not allowed. 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. Invalid quantity for the National Drug Code (NDC) submitted with this HCPCS code. Services Are Covered For Medically Needy Members Only When Healthcheck Referral is Indicated On Claim. The Billing Providers taxonomy code is missing. The Billing Providers taxonomy code is invalid. Other Insurance Disclaimer Code Invalid. HMO Payment Equals Or Exceeds Hospital Rate Per Discharge. Claim Generated An Informational ProDUR Alert, Drug-Drug Interaction prospective DUR alert, Drug-Disease (reported) prospective DUR alert, Drug-Disease (inferred) prospective DUR alert, Therapeutic Duplication prospective DUR alert, Suboptimal Regiment prospective DUR alert, Insufficient Quantity prospective DUR alert. Occurrence Code is required when an Occurrence Date is present. Claim Not Payable With Multiple Referral Codes For Same Screening Test. This Payment Is A Refund For An Overpayment Of A Provider Assessment, Thank You For Your Assessment Payment By Check, In Accordance With Your Request, EDS Has Deducted Your Assessment From This Payment. The Total Billed Amount is missing or incorrect. Allstate insurance code: 37907. . Claim Denied. (part JHandbook). 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. What your insurance agreed to pay. Personal injury protection insurance is mandatory in some states and optional or not offered at all in other states. Department of Health Services (DHS) Authorized Payment Is Being Withheld Due toan Audit. Member has Medicare Managed Care for the Date(s) of Service. Unable To Process Your Adjustment Request due to Claim Has Already Been Adjusted. Pharmaceutical care reimbursement for tablet splitting is limited to three permonth, per member. Reimbursement For IUD Insertion Includes The Office Visit. Denied. EOB Code Description Rejection Code Group Code Reason Code Remark Code 074 Denied. The HCPCS procedure code listed for revenue code 0624 is either invalid or non-reimburseable. Rendering Provider is not a certified provider for . A valid procedure code is required on WWWP institutional claims. The number of units billed for dialysis services exceeds the routine limits. All The Teeth Do Not Meet Generally Accepted Criteria Requiring Gingivectomy. Members Up To 3 Years Of Age Are Limited To 2 Healthcheck Screens Per 12 Months. The Surgical Procedure Code has Diagnosis restrictions. The Date Of The Screening Request Or The Date Of Screening Is Invalid Or Missing. Inpatient mental health services performed by masters level psychotherapists or substance abuse counselors are not covered. An Explanation of Benefits (EOB) code corresponds to a printed message about the status or action taken on a claim. Please verify billing. Please Correct And Resubmit. Denied due to The Members Last Name Is Missing. This Payment Is To Satisfy The Amount Owed For OBRA Nurse Aid Training. Please Disregard Additional Informational Messages For This Claim. Service(s) Approved By DHS Transportation Consultant. The Insurance EOB Does Not Correspond To The Dates Of Service/servicesBeing Billed. The value code 48 (Hemoglobin reading) or 49 (Hematocrit) is required for the revenue code/HCPCS code combination. Submitted referring provider NPI in the header is invalid. Replacement and repair of this item is not covered by L&I. NULL CO 96, A1 N171 Birth to 3 enhancement is not reimbursable for place of service billed. Drugs Prescribed and Filled on the Same Day, Cannot have a Refill Greater thanZero. The EOB comes before you receive a bill. The Competency Test Date On The Request Does Not Match The CNAs Test Date OnThe WI Nurse Aide Registry. Denied. Insurance Appeals (BIIA). Goals Are Not Realistic To The Members Way Of Life Or Home Situation, And Serve No Functional Or Maintenance Service. Preventive Medicine Code Billed Is Allowed For Health Check Agencies Only With The Appropriate Healthcheck Modifier. Claim Indicates Other Insurance/TPL Payment Must Be Received Prior To Filing Claim. Please Do Not Resubmit Your Claim, And Disregard Additional Informational Messages for this claim. MECOSH0086COEOB Billing/performing Provider Indicated On Claim Is Not Allowable. Schedule 3, 4 or 5 drugs are limited to the original dispensing plus 5 refillsor 6 months. Invalid Admission Date. The Timeframe Between Certification, Test, Date And Hire Date Exceeds A Year. Quantity Billed is missing or exceeds the maximum allowed per Date Of Service(DOS). Please Review Remittance And Status Report. You Must Adjust The Nursing Home Coinsurance Claim. Patient Status Code is incorrect for Long Term Care claims. Resubmit Claim With Corrected Tooth Number/letter Or With X-ray Documenting Tooth Placement. The Dispense As Written (Daw) Indicator Is Not Allowed For The National Drug Code. Denied. Request For Training Reimbursement Denied. PIP coverage protects you regardless of who is at fault. Repackaged National Drug Codes (NDCs) are not covered. Reimbursement rate is not on file for members level of care. Services Not Provided Under Primary Provider Program. The Dispense As Written (DAW) indicator is not allowed for the National Drug Code. Denied due to Provider Signature Is Missing. Condition code 70-76 is required on an ESRD claim when Influenza/PPV/HEP B HCPCS codes are the only codes being billed with condition code A6. 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. The National Drug Code (NDC) is not payable for a Family Planning Waiver member. the service performedthe date of the . Claim Denied For Invalid Billing Type Frequency Code, Claim Type, Or SubmittedAdjustment Provider Number Does Not Match Original Claims Provider Number. Etiology Diagnosis Code(s) (E-Codes) are invalid as the Admitting/Principal Diagnosis 1. Please show the appropriate multichanel HCPCS code rather than the individual HCPCS code. Revenue code is not valid for the type of bill submitted. The Members Past History Indicates Reduced Treatment Hours Are Warranted. A Description Of The Service Or A Photocopy Of The Physicians Signed And Dated Prescription Is Required In Order To Process. We Are Recouping The Payment. Three Or More Different Individual Chemistry Tests Performed Per Member/Provider/Date Of Service Must Be Billed As A Panel. Please Refer To The Original R&S. Received Beyond Special Filing Deadline For ThisType Of Claim Or Adjustment/reconsideration. We have created a list of EOB reason codes for the help of people who are working on denials, AR-follow-up, medical coding, etc. Another PNCC Has Billed For This Member In The Last Six Months. Reimbursement For This Detail Does Not Include Unit DoseDispensing Fee. Supplemental Payment Authorized By Department of Health Services (DHS) Due to aAudit. All services should be coordinated with the Hospice provider. Please Rebill Only CoveredDates. Result of Service code is invalid. Other Insurance Disclaimer Code Used Is Inappropriate For This Members Insurance Coverage. A Second Surgical Opinion Is Required For This Service. Please Verify That Physician Has No DEA Number. Duplicate Item Of A Claim Being Processed. This Payment Is To Satisfy The Amount Owed For OBRA Level 1. Rqst For An Acute Episode Is Denied. No Complete Program Enrollment Form Is On File For This Client Or The Client Is Not Eligible For The Date Of Service(DOS) On The Clai im. Please Request Prior Authorization For Additional Days. Other Payer Date can not be after claim receipt date. This Is A Duplicate Request. Multiple Carry Procedure Codes Are Not Payable When Billed With Modifiers. The Service Requested Is Inappropriate For The Members Diagnosis. Date(s) Of Service on detail must be within a Sunday thru Saturday calendar week. Denied. Valid Numbers AreImportant For DUR Purposes. PA required for payment of this service. The Service Performed Was Not The Same As That Authorized By . This National Drug Code (NDC) is only payable as part of a compound drug. Unable To Process Your Adjustment Request due to Claim ICN Not Found. Purchase Only Allowed; Medical Need For Rental Has Not Been Documented. Procedure Code Changed To Permit Appropriate Claims Processing. Supplemental Payment Authorized By Department of Health Services (DHS) Due to a Department Of Justice Settlement. This ProviderMay Only Bill For Coinsurance And Deductible On A Medicare Crossover Claim. Pricing Adjustment/ Maximum Flat Fee Level 2 pricing applied. Header To Date Of Service(DOS) is invalid. The Total Number Of Hours Per Day Requested For AODA Day Treatment Exceeds Guidelines And The Request Has Been Adjusted Accordingly. Excessive height and/or weight reported on claim. Member is enrolled in a State-contracted managed care program for the Date(s) of Service. The detail From or To Date Of Service(DOS) is missing or incorrect. Paid In Accordance With Dental Policy Guide Determined By DHS. Procedure Code Used Is Not Applicable To Your Provider Type. Service Denied. The Number Of Weeks Has Been Reduced Consistent With Goals And Progress Documented. Prescribing Provider UPIN Or Provider Number Missing. Services Requested Do Not Meet The Criteria for an Acute Episode. Pricing Adjustment. 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. An Alert willbe posted to the portal on how to resubmit. Service not covered as determined by a medical consultant. Please File With Champus Carrier. The fair market value of property; technically, replacement cost less depreciation.. Actuary. Disallow - See No. This drug has been paid under an equivalent code within seven days of this Date Of Service(DOS). 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. Service billed is bundled with another service and cannot be reimbursed separately. Pricing Adjustment/ SeniorCare claim cutback because of Patient Liability and/or other insurace paid amounts. The Service Requested Is Covered By The HMO. Training Completion Date Must Be Prior To And Within A Year Of The CNAs Certification Date. The Requested Procedure Is Cosmetic In Nature, Therefore Not Covered By . You will receive this statement once the health insurance provider submits the claims for the services. Denied. Please show the entire amount of the premium progressive on the V2781 service line. Pricing Adjustment/ Pharmacy dispensing fee applied. New and Current Explanation of Benefit (EOB) Codes - Effective August 1, 2020 EOB Code EOB Description Claim Adjustment . Training CompletionDate Exceeds The Current Eligibility Timeline. CO 13 and CO 14 Denial Code. First modifier code is invalid for Date Of Service(DOS). The Documentation Submitted Does Not Substantiate Additional Care. Home Health Services In Excess Of 160 Home Health Visits Per Calendar Year PerMember Require Prior Authorization. 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. Research Has Determined That The Member Does Not Qualify For Retroactive Eligibility According To Hfs 106.03(3)(b) Of The Wisconsin Administrative Code. This Payment Is To Satisfy The Amount Indicated On The Administrative Claiming Reimbursement Summary Report. Member enrolled in QMB-Only Benefit plan. Your Adjustment/reconsideration Request For Additional Payment Has Been Denied, Request Was Received Beyond The 90 Day Requirement For Payment Reconsideration. Do Not Indicate A Hcpcs Or Cpt Procedure Code On An Inpatient Claim. Effective 04/01/09, the BadgerCare Plus Core Plan will limit coverage for Brochodilators-Beta Agonists to Proventil HFA and Serevent. PleaseResubmit Charges For Each Condition Code On A Separate Claim. Member is not Medicare enrolled and/or provider is not Medicare certified. Individual Test Paid. Please Indicate The Revenue Code/procedure Code/NDC Code For Which The Credit is To Be Applied. Good Faith Claim Has Previously Been Denied By Certifying Agency. Will Only Pay For One. The Medical Need For Some Requested Services Is Not Supported By Documentation. HIPAA EOB codes are returned on the 835 Remittance Advice file and are maintained by the Washington Publishing Company. To Date Of Service(DOS) Precedes From Date Of Service(DOS). Services Included In The Inpatient Hospital Rate Are Not Separately Reimbursable. Procedue Code is allowed once per member per calendar year. An xray or diagnostic urinalysis is reimbursable only when performed on the same Date Of Service(DOS) and billed on the same claim as the initial office visit. This claim is being denied because it is an exact duplicate of claim submitted. A Procedure Code without a modifier billed on the same day as a Procedure Codewith modifier 11 are viewed as the same trip. NUMBER IS MISSING OR INCORRECT 0002 01/01/1900 COULD NOT PROCESS CLAIM. Please Indicate Separately On Each Detail. Billing Provider indicated is not certified as a billing provider. Member Is Enrolled In A Family Care CMO. The Procedure Requested Is Not Allowable For The Process Type Indicated On TheRequest. The Rendering Providers taxonomy code in the header is invalid. All ESRD clinical diagnostic laboratory tests must be billed individually to ensure that automated multi-chanel chemistry tests are paid in accordance with the Medicare Provider Reimbursement Manual (PRM) 2711. Errors in one of the following data elements exceed their field size: Statement covered FROM Date, Admission date, Date Of Service(DOS), Revenue code. Accommodation Days Missing/invalid. The Materials/services Requested Are Not Medically Or Visually Necessary. Please Verify The Units And Dollars Billed. This obstetrical service was previously paid for this Date Of Service(DOS) for thismember. Claim Or Adjustment Request Should Include Documents That Best Describe Services Provided (ie Op Report, Admission History and Physical, Progress Notes and Anesthesia Report). This service is not covered under the ESRD benefit. Service is not reimbursable for Date(s) of Service. Therefore itIs Not Necessary To Wait The Full 6 Weeks After Extractions Before Taking Denture Impressions. 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 . Reimbursement determination has been made under DRG 981, 982, or 983. Please Refer To Update No. Procedure Code is restricted by member age. One or more Diagnosis Code(s) is not payable by Wisconsin Chronic Disease Program for the Date Of Service(DOS). Voided Claim Has Been Credited To Your 1099 Liability. Dispense Date Of Service(DOS) exceeds Prescription Date by more than one year. Member File Indicates Part B Coverage Please Resubmit Indicating Value Code 81and The Part B Payable Charges. Member first name does not match Member ID. Pricing Adjustment. Please Reference Payment Report Mailed Separately. Does not reimburse both the global service and the individual component parts of the service for the same Date Of Service(DOS). Denied due to Claim Contains Future Dates Of Service. Detail Rendering Provider certification is cancelled for the Date Of Service(DOS). Amount billed - See No. Service Denied. The procedure code and modifier combination is not payable for the members benefit plan. Training Completion Date Is Not A Valid Date. Services Not Payable When Rendered To An Individual Aged 21-64 Who Is A Resident Of A Nursing Home Imd. Denied due to The Member WCDP Id Number Is Incorrect Or Not On Our Current Eligibility File. Multiple Referral Charges To Same Provider Not Payble. The Ninth Diagnosis Code (dx) is invalid. Service (Procedure Code/Modifier Combination) is not reimbursable for Date Of Service(DOS). Refer To Notice From DHS. Denture Repair And/or Recement Bridge Must Be Submitted On A Paper Claim With ADescription Of Service And Documentation Of A Healthcheck Screen Attached. Secondary Diagnosis Code (dx) is not on file. Service Denied. Dates of Service reflected by the Quantity Billed for dialysis exceeds the Statement Covers Period. This detail is denied. Dosings for Narcotic Treatment Service program are limited to six per Sunday thru Saturday calendar week. EOB codes provide details about a claim's status, as well as information regarding any action that might be required. NDC- National Drug Code is invalid for the Dispense Date Of Service(DOS). 140 only revenue codes 300 or 310 are allowed on outpatient claims when billing lab A valid Prior Authorization is required for Brand Medically Necessary Drugs. 2 above. 100 Days Supply Opportunity. Denied. Reference: Transmittal 477, change request 3720 issued February 18, 2005. Benefit Payment Determined By Fiscal Agent Review. CORE Plan Members are limited to 25 non-emergency outpatient hospital visits per enrollment year. Prior authorization is required for Maxalt when Maxalt or sumatriptan productshave not been reimbursed within 365 days. Claim Denied Due To Invalid Occurrence Code(s). The Resident Or CNAs Name Is Missing. Claim Must Indicate A New Spell Of Illness And Date Of Onset. More than one PPV or Influenza vaccine billed on the same Date Of Service(DOS) for the same member is not allowed. Pricing Adjustment/ Paid according to program policy. It breaks down the information like this: The services we provided. 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. Newborn Care Must Be Billed Under Newborn Name And Number; Occurrence Codes 50& 51 Cannotbe Present if Billing Under Newborn Name. Eyeglasses limited to original plus 1 replacement pair, lens or frame in 12 wit hout Prior Authorization. Inpatient psychiatric services are not reimbursable for members age 21 65 (age 22 if receiving services prior to 21st birthday). A WCDP drug rebate agreement for this drug is not on file for the Date Of Service(DOS). The Clinical Profile And Narrative History Indicate Day Treatment Is Neither Appropriate Nor A Medical Necessity For This Member.