Denied due to Diagnosis Code Is Not Allowable. Pricing Adjustment/ Payment reduced due to the inpatient or outpatient deductible. Reimbursement For Panel Test Only- Individual Tests In Addition To Panel Test Disallowed. Claim Denied. Denied. This Member is enrolled in Wisconsin or BadgerCare Plus for Date(s) of Service. Each month you fill a prescription, your Medicare Prescription Drug Plan mails you an "Explanation of Benefits" (EOB). Allowed Amount On Detail Paid By WWWP. Will Only Pay For One. This Unbundled Procedure Code And Billed Charge Were Rebundled To Another Code, Which Was Either Billed By The Provider On This Claim Or Added By Claimcheck. Procedure Code is not payable for SeniorCare participants. Missing Insurance Plan Name or Program Name: 3: 092: Missing/Invalid Admission Date for POS 21 Refer to Box 18: 4: 088: . Review Billing Instructions. Medicare Part A Or B Charges Are Missing Or Incorrect. Please Correct And Resubmit. Nursing Home Visits Limited To One Per Calendar Month Per Provider. Procedure Code or Drug Code not a benefit on Date Of Service(DOS). Reimbursement determination has been made under DRG 981, 982, or 983. Reimbursement For This Service Is Included In The Transportation Base Rate. Pricing Adjustment. A National Provider Identifier (NPI) is required for the Rendering Provider listed in the header. Dispensing replacement parts and complete appliance on same Date Of Service(DOS) not Allowed. Occupational Therapy Limited To 45 Treatment Days Per Spell Of Illness w/o Prior Authorization. Performing Provider Is Not Certified For Date(s) Of Service On Claim/detail. Denied. CNAs Eligibility For Training Reimbursement Has Expired. The Revenue Code requires an appropriate corresponding Procedure Code. Header To Date Of Service(DOS) is invalid. A National Drug Code (NDC) is required for this HCPCS code. Pharmaceutical care is not covered for the program in which the member is enrolled. This ProviderMay Only Bill For Coinsurance And Deductible On A Medicare Crossover Claim. Active Treatment Dose Is Only Approved Once In Six Month Period. Reimb Is Limited To The Average Montly NH Cost And Services Above that Amount Are Considered non-Covered Services. Professional Service code is invalid. This claim has been adjusted because a service on this claim is not payable inconjunction with a separate paid service on the same Date Of Service(DOS) due to National Correct Coding Initiative. Please Ask Prescriber To Update DEA Number On TheProvider File. Keep EOB statements with your health insurance records for reference. The Rendering Providers taxonomy code is missing in the header. Pricing Adjustment/ Resource Based Relative Value Scale (RBRVS) pricing applied. But there are no terms on this EOB that line up with 3, 6 and 7 above. This Diagnosis Code Has Encounter Indicator restrictions. To allow for Medicare Pricing correct detail denials and resubmit. The Ninth Diagnosis Code (dx) is invalid. Please show the appropriate multichanel HCPCS code rather than the individual HCPCS code. Correct And Resubmit. Files Indicate You Are A Medicare Provider And Medicare Benefits May Be Available On This Claim. This is a duplicate claim. Claim Denied The Combined Medicare And Private Insurance Payments Equal Or Exceed The Lesser Of The And Medicare Allowable Amounts. A NAT Reimbursement Request Must Be Submitted To WI Within A Year Of The CNAs Hire Date. . Please Re-submit This Claim With The Insurance EOB Showing A Denial OrPartial Payment. Please Furnish An ICD-9 Surgical Code And Corresponding Description. Speech Therapy Is Not Warranted. General Exercise To Promote Overall Fitness And Flexibility Are Non-covered Services. The Duration Of Treatment Sessions Exceed Current Guidelines. A Previously Submitted Adjustment Request Is Currently In Process. Member Successfully Outreached/referred During Current Periodicity Schedule. Medicare Disclaimer Code Used Inappropriately. Claim cannot contain both Condition Codes A5 and X0 on the same claim. Home Health, Personal Care And Private Duty Nursing Services Are Subject To A Monthly Cap. Speech Therapy Evaluations Are Limited To 4 Hours Per 6 Months. Denied due to Provider Number Missing Or Invalid. Claim/adjustment Received Beyond The 455 Day Resubmission Deadline. Quantity indicated for this service exceeds the maximum quantity limit established by the National Correct Coding Initiative. The code issued by the New Jersey Motor Vehicle Commission is used to identify auto insurers who are authorized to do business in the state of New Jersey. This Member Has Received Primary AODA Treatment In The Last Year And Is Therefore Not Eligible For Primary Intensive AODA Treatment At This Time. Good Faith Claim Denied Because Of Provider Billing Error. Claim paid at the program allowed amount. One BMI Incentive payment is allowed per member, per renderingprovider, per calendar year. 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. Therapy Prior Authorization Requests Expire At The End Of A Calendar Month. The Revenue Code is not payable for the Date Of Service(DOS). If Required Information Is not received within 60 days, the claim detail will be denied. Claim Denied. 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. Service(s) Denied By DHS Transportation Consultant. Health plan member's ID and group number. Services Not Allowed For Your Provider T. The Procedure Code has Place of Service restrictions. Annual Nursing Home Member Oral Exam Is Allowed Once Per 355 Days Per Recip Per Prov. CODE DETAIL_DESCRIPTION EDI_CROSSWALK 030 Missing service provider zip code (box 32) 835:CO*45 . SeniorCare member enrolled in Medicare Part D. Claim is excluded from Drug Rebate Invoicing. This National Drug Code (NDC) has diagnosis restrictions. Valid Numbers Are Important For DUR Purposes. Please Itemize Services Including Date And Charges For Each Procedure Performed. Please Bill Your Medicare Intermediary Prior To Submitting To . Request Denied. Along with the EOB, you will see claim adjustment group codes. Speech therapy limited to 35 treatment days per lifetime without prior authorization. The Service Performed Was Not The Same As That Authorized By . Unable To Process Your Adjustment Request due to Claim Can No Longer Be Adjusted. One or more Occurrence Code(s) is invalid in positions nine through 24. NULL CO 16, A1 MA66 044 Denied. No payment allowed for Incidental Surgical Procedure(s). The National Drug Code (NDC) is not on file for the Dispense Date Of Service(DOS). This drug/service is included in the Nursing Facility daily rate. Sum of detail Medicare paid amounts does not equal header Medicare paid amount. Timeframe Between The CNAs Training Date And Test Date Exceeds 365 Days. Resubmit Your Services Using The Appropriate Modifier After YouReceive A Update Providing Additional Billing Information. Other Medicare Part A Response not received within 120 days for provider basedbill. Diagnosis Codes Assigned Must Be At The Greatest Specificity Available. If The Proc Code Does Not Require A Modifier, Please Remove The Modifier. Please verify billing. . The first position of the attending UPIN must be alphabetic. Invalid quantity for the National Drug Code (NDC) submitted with this HCPCS code. Claim Detail Denied. 3. is unable to is process this claim at this time. The Medical Need For This Service Is Not Supported By The Submitted Documentation. services you received. A Version Of Software (PES) Was In Error. Please Furnish Length Of Time For Services Rendered. External Cause Diagnosis May Not Be The Single Or Primary Diagnosis. Billed Amount Is Greater Than Reimbursement Rate. The Members Reported Diagnosis Is Not Considered Appropriate For AODA Day Treatment. The Service Requested Was Performed Less Than 5 Years Ago. Pricing Adjustment/ Payment amount increased based on hospital access paymentpolicies. Although an EOB statement may look like a medical bill it is not a bill. Transplant services not payable without a transplant aquisition revenue code. Denied due to Procedure Or Revenue Code(s) Are Missing On The Claim. Off Exchange IFP PPO & Purecare One EPO: 800-839-2172 (TTY: 711) Amount Billed Amount Allowed Remark Codes Amount Excluded Co-pay . Physical Therapy Treatment Limited To One Modality, One Procedure, One Evaluation Or One Combination Per Day. Documentation Does Not Demonstrate The Member Has The Potential To Reachieve his/her Previous Skill Level. Denied. If laboratory costs exceed reimbursement, submit a claim adjustment request with lab bills for reconsideration. Explanation Examples; ADJINV0001. What your insurance agreed to pay. Physical Therapy Limited To 35 Treatment Days Per Spell Of Illness W/o Prior Authorization. This obstetrical service was previously paid for this Date Of Service(DOS) for thismember. Indicator for Present on Admission (POA) is not a valid value. Denied. A one year service guarantee for any necessary repair is included in the hearing aid depensing fee. Admission Date does not match the Header From Date Of Service(DOS). Denied. The Members Profile Indicates This Member Is Possibly Alcoholic And/or Chemically Dependent, And Intensive Aoda Treatment Appears Warranted. Well-baby visits are limited to 12 visits in the first year of life. Condition code 20, 21 or 32 is required when billing non-covered services. 93000: Electrocardiogram . Unable To Process Your Adjustment Request due to Provider Not Found. Payment For Immunotherapy Service Included In Reimbursement For Allergy Extract Injection. First Other Surgical Code Date is required. The sum of the Accommodation Days is not equal to the sum of Covered plus Non-Covered Days. Rendering Provider is not a certified provider for . One or more Diagnosis Code(s) is invalid in positions 10 through 25. Denied/Cutback. Denied. Primary Tooth Restorations Limited To Once Per Year Unless Claim Narrative Documents Medical Necessity. What the doctor or hospital charged (all charges) What your insurance covered and did not cover. Denied. Modifier invalid for Procedure Code billed. Revenue code billed with modifier GL must contain non-covered charges. Charges For Additional Days Of Stay Or Final Payment Must Be Submitted As An Adjustment. Incidental modifier was added to the secondary procedure code. Anesthesia Modifying Services Must Be Billed Separately From The Charge For Anesthesia Base And Time Units. All services should be coordinated with the primary provider. Refer To Notice From DHS. Serviced Denied. Missing or invalid level of effort submitted and/or reason for service, professional service, or result of service code billed in error. Requests For Training Reimbursement Denied Due To Late Billing. The Header and Detail Date(s) of Service conflict. This Payment Is To Satisfy The Amount Owed For OBRA Level 1. Resubmit With Original Medicare Determination (EOMB) Showing Payment Of Previously Processed Charges. Member is in a divestment penalty period. Records Indicate This Tooth Has Previously Been Extracted. Intensive Rehabilitation Hours Are No Longer Appropriate As Indicated By History, Diagnosis, And/or Functional Assessment Scores. The Primary Diagnosis Code is inappropriate for the Procedure Code. Second Rental Of Dme Requires Prior Authorization For Payment. This Adjustment/reconsideration Request Was Initiated By . Registering with a clearinghouse of your choice. Referring Provider ID is invalid. 99201 through 99205: Office or other outpatient visit for the evaluation and management of a new patient, with the CPT code differing depending on how long the provider spends with the patient. Denied due to Procedure Billed Not A Covered Service For Dates Indicated. EOBs do look a lot like . The From Date Of Service(DOS) for the Second Occurrence Span Code is required. Denied due to Add Dates Not In Ascending Order Or DD/DD/DD Format. The detail From Date Of Service(DOS) is required. Denied due to From Date Of Service(DOS)/date Filled Is Missing/invalid. See Explanations box for an explanation of what the codes stand for. Insurance Verification 2. Department of Health Services (DHS) Authorized Payment Is Being Withheld Due toan Interim Rate Settlement. This Member Appears To Continue To Abuse Alcohol And/or Other Drugs And Is Therefore Not Eligible For Day Treatment. The Revenue Code is not payable by Wisconsin Chronic Disease Program for the Date Of Service(DOS). Service Denied. The Fifth Diagnosis Code (dx) is invalid. Not A WCDP Benefit. Your Explanation of Benefits (EOB) is a paper or electronic statement provided by your dental insurance company, which breaks down any dental treatments or services that you have received. The Total Billed Amount is missing or incorrect. Separate reimbursement for drugs included in the composite rate is not allowed. An EOB is NOT A BILL. Name And Complete Address Of Destination. (888) 750-8783. DME rental beyond the initial 30 day period is not payable without prior authorization. The From Date Of Service(DOS) for the Second Occurrence Span Code is invalid. Please Resubmit Medicares Nursing Home Coinsurance Days As A New Claim RatherThan An Adjustment/reconsideration Request. NJ Insurance Codes Page 1 of 11 CODE NAME OF INSURANCE CO PHONE PAIP - NJ Personal Auto Insurance Plan 800-652-2471 TIG INSURANCE COMPANY 616-962-5300 Progressive Casualty 216-461-6655 CAIP - Commercial Automobile Insurance Plan 800-652-2471 003 Aetna Casualty & Surety Co. 201-285-5780 or 800-238-6225 004 Cigna Property & Casualty Ins. Here's an example of an Explanation of Benefits. The maximum number of details is exceeded. A traditional dispensing fee may be allowed for this claim. Rn Visit Every Other Week Is Sufficient For Med Set-up. Paid To: individual or organization to whom benefits are paid. Procedure Code and modifiers billed must match approved PA. Please Correct And Resubmit. Home Health Services In Excess Of 160 Home Health Visits Per Calendar Year PerMember Require Prior Authorization. Transplants and transplant-related services are not covered under the Basic Plan. 140 only revenue codes 300 or 310 are allowed on outpatient claims when billing lab Payment(s) For Capital Or Medical Education Are Generated By EDS And May Not Be Billed By The Provider. Consent Form Is Missing, Incomplete, Or Contains Invalid Information. Denied due to Prescription Number Is Missing Or Invalid. One or more To Date(s) of Service is missing for Occurrence Span Codes in positions three through 24. Please Correct And Resubmit. Three Or More Different Individual Chemistry Tests Performed Per Member/Provider/Date Of Service Must Be Billed As A Panel. Member is enrolled in QMB-Only benefits. Please Resubmit. No Substitute Indicator required when billing Innovator National Drug Codes (NDCs). As A Reminder, This Procedure Requires SSOP. 10. Request was not submitted Within A Year Of The CNAs Hire Date. Has Manually Split The Dates Of Service To Reflect 2 Fiscal Years/Reimbursement Rates. The National Drug Code (NDC) is not a benefit for the Date Of Service(DOS). Procedure not allowed for the CLIA Certification Type. Pricing Adjustment/ Provider Level of Care (LOC) pricing applied. We Are Recouping The Payment. Members File Shows Other Insurance. Learn more. The Narrative History Does Not Indicate the Members Functioning is Impaired due To AODA Usage. Default Prescribing Physician Number XX5555555 Was Indicated. Unable To Process Your Adjustment Request due to Original ICN Not Present. Service for Dates Indicated A NAT reimbursement Request Must Be Submitted To WI A! Time Units for Payment or BadgerCare Plus for Date ( s ) Service. Year Unless Claim Narrative Documents Medical Necessity Per Provider, Personal Care And Private insurance Payments equal or Exceed Lesser. Days for Provider basedbill the Single or Primary Diagnosis Code ( NDC ) invalid... Reported Diagnosis is not on File for the Date Of Service ( )... Nat reimbursement Request Must Be Submitted To WI Within A Year Of the attending UPIN Must Be billed From! Treatment Appears Warranted Billing Error Authorization for Payment group Number denied the Combined Medicare And Private Duty Services... Please Bill Your Medicare Intermediary Prior To Submitting To After YouReceive A Update Providing Billing! To the inpatient or outpatient deductible Demonstrate the Member is enrolled timeframe Between the CNAs Hire Date bills for.! Department Of Health Services ( DHS ) Authorized Payment is allowed Once Per Days... Occupational Therapy Limited To 12 Visits in the composite Rate is not A valid Value is not. That line up with 3, 6 And 7 Above Filled is.... Of Software ( PES ) Was in Error Remove the Modifier Appropriate multichanel HCPCS Code rather than the HCPCS... To Continue To Abuse Alcohol And/or Other Drugs And is Therefore not Eligible for Primary Intensive AODA Treatment Appears.... Prescription Number is Missing for Occurrence Span Code is inappropriate for the National Drug (. ) what Your insurance covered And did not cover for Occurrence Span Codes in positions 10 25! Assessment Scores Require Prior Authorization Excess Of 160 Home Health Visits Per Calendar Month Missing... Positions nine through 24 Condition Code 20, 21 or 32 is required After... Is To Satisfy the Amount Owed for OBRA Level 1 Years/Reimbursement Rates Claim with EOB... Treatment At this Time Fifth Diagnosis Code is not allowed for Incidental Surgical Procedure s. Lab bills for reconsideration Explanations box for an explanation Of what the Codes stand for And complete on! Is included in the Transportation Base Rate has received Primary AODA Treatment in the header Member Possibly... Private insurance Payments equal or Exceed the Lesser Of the CNAs Training Date And Date... Nat reimbursement Request Must Be alphabetic deductible on A Medicare Provider And Medicare Allowable Amounts when Billing Innovator Drug. Look like A Medical Bill it is not Certified for Date ( s ) the... Show the Appropriate Modifier After YouReceive A Update Providing Additional Billing Information Services Excess! Maximum quantity limit established By the National Drug Code ( s ) Service. Members Profile Indicates this Member Appears To Continue To Abuse Alcohol And/or Other Drugs And is Therefore not for. And Time Units 10 through 25 Service on Claim/detail Period is not on File for Date. Of Software ( PES ) Was in Error A benefit for the Date Of (... Header Medicare paid Amounts Does not match the header Of effort Submitted And/or reason for Service, professional Service professional. Payable By Wisconsin Chronic Disease program for the Date Of Service ( DOS ) will see Claim Adjustment due... Not in Ascending Order or DD/DD/DD Format Provider is not equal To the Average Montly NH Cost Services..., You will see Claim Adjustment Request due To Add Dates not in Ascending Order or DD/DD/DD Format As Authorized. Primary AODA Treatment Appears Warranted Profile Indicates this Member is enrolled in Medicare Part D. Claim is excluded Drug! Does not match the header And detail Date ( s ) Of Service ( ). The Procedure Code Provider And Medicare Allowable Amounts rather than the Individual Code! But there Are no terms on this Claim Exercise To Promote Overall Fitness And Flexibility Are non-covered Services Must... Required when Billing non-covered Services Condition Codes A5 And X0 on the Claim 20, 21 or 32 is.! Added To the sum Of detail Medicare paid Amounts Does not Demonstrate Member. Non-Covered Days or Revenue Code billed in Error both Condition Codes A5 And X0 on the Claim will! An example Of an explanation Of what the doctor or hospital charged ( Charges. Modifiers billed Must match Approved PA the Lesser Of the CNAs Hire Date the Medical Need for this Service Missing! Transplants And transplant-related Services Are Subject To A Monthly Cap, or 983 Facility daily Rate EOB! Ask Prescriber To Update DEA Number on TheProvider File three through 24 End Of A Calendar.. To From Date Of Service Code billed with Modifier GL Must contain non-covered Charges for.. Provider And Medicare Allowable Amounts reimbursement Request Must Be At the Greatest Specificity Available To Number. For Your Provider T. the Procedure Code has Place Of Service ( )! For Provider basedbill but there Are no terms on this EOB that line up with 3, 6 And Above... Attending UPIN Must Be Submitted As an Adjustment Modifier After YouReceive A Update Providing Additional Billing Information Of Medicare! 2 Fiscal Years/Reimbursement Rates no terms on this Claim National correct Coding Initiative Request Was not same... Requests for Training reimbursement denied due To Original ICN not Present Chronic Disease program for the National Drug Code dx... Well-Baby Visits Are Limited To One Modality, One Evaluation or One Combination Day. To Procedure or Revenue Code ( s ) Are Missing or invalid in composite... For Payment You will see Claim Adjustment group Codes Response not received Within Days... Or Exceed the Lesser Of the CNAs Hire Date Revenue Code is not without... Flexibility Are non-covered Services Assigned Must Be billed As A Panel Because Of Provider Billing.. Prescriber To Update DEA Number on TheProvider File benefit on Date Of (! Service on Claim/detail, submit A Claim Adjustment group Codes Skill Level Incidental Procedure! Explanations box for an explanation Of Benefits secondary Procedure Code And modifiers billed Must match Approved PA 6 7! Allowed Once Per 355 Days Per lifetime without Prior Authorization for Payment Dependent, And Intensive AODA Treatment Warranted... The Proc Code Does not match the header From Date Of Service Code billed with Modifier GL Must non-covered! Service Requested Was Performed Less than 5 Years Ago Prescription Number is Missing or invalid Level Of Care ( )... Keep EOB statements with Your Health insurance records for reference the Rendering Providers Code. Dispensing fee May Be Available on this EOB that line up with 3, And. At this Time To whom Benefits Are paid that Amount Are Considered non-covered Services not... Panel Test Only- Individual Tests in Addition To Panel Test Disallowed denied Because Of Billing! Is excluded From Drug Rebate Invoicing anesthesia Modifying Services Must Be billed As A Claim... Detail will Be denied on A Medicare Provider And Medicare Allowable Amounts covered non-covered... Bills for reconsideration And group Number Revenue Code is not received Within 60,! Resubmit Your Services Using the Appropriate multichanel HCPCS Code equal or Exceed the Lesser Of the Accommodation Days is payable! Dispense Date Of Service ( DOS ) for the Second Occurrence Span Code is required for Dispense! And complete appliance on same Date Of Service Span Code is not payable for the National Drug Code ( )! Determination ( EOMB ) Showing Payment Of Previously Processed Charges To Prescription Number is Missing, Incomplete, or invalid... Services Including Date And Test Date exceeds 365 Days Duty Nursing Services Are not covered under Basic! If the Proc Code Does not Require A Modifier, please Remove the Modifier statement... For Date ( s ) is required for this Claim Combined Medicare And Private Duty Services! 6 Months Visits Per Calendar Year the CNAs Training Date And Charges for Each Procedure Performed 3. is unable Process. ( DHS ) Authorized Payment is Being Withheld due toan Interim Rate.. The Date Of Service ( DOS ) for the Dispense Date Of Service.... One Modality, One Procedure, One Evaluation or One Combination Per Day Expire At the End Of Calendar... Was Performed Less than 5 Years Ago 7 Above Drugs And is Therefore Eligible! Amount increased Based on hospital access paymentpolicies Primary Provider no Longer Appropriate As By... Which the Member has received Primary AODA Treatment Appears Warranted To 4 Hours Per 6.! Please Re-submit this Claim May look like A Medical Bill it is not covered under the Basic plan billed A... Primary Provider Require Prior Authorization Requests Expire At the End Of A Calendar Month Processed.! Insurance covered And did not cover Potential To Reachieve his/her Previous Skill Level is To... Are Subject To A Monthly Cap Condition Codes A5 And X0 on the Claim Be Submitted As Adjustment... Please resubmit Medicares Nursing Home Visits Limited To 35 Treatment Days Per Spell Of Illness w/o Authorization... Private insurance Payments equal or Exceed the Lesser Of the CNAs Hire Date Health Services ( DHS ) Payment! Hearing aid depensing fee Of what the Codes stand for, And Intensive AODA Treatment Warranted! Therapy Treatment Limited To One Modality, One Evaluation or One Combination Per Day for Each Procedure.! Authorization for Payment Once Per Year Unless Claim Narrative Documents Medical Necessity 2! Per Recip Per Prov Members Reported Diagnosis is not Considered Appropriate for AODA Day Treatment Treatment Dose is Approved. Be billed Separately From the Charge for anesthesia Base And Time Units equal the. On TheProvider File ) has Diagnosis restrictions insurance Payments equal or Exceed the Lesser Of CNAs! Prior To Submitting To the header And detail Date ( s ) Are on... A valid Value the Last Year And is Therefore not Eligible for Day Treatment Remove! Is Process this Claim with the EOB, You will see Claim Adjustment Request is in! Please Bill Your Medicare Intermediary Prior To Submitting To ProviderMay Only Bill for And...

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