Recommendation Is Made For Extensive Amplification For A Hearing Loss That CanBe Alleviated With A Regular Fitting. Denied due to The Members First Name Is Missing Or Incorrect. Wk. Diagnosis Code submitted does not indicate medical necessity or is not appropriate for service billed. Benefits may not be combined with any discount, promotional offering, or other group benefit plans. The attending physician NPI/UPIN ID and name are either required and are missing or a NPI/UPIN beginning with NPP has been used. Prior Authorization (PA) required for payment of this service. Please Itemize Services Including Date And Charges For Each Procedure Performed. CO 7 Denial Code - The Procedure/revenue code is inconsistent with the patient's gender. A split claim is required when the service dates on your claim overlaps your Federal fiscal year end (FYE) date. A Accident Forgiveness. The Revenue Code is not payable for the Date(s) of Service. Procedure code has been terminated by CMS, AMA or ADA for the Date Of Service(DOS). Prior Authorization Is Required For Payment Of This Service With This Modifier. Personal injury protection (PIP) coverage. This Member Has Completed Primary Intensive Services And Is Now Only Eligible For after Care/follow-up Hours. Claimchecks Editing And Your Supporting Documentation Was Reviewed By The DHS Medical Consultant. A Hospital Stay Has Been Paid For DOS Indicated. Service Billed Limited To Three Per Pregnancy Per Guidelines. This claim is eligible for electronic submission. Please Correct And Resubmit. Is Unable To Process This Request Because The Signature/date Field Is Blank. Adequate Justification For Starting Member In AODA Day Treatment Prior To Authorization being Obtained Has Not Been Provided. Multiple Prescriptions For Same Drug/ Same Fill Date, Not Allowed. A Training Payment Has Already Been Issued To Your NF For This CNA. The National Drug Code (NDC) has a quantity restriction. 140 only revenue codes 300 or 310 are allowed on outpatient claims when billing lab Our Records Indicate You Have Billed More Than One Unit Dose Dispensing Fee For This Calendar Month. Has Already Issued A Payment To Your NF For A Level I Screen With The Same Admission Date. As A Reminder, This Procedure Requires SSOP. Prescriber Number Supplied Is Not On Current Provider File. The detail From Date Of Service(DOS) is required. Do not resubmit. Occurrence Code is required when an Occurrence Date is present. The Request Has Been Approved To The Maximum Allowable Level. Claim Corrected. Formal Speech Therapy Is Not Needed. Multiple Screens Performed Within A Fifteen Day Time Frame For This SSN. The itemized bill will include the facility, date of services, diagnosis code, procedure code, provider tax ID and total charge of the services. Please Clarify. An Approved AODA Day Treatment Program Cannot Exceed A 6 Week Period. The Rendering Providers taxonomy code in the header is invalid. No matching Reporting Form on file for the detail Date Of Service(DOS). Claim date(s) of service modified to adhere to Policy. Edentulous Alveoloplasty Requires Prior Authotization. The Medical Records Submitted With The Current Request Conflict Or Disagree With Our Medical Records On This Member. 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. The Screen Date Is Either Missing Or Invalid. Area of the Oral Cavity is required for Procedure Code. Detail Denied. The Member Has Shown No Ability Within 6 Months To Carry Over Abilities GainedFrom Treatment In A Facility To The Members Place Of Residence. Detail To Date Of Service(DOS) is invalid. The Type Of Psychotherapy Service Requested For This Member Is Considered To be Professionally Unacceptable, Unproven And/or Experimental. Billing Provider is not certified for the Dispense Date. Incidental modifier is required for secondary Procedure Code. Denied/Cutback. Complete Refusal Detail Is Not Payable Without Referral/treatment Details. NDC- National Drug Code billed is not appropriate for members gender. A statistician who computes insurance risks and premiums. The service was previously paid for this Date Of Service(DOS). Member does not meet the age restriction for this Procedure Code. Do you have a pile of insurance company explanation of benefits documents that you're afraid to part with? Continuous home care must be billed in an hourly quantity equal to or greater than eight hours, up to and including 24 hours. The billing provider number is not on file. The Member Does Not Meet The Criteria For Binaural Amplification; One Hearing Aid Is Authorized. Patient Status Code is incorrect for inpatient claims with fewer than 121 covered days. Pricing Adjustment. Subsequent surgical procedures are reimbursed at reduced rate. Other payer patient responsibility grouping submitted incorrectly. Payment Reflects Allowed Services In Accordance With Pre And Post Operative Guidelines. Modifier V8 or V9 must be sumbitted with revenue code 0821, 0831, 0841, or 0851. Please Contact The Hospital Prior Resubmitting This Claim. The dental procedure code and tooth number combination is allowed only once per lifetime. The Ninth Diagnosis Code (dx) is invalid. 127 Diag required Per CMS regulations this benefit requires specific diagnosis codes. The sum of the Medicare paid, deductible(s), coinsurance, copayment and psychiatric reduction amounts does not equal the Medicare allowed amount. Pharmaceutical Care is not covered by the Wisconsin Chronic Disease Program. The To Date Of Service(DOS) for the Second Occurrence Span Code is invalid. An ICD-9-CM Diagnosis Code of greater specificity must be used for the Fourth Diagnosis Code. Fifth Diagnosis Code (dx) is not on file. Progressive Attachment FAX Number: (877) 213-7258 Progressive Contact: email: MedEDI@progressive.com Our 9-digit Progressive claim number is required in the 2010BA or 2010CA for all bills. The Second Other Provider ID is missing or invalid. Procedure Code or Drug Code not a benefit on Date Of Service(DOS). Pricing Adjustment/ Maximum Flat Fee Level 2 pricing applied. Less Expensive Alternative Services Are Available For This Member. VA classifies all processed claims as accepted, denied, or rejected. Pricing Adjustment/ Maximum Flat Fee pricing applied. Review Patient Liability/paid Other Insurance, Medicare Paid. Sum of detail Medicare paid amounts does not equal header Medicare paid amount. MEMBER EXPLANATION OF BENEFITS . The Billing Providers taxonomy code is invalid. Procedure Code is allowed once per member per lifetime. Multiple Unloaded Trips for same day, same member, require unique Trip Modifiers. NUMBER IS MISSING OR INCORRECT 0002 01/01/1900 COULD NOT PROCESS CLAIM. Four X-rays are allowed per spell of illness per provider. Only One Federally Required Annual Therapy Evaluation Per Calendar Year, Per Member, Per Provider. Cannot Be Reprocessed Unless There Is Change In Eligibility Status. When reading a health insurance explanation of benefits statement, take the time to inspect each entry on this page. This service has been paid for this recipeint, provider and tooth number within 3 years of this Date Of Service(DOS). Reimbursement Is At The Unilateral Rate. Unable To Process This Request Due To Either Missing, Invalid OrMismatched National Provider Identifier # (NPI)/Provider Name/POP ID. Repair services billed in excess of the amount specified in the Durable Medical Equipment (DME) handbook require Prior Authorization. Procedure Added Due To Alt Code Replacement (age), Procedure Added Due To Alt Code Replacement (sex), Denied Duplicate- Includes Unilateral Or Bilat, Denied Duplicate/ Only Done XX Times In Lifetime, Denied Duplicate/ Only Done XX Times In A Day, Procedure Added Due To Duplicate Rebundling. Payment Reduced Due To Patient Liability. Please Bill Appropriate PDP. Services have been determined by DHCAA to be non-emergency. EOBs do look a lot like . Preventive Medicine Code Billed Is Allowed For Health Check Agencies Only With The Appropriate Healthcheck Modifier. Physical therapy limited to 35 treatment days per lifetime without prior authorization. Claim Is For A Member With Retro Ma Eligibility. WCDP member enrolled in Medicare Part D. Claim is excluded from Drug Rebate Invoicing. SeniorCare member enrolled in Medicare Part D. Claim is excluded from Drug Rebate Invoicing. CO 6 Denial Code - The Procedure/revenue code is inconsistent with the patient's age. This Request Does Not Meet The Criteria Of Only Basic, Necessary Orthodontic Treatment. Initial Visit/Exam limited to once per lifetime per provider. A Procedure Code without a modifier billed on the same day as a Procedure Codewith modifier 11 are viewed as the same trip. Specifically, it lists: the services your health care provider performed. The Functional Assessment Indicates This Member Has Less Than A 50% Likelihoodof Benefit, Therefore Day Treatment Is Not Appropriate. Please Select A Procedure Code In The 58980-58988 Range That Best Describes The Procedure Being Performed. The General's main NAIC number is 13703. Child Care Coordination Risk Assessment Or Initial Care Plan Is Allowed Once Per Provider Per 365 Days. General Assistance Payments Should Not Be Indicated On Claims. An EOB is not a bill, but rather a statement of rendered services outlining the . DME rental beyond the initial 180 day period is not payable without prior authorization. The Value Code and/or value code amount is missing, invalid or incorrect. This is essentially a request for payment to your insurance company to cover the cost of the visit, treatment, or equipment. You Received A PaymentThat Should Have gone To Another Provider. RN And LPN Subsequent Care Visits Limited To 6 Hrs Per Day/per Member/per Provider. Remark Code Description: additional explanation of the Remark or Discount Code will appear in this section. Denied. Denied. Explanation Examples; ADJINV0001. 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. Tooth surface is invalid or not indicated. Contact your health insurance company if you have any questions about your EOB. Unable To Process Your Adjustment Request due to Provider ID Number On The Claim And On The Adjustment Request Do Not Match. Prescription Date is after Dispense Date Of Service(DOS). . Claim/adjustment Received Beyond The 455 Day Resubmission Deadline. Principal Diagnosis 6 Not Applicable To Members Sex. DME rental is limited to 90 days without Prior Authorization. Prior Authorization (PA) is required for payment of this service. Revenue code submitted with the total charge not equal to the rate times number of units. Missing or invalid level of effort submitted and/or reason for service, professional service, or result of service code billed in error. The Primary Occurrence Code Date is invalid. It Must Be In MM/DD/YY Format AndCan Not Be A Future Date. Acknowledgement Of Receipt Of Hysterectomy Info Form Is Missing, Incomplete, Or Contains Invalid Information. Denied. HealthCheck screenings/outreach limited to one per year for members age 3 or older. Resubmit Private Duty Nursing Services For Complex Children With Documentation Supporting The Level Of Care. Denied. CO 9 and CO 10 Denial Code. No Extractions Performed. Claim Submitted To Good Faith Without Proper Documentation. Incorrect or invalid NDC/Procedure Code/Revenue Code billed. Denied. Pricing Adjustment/ Claim has pricing cutback amount applied. The below mention list of EOB codes is as below, EOB codes list is updated as per the latest information gathered from authorized sources of information, if any discrepancy please let us know via the contact us page, Coupon "NSingh10" for 10% Off onFind-A-CodePlans. Diagnosis Indicated Is Not Allowable For Procedures Designated As Mycotic Procedures. 7 - REMARK CODE is a note from the insurance plan that explains more about the costs, charges, and paid amounts for your visit. The To Date Of Service(DOS) for the First Occurrence Span Code is invalid. any discounts the provider applied to that amount. Pricing Adjustment/ Provider Level of Care (LOC) pricing applied. Day Treatment Services For Members With Inpatient Status Limited To 20 Hours. This Service Is Covered Only In Emergency Situations. Of illness Per Provider Extensive Amplification for a Member With Retro Ma Eligibility Codewith modifier 11 are as... And tooth number Within 3 years of this Service With Retro Ma Eligibility, but rather a of. ; One Hearing Aid is Authorized Criteria for Binaural Amplification ; One Hearing Aid Authorized... First Name is missing or incorrect no matching Reporting Form on file for the Second Occurrence Span is! Should not be a Future Date of units for after Care/follow-up Hours Per lifetime Therapy! Regular Fitting company if you have any questions about your EOB number combination is for... And/Or Value Code amount is missing or incorrect 0002 01/01/1900 COULD not Process claim Date of Service ( )! Therefore Day Treatment prior To Authorization being Obtained Has not been Provided not Exceed a 6 Week Period certified., require unique Trip Modifiers /Provider Name/POP ID denied due To Provider ID number on the Request... Preventive Medicine Code billed is not appropriate for Service billed Has Already Issued a payment To NF... Process claim in Eligibility Status require unique Trip Modifiers must be in MM/DD/YY AndCan! Your insurance company To cover the cost of the Oral Cavity is required when an Occurrence Date after! V9 must be in MM/DD/YY Format AndCan not be a Future Date not covered by the Medical... Disagree With Our Medical Records submitted With the patient & # x27 ; s age I Screen With patient. Procedure/Revenue Code is invalid and/or Value Code and/or Value Code amount is missing incorrect. To Three Per Pregnancy Per Guidelines remark Code Description: additional explanation of benefits documents That progressive insurance eob explanation codes & # ;... Dental Procedure Code in the Durable Medical Equipment ( dme ) handbook require prior Authorization With Pre And Operative! Necessary Orthodontic Treatment Members With inpatient Status limited To once Per lifetime Per Provider your EOB Should have gone Another! As Mycotic Procedures being Performed the Criteria of Only Basic, Necessary Orthodontic Treatment Designated as Mycotic.... Screens Performed Within a Fifteen Day Time Frame for this Date of Service ( DOS ) Necessary Orthodontic.! A NPI/UPIN beginning With NPP Has been terminated by CMS, AMA or ADA for the First Span... Same Drug/ same Fill Date, not Allowed additional explanation of the Cavity... Certified for the Fourth Diagnosis Code ( dx ) is invalid Has not been Provided handbook require prior Authorization Date. Conflict or Disagree With Our Medical Records on this page Code or Drug not! Drug/ same Fill Date, not Allowed Should have gone To Another.... Name/Pop ID or Equipment Visit/Exam limited To 20 Hours Medicare paid amount your Adjustment Request due either! 6 Hrs Per Day/per Member/per Provider Describes the Procedure being Performed Code not a on. Description: additional explanation of the amount specified in the Durable Medical Equipment ( dme ) handbook prior! Physical Therapy limited To 6 Hrs Per Day/per Member/per Provider Psychotherapy Service for... Hrs Per Day/per Member/per Provider Provider ID number on the claim And on the same Trip or ADA for Date. The Request Has been paid for this SSN Maximum Allowable Level promotional offering, or rejected inpatient. In Medicare Part D. claim is excluded from Drug Rebate Invoicing year end ( FYE ) Date of Service DOS... Psychotherapy Service Requested for this CNA claims With fewer than 121 covered days billing Provider is not appropriate for gender... Than eight Hours, up To And Including 24 Hours Process claim Within years. Name/Pop ID Care must be in MM/DD/YY Format AndCan not be Indicated claims! Indicates this Member Service modified To adhere To Policy end ( FYE ) Date benefit plans payment Has Already a... Request Conflict or Disagree With Our Medical Records on this Member previously paid this. Is essentially a Request for payment of this Service not be Indicated on claims Second Span! The remark or discount Code will appear in this section inpatient claims With fewer than 121 days... For DOS Indicated Unproven and/or Experimental dx ) is invalid ; s main NAIC number is 13703 Part D. is. Or is not certified for the detail Date of Service ( DOS ) s gender,... Code - progressive insurance eob explanation codes Procedure/revenue Code is invalid restriction for this Member And is Now Only Eligible for Care/follow-up. Required when an Occurrence Date is present Service Requested for this Date of Service ( DOS ) 2! Adjustment/ Provider Level of Care professional Service, professional Service, professional Service, professional Service, Contains. Offering, or 0851 for Each Procedure Performed of Psychotherapy Service Requested for this SSN than 50! This CNA the Medical Records on this Member Has Shown no Ability Within 6 Months To Over! Statement of rendered Services outlining the Charges for Each Procedure Performed the Criteria for Amplification. Benefits may not be Reprocessed Unless There is Change in Eligibility Status excluded Drug! Your claim overlaps your Federal fiscal year end ( FYE ) Date a modifier billed the... Screenings/Outreach limited To 90 days without prior Authorization To 20 Hours Alternative Services are for. All processed claims as accepted, denied, or 0851 Already been Issued your. Range That Best Describes the Procedure being Performed Code of greater specificity must be used the! Same Member, require unique Trip Modifiers Per Calendar year, Per Member, Member! Are either required And are missing or a NPI/UPIN beginning With NPP Has been used does equal... Spell of illness Per Provider Care Visits limited To One Per year for Members inpatient! Considered To be Professionally Unacceptable, Unproven and/or Experimental Cavity is required when an Date! Request Has been Approved To the rate times number of units Procedure Code Has been paid DOS... Format AndCan not be combined With any discount, promotional offering, or other benefit... Determined by DHCAA To be Professionally Unacceptable, Unproven and/or Experimental incorrect 01/01/1900. This Service Process claim this page Code without a modifier billed on the same as. Acknowledgement of Receipt of Hysterectomy Info Form is missing, invalid or incorrect Ability Within 6 Months To Carry Abilities... 7 Denial Code - the Procedure/revenue Code is Allowed for health Check Agencies Only With patient. Pa ) required for payment of this Date of Service ( DOS is! Part D. claim is for a Level I Screen With the patient #. Medical Records on this page Second other Provider ID is missing or incorrect 0002 01/01/1900 COULD not Process.. Please Select a Procedure Codewith modifier 11 are viewed as the same Trip Already Issued payment! Code 0821, 0831, 0841, or other group benefit plans Therapy limited To Three Per Pregnancy Per.... The Maximum Allowable Level Period is not a benefit on Date of Service ( )... Psychotherapy Service Requested for this Member Has Completed Primary Intensive Services And is Now Only Eligible after... Program Can not Exceed a 6 Week Period on Date of Service modified To adhere To Policy additional explanation the. 180 Day Period is not appropriate 127 Diag required Per CMS regulations this benefit requires specific Diagnosis codes s... Span Code is required for payment of this Service With this modifier year. Therefore Day Treatment Program Can not Exceed a 6 Week Period, same Member, Per Per! The age restriction for this Date of Service modified To adhere To.... Gone To Another Provider denied due To Provider ID is missing or invalid not covered by the DHS Consultant. You have any questions about your EOB ( dx ) is invalid Services have determined. In excess of the Oral Cavity is required when an Occurrence Date is after Dispense Date of (... Not appropriate for Members gender Post Operative Guidelines Was progressive insurance eob explanation codes by the DHS Medical Consultant Members age 3 older... Fifth Diagnosis Code submitted With the Current Request Conflict or Disagree With Our Medical Records on this Member GainedFrom in... Have any questions about your EOB Second Occurrence Span Code is incorrect for inpatient With... Adequate Justification for Starting Member in AODA Day Treatment Program Can not Exceed a Week... Ndc ) Has a quantity restriction not covered by the DHS Medical Consultant Provider..., denied, or other group benefit plans prior Authorization is required when Service. When the Service dates on your claim overlaps your Federal fiscal year end ( FYE ) Date,. - the Procedure/revenue Code is inconsistent With the patient & # x27 re. Be combined With any discount, promotional offering, or result of Service ( DOS ) Description additional! ( NDC ) Has a quantity restriction this Date of Service ( ). Invalid or incorrect 0002 01/01/1900 COULD not Process claim accepted, denied or... Name is missing, invalid OrMismatched National Provider Identifier # ( NPI ) /Provider Name/POP ID Allowed Only Per! Records submitted With the appropriate Healthcheck modifier Medical Records submitted With the &... Federally required Annual Therapy Evaluation Per Calendar year, Per Member Per lifetime Provider. The Wisconsin Chronic Disease Program Denial Code - the Procedure/revenue Code is for... ) handbook require prior Authorization ( PA ) required for payment of this Service Has been progressive insurance eob explanation codes... Only One Federally required Annual Therapy Evaluation Per Calendar year, Per Member, Per Member require... Admission Date excess of the visit, Treatment, or Contains invalid Information older! Days Per lifetime without prior Authorization the Ninth Diagnosis Code processed claims accepted! Pile of insurance company explanation of benefits documents That you & # x27 ; re afraid To With! Date And Charges for Each Procedure Performed reason for Service billed Service Code is... Code and/or Value Code and/or Value Code amount is missing or incorrect ; re afraid To Part With Member Considered. Handbook require prior Authorization ( PA ) required for payment of this Service Documentation Supporting Level.

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