Participants Eligibility Not Complete, Please Re-submit Claim At Later Date. Diagnosis Codes Assigned Must Be At The Greatest Specificity Available. It breaks down the information like this: The services we provided. 2 above. One or more Surgical Code Date(s) is missing in positions seven through 24. Modifier Submitted Is Invalid For The Member Age. Pricing Adjustment/ Ambulatory Payment Classification (APC) pricing applied. the service performedthe date of the . Denied. Denied. is unable to is process this claim at this time. This claim is being denied because it is an exact duplicate of claim submitted. You Must Adjust The Nursing Home Coinsurance Claim. Verify billed amount and quantity billed. Rejected Claims-Explanation of Codes. Multiple Prescriptions For Same Drug/ Same Fill Date, Not Allowed. No Matching, Complete Reporting Form Is On File For This Client. Claim Number Given Is Not The Most Recent Number. . If it is medically necessary to exceed the limitation, submit an Adjustment/Reconsideration request with supporting documentation. Tooth surface is invalid or not indicated. Procedure Code is allowed once per member per lifetime. The Member Does Not Meet The Criteria For Binaural Amplification; One Hearing Aid Is Authorized. Billing Provider Type and/or Specialty is not allowable for the service billed. First Other Surgical Code Date is invalid. The Revenue Code is not payable by Wisconsin Well Woman Program for the Date(s) of Service. Procedure Code 59420 Must Be Used For 5 Or More Prenatal Visits With One Charge. Quantity Would Always Be 00010 If Number Of Pounds Not Indicated. An NCCI-associated modifier was appended to one or both procedure codes. The value code 48 (Hemoglobin reading) or 49 (Hematocrit) is required for the revenue code/HCPCS code combination. You may receive an Explanation of Beneits (EOB) from Health Net of California, Inc. or Health Net Life Insurance Company . Please Bill Medicare First. Please Request A Corrected EOMB Through The Medicare Carrier And Adjust With The Corrected EOMB. Prior Authorization Is Required For Payment Of This Service With This Modifier. Effective August 1 2020, the new process applies coding . Claim Reduced Due To Member Income Available Toward Cost Of Care (Nursing Home Liability). Assistance. The Service(s) Billed Are Considered Paid In The Payment For The Surgical Procedure. EOB Code Description Rejection Code Group Code Reason Code Remark Code 074 Denied. 10. The detail From Date Of Service(DOS) is required. So, what is an EOB? Independent RHCs Must Bill Codes W6251, W6252, W6253, W6254 Or W6255. Click here to access the Explanation of Benefit Codes (EOBs) as of March 17, 2022. Multiple Service Location Found For the Billing Provider NPI. Ninth Diagnosis Code (dx) is not on file. Service Denied. Denied/Cutback. No Complete WWWP Participation Agreement Is On File For This Provider. Patient Demographic Entry 3. Unable To Process Your Adjustment Request due to Provider Not Found. If Required Information Is not received within 60 days, the claim detail will be denied. Please Correct And Resubmit. A valid Referring Provider ID is required. Comprehension And Language Production Are Age-appropriate. This Is Not A Preadmission Screen And Is Not Reimbursable. Add-on codes are not separately reimburseable when submitted as a stand-alone code. Submitted rendering provider NPI in the detail is invalid. Denied due to The Members Last Name Is Missing. For Correct Liability Reimbursement, Do Not Adjust The Level Of Care Days Claim. Please File With Champus Carrier. What Is an Explanation of Benefits (EOB) statement? Request Denied Due To Late Billing. X-rays and some lab tests are not billable on a 72X claim. This HMO Capitation Payment Is Being Recouped It Was Inappropriately Paid During The Inital February HMO Capitation Cycle. These case coordination services exceed the limit. Denied. The National Drug Code (NDC) has a quantity restriction. Enhanced payment for providing services in a natural environment is limited toone service per discipline per day. Risk Assessment/Care Plan is limited to one per member per pregnancy. This Member Is Involved In Non-covered Services, And Hours Are Reduced Accordingly. Correct Claim Or Resubmit With X-ray. Treatment With More Than One Drug Per Class Of Ulcer Treatment Drug At The Same Time Is Not Allowed Through Stat PA. Service not covered as determined by a medical consultant. Dispense as Written indicator is not accepted by . The billing provider number is not on file. A Google Certified Publishing Partner. The Related Surgical Procedure is not a covered service under Wisconsin Medicaid or BadgerCare Plus. Pricing Adjustment/ Level of effort dispensing fee applied. Reimbursement Is Limited To The Average Monthly Nursing Home Cost And Services Above That Amount Are Considered Non-covered Services. Reimbursement limit for all adjunctive emergency services is exceeded. Another PNCC Has Billed For This Member In The Last Six Months. Members Up To 3 Years Of Age Are Limited To 2 Healthcheck Screens Per 12 Months. Resubmit Your Services Using The Appropriate Modifier After YouReceive A Update Providing Additional Billing Information. Total billed amount is less than the sum of the detail billed amounts. Billing Provider is not certified for the Dispense Date. Effective 04/01/09, the BadgerCare Plus Core Plan will limit coverage for Brochodilators-Beta Agonists to Proventil HFA and Serevent. Other Bifocal/Trifocal Lenses Acceptable Code Modifier V2219 Seg.width>28mm (explanation required) V2219 Flat Top 35 V2219 Executive V2220 Add >3.25D V2319 Seg.width>28mm (explanation required) V2319 Flat Top . Additional services mustbe billed as treatment services and count towards the Mental Health and/or substance abuse treatment policy for prior authorization. Pediatric Community Care is limited to 12 hours per DOS. The Procedure Code has Encounter Indicator restrictions. Claims For Sterilization Procedures Must Reflect ICD-9 Diagnosis Code V25.2. Admission Denied In Accordance With Pre-admission Review Criteria. Rqst For An Acute Episode Is Denied. Refill Indicator Missing Or Invalid. Claim Detail from Date Of Service(DOS) And to Date Of Service(DOS) Are Required And Must Be Within The Same Calendar Month. No Reimbursement Rates on file for the Date(s) of Service. Header From Date Of Service(DOS) is after the date of receipt of the claim. Valid Numbers AreImportant For DUR Purposes. Submit Claim To Insurance Carrier. Child Care Coordination services are reimbursable only if both the member and provider are located in Milwaukee County. EOBs are created when an insurance provider processes a claim for services received. The Hearing Aid Recommended Is Not Necessary; The Member Could Be Adequately Fitted With A Conventional Aid. Day Treatment Exceeding 5 Hours/day Not Payable Regardless Of Prior Authorization. Please Indicate Mileage Traveled. Unable To Process Your Adjustment Request due to Financial Payer Not Indicated. Please Contact The Hospital Prior Resubmitting This Claim. Annual Nursing Home Member Oral Exam Is Allowed Once Per 355 Days Per Recip Per Prov. Date of service is on or after July 1, 2010 and TOB is 72X, value code D5 mustbe present. NJM Insurance Codes. Additional Reimbursement Is Denied. Services Are Covered For Medically Needy Members Only When Healthcheck Referral is Indicated On Claim. The Screen Date Is Either Missing Or Invalid. MEMBER EXPLANATION OF BENEFITS . WCDP member enrolled in Medicare Part D. Claim is excluded from Drug Rebate Invoicing. 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. Result of Service code is invalid. Payspan's Electronic Explanation of Benefits (eEOB) is an electronically delivered version of the traditional EOB that leverages the Core Payspan Network . The Fax number is (877) 213-7258. A dispense as written indicator is not allowed for this generic drug. The Diagnosis Code is not payable for the member. Was Unable To Process This Request. Compound Ingredient Quantity must be greater than zero. Complex care of 17-plus hours and complex care of less than 17 hours are not allowed on the same Date Of Service(DOS). The Other Payer ID qualifier is invalid for . The Performing Or Billing Provider On The Claim Does Not Match The Billing Provider On Theprior Authorization File. BILLING PROVIDER ID NUMBER MISSING: 0202; BILLING PROVIDER ID IN INVALID FORMAT . Prescriber ID and Prescriber ID Qualifier do not match. The Procedure Requested Is Not On s Files. Service Denied. Psych Evaluation And/or Functional Assessment Ser. Repackaging Allowance for this National Drug Code (NDC) is not reimbursable. 2 above. Level, Intensity Or Extent Of Service(s) Requested Has Been Modified Consistent With Medical Need As Defined In The Plan Of Care. After Progressive adjudicates the bill, AccidentEDI will send an 835 Denied due to Statement From Date Of Service(DOS) Is After The Through Date Of Service(DOS). CO 9 and CO 10 Denial Code. A statistician who computes insurance risks and premiums. The dental procedure code and tooth number combination is allowed only once per lifetime. Cutback/denied. Denied. The Reimbursement Code Assigned To This Certification Segment Does Not Authorize a Training Payment. Birth to 3 enhancement is not reimbursable for place of service billed. DME rental is limited to 90 days without Prior Authorization. A Version Of Software (PES) Was In Error. The Clinical Status Of The Member Does Not Meet Standards Accepted By The Department Of Health And Family Services For Transplant. Condition code 20, 21 or 32 is required when billing non-covered services. Questionable Long Term Prognosis Due To Gum And Bone Disease. PIP coverage protects you regardless of who is at fault. The header total billed amount is invalid. Value Code 48 And 49 Must Have A Zero In The Far Right Position. Member is enrolled in Medicare Part D for the Dispense Date Of Service(DOS). Service(s) paid in accordance with program policy limitation. Concurrent Services Are Not Appropriate. Effective 04/01/09, the BadgerCare Plus Core Plan will limit coverage for Hypoglycemics-Insulin to Humalog and Lantus. The Eighth Diagnosis Code (dx) is invalid. The attending physician NPI/UPIN ID and name are either required and are missing or a NPI/UPIN beginning with NPP has been used. Please Re-submit This Claim With The Insurance EOB Showing A Denial OrPartial Payment. Claim Denied Due To Absent Or Incorrect Discharge (to) Date. Denied. BMN prior authorization may be submitted for Mental Health drugs for which a Core Plan transitioned member has been previously grandfathered. Compound Drugs require a minimum of two ingredients with at least one payable BadgerCare Plus covered drug. . A SeniorCare drug rebate agreement is not on file for this drug for the Date Of Service(DOS). It is a duplicate of another detail on the same claim. Gastrointestinal Surgery For The Purpose Of Weight Control Is Covered Only As An Emergency Procedure. Payment has been reduced or denied because the maximum allowance of this ESRD service has been reached. Only One Service/ Per Date Of Service(DOS)/ Per Provider For Diagnostic Testing Services. . Contact your health insurance company if you have any questions about your EOB. ICD-9-CM Diagnosis code in diagnosis code field(s) 1 through 9 is missing or incorrect. Providing services in a natural environment is limited toone Service per discipline per day one per! 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