Area of the Oral Cavity is required for Procedure Code. An Explanation of Benefits, or EOB, is a statement that shows information about how your claim for health care services was processed by us. Allowance For Coinsurance Is Limited To Allowable Amount Less Medicares Payment. Member is assigned to a Lock-in primary provider. Prescription Drug Plan (PDP) payment/denial information required on the claim to WCDP. This HMO Capitation Payment Is Being Recouped It Was Inappropriately Paid During The Inital February HMO Capitation Cycle. Note: The Group, Reason and Remark Codes are HIPAA EOB codes and are cross-walked to L&I's EOB codes. Members I.d. PleaseResubmit Charges For Each Condition Code On A Separate Claim. Denied due to NDC Is Not Allowable Or NDC Is Not On File. Liberty Mutual insurance code: 23043. ICD-9-CM Diagnosis code in diagnosis code field(s) 1 through 9 is missing or incorrect. Member is enrolled in a State-contracted managed care program for the Date(s) of Service. A number is required in the Covered Days field. Pricing Adjustment/ Reimbursement reduced by the members copayment amount. Condition code 80 is present without condition code 74. 51.42 Board Directors Or Designees Statement & Signature Required OnThe Claim Form For Payment Of Functional Assessment. Medical Need For Equipment/supply Requested Is Not Supported By Documentation Submitted. Provider Not Eligible For Outlier Payment. A split claim is required when the service dates on your claim overlaps your Federal fiscal year end (FYE) date. No Supporting Documentation. Procedure Code Modifier(s) Invalid For Date Of Service(DOS) Or For Prior Authorization Date Of Receipt. Crossover Claims/adjustments Must Be Received Within 180 Days Of The Medicare Paid Date. A covered DRG cannot be assigned to the claim. Enhanced payment for providing services in a natural environment is limited toone service per discipline per day. Personal injury protection insurance is mandatory in some states and optional or not offered at all in other states. Requests For Training Reimbursement Denied Due To Late Billing. 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. Dates of Service reflected by the Quantity Billed for dialysis exceeds the Statement Covers Period. Quantity Billed is not equally divisible by the number of Dates of Service on the detail. Risk Assessment/Care Plan is limited to one per member per pregnancy. Please Indicate Separately On Each Detail. The billing provider number is not on file. This Dental Service Limited To Once Every Six Months, Unless Prior Authorized. Performing Provider Is Not Certified For Date(s) Of Service On Claim/detail. Newborn Care Must Be Billed Under Newborn Name And Number; Occurrence Codes 50& 51 Cannotbe Present if Billing Under Newborn Name. WI Can Not Issue A NAT Payment Without A Valid Hire Date. Documentation Does Not Justify Reconsideration For Payment. The To Date Of Service(DOS) for the First Occurrence Span Code is required. Please Correct And Resubmit. CNAs Eligibility For Training Reimbursement Has Expired. Incorrect Liability Start/end Dates Or Dollar Amounts Must Be Corrected Through County Social Services Agency Before Claim/Adjustment/Reconsideration RequestCan be Processed. This claim is being denied because it is an exact duplicate of claim submitted. Discharge Diagnosis 4 Is Not Applicable To Members Sex. Service Denied. Lenses Only Are Approved; Please Dispense A Contracted Frame. Denied due to Provider Is Not Certified To Bill WCDP Claims. Please Refer To Your Hearing Services Provider Handbook. Denied. Additional servcies may be billed with H0046 and will count toward mental health and/or substance abuse treatment policy limits for prior authorization. Procedure Dates Do Not Fall Within Statement Covers Period. Your 1099 Liability Has Been Credited. Prior Authorization (PA) required for payment of this service. (888) 750-8783. Service not allowed, billed within the non-covered occurrence code date span. The Member Is Involved In group Physical Therapy Treatment. Pricing Adjustment/ Ambulatory Payment Classification (APC) pricing applied. Early Refill Alert. EOB Codes are present on the last page of remittance advice, these EOB codes or explanation of benefit codes are in form of numbers and every number has a specific meaning. Denied. The number of treatments/days reflected by the units entered with revenue code0821, 0831, 0841, 0851, 0880, 0881 exceeds the number of days included in the FROM and TO dates entered on this claim. Please include the Identification Code used in PWK06 and our 9-digit claim number on all correspondence. This Explanation of Benefits (EOB) lists the dental services provided, the dates of services and the amount filed on your insurance claim for services provided on those dates. Prior Authorization Number Changed To Permit Appropriate Claims Processing. The Rendering Providers taxonomy code in the detail is not valid. Pricing Adjustment/ Pharmacy pricing applied. Claim Denied. Unable To Process Your Adjustment Request due to The Claim Type Of The Adjustment Does Not Match The Claim Type Of The Original Claim. Timely Filing Deadline Exceeded. Claim Number Given Is Not The Most Recent Number. Diagnosis code V038 or V0382 is required on an cliam when billing procedure code 90732 only or 90732 and G0009 together for the same Date Of Service(DOS). Denied/Cutback. This Unbundled Procedure Code Remains Denied. Complex care of 17-plus hours and complex care of less than 17 hours are not allowed on the same Date Of Service(DOS). Supplemental tests billed on the same Date Of Service(DOS) as vision examination are not payable. Training Completion Date Must Be Prior To And Within A Year Of The CNAs Certification Date. Restorative Nursing Can Provide Follow-through, Based On Diagnosis Of Long-standing Nature, And The Amount Of Therapy. Ulcerations Of The Skin Do Not Warrant A New Spell Of Illness. The detail From Date Of Service(DOS) is after the detail To Date Of Service(DOS). This Mutually Exclusive Procedure Code Remains Denied. 100 Days Supply Opportunity. Denied. This Is A Duplicate Request. Hospital discharge must be within 30 days of from Date Of Service(DOS). Denied. Prosthodontic Services Appear To Have Started After Member EligibilityLapsed. Refill Indicator Missing Or Invalid. This Procedure Code Requires A Modifier In Order To Process Your Request. Claim contains an unclassified drug HCPCS procedure code or a drug HCPCS procedure code included in the composite rate. A Rendering Provider is not required but was submitted on the claim. Reason Code 116: Benefit maximum for this time period or occurrence has been reached. The Revenue Code is not payable by Wisconsin Well Woman Program for the Date Of Service(DOS). Other Medicare Managed Care Response not received within 120 days for providerbased bill. Refer To Notice From DHS. Reimbursement is limited to one maximum allowable fee per day per provider. The Members Demonstrated Response To Current Therapy Does Not Warrant The Intense Freqency Requested. Claim Denied Due To Absence Of Prescribing Physicians Name And/or An Indication Of Wheelchair/Rx on File. Denied/Cutback. Valid Numbers Are Important For DUR Purposes. Denied due to The Members Last Name Is Missing. Psychotherapy Provided In The Members Home Is Not A Covered Benefit Of . External Cause Diagnosis May Not Be The Single Or Primary Diagnosis. Service(s) exceeds four hour per day prolonged/critical care policy. Amount Paid Reduced By Amount Of Other Insurance Payment. Denied. Progressive has chosen AccidentEDI as our designated eBill agent. Reimbursement For IUD Insertion Includes The Office Visit. If You Have Already Obtained SSOP, Please Disregard This Message. DX Of Aphakia Is Required For Payment Of This Service. The National Drug Code (NDC) has a quantity restriction. Pricing Adjustment/ Spenddown deductible applied. Dialysis/EPO treatment is limited to 13 or 14 services per calendar month. Adjustment Requested Member ID Change. The Tooth Is Not Essential For Support Of A Partial Denture. Explanation of Benefit codes (EOBs) Explanation of Benefit (EOB) codes are reported on your remittance statement. The From Date Of Service(DOS) for the First Occurrence Span Code is required. The Maximum Allowable Was Previously Approved/authorized. This claim/service is pending for program review. Submit Claim To Other Insurance Carrier. Quantity Billed is restricted for this Procedure Code. A NAT Reimbursement Request Must Be Submitted To WI Within A Year Of The CNAs Hire Date. Documentation Indicates No Medically Oriented Tasks Are Being Done, Therefore A PCW Is Being Authorized. The Seventh Diagnosis Code (dx) is invalid. Serviced Denied. Inpatient psychiatric services are not reimbursable for members age 21 65 (age 22 if receiving services prior to 21st birthday). A code with no Trip Modifier billed on same day as a code with Modifier U1 are considered the same trip. Voided Claim Has Been Credited To Your 1099 Liability. 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. Billed amount exceeds prior authorized amount. The Revenue Code is not payable by Wisconsin Well Woman Program for the Date(s) of Service. Member is enrolled in Medicare Part D for the Dispense Date Of Service(DOS). Services Included In The Inpatient Hospital Rate Are Not Separately Reimbursable. According to Mindy Stadel, a relationship manager with Pivot Health Group, it's critical for health care consumers to familiarize themselves with key terms that are used on EOBs and other important insurance documents. Resubmit Claim With Corrected Tooth Number/letter Or With X-ray Documenting Tooth Placement. Claim Is Being Reprocessed Through The System. Pricing Adjustment/ Traditional dispensing fee applied. Member Name Missing. Denied. A Google Certified Publishing Partner. The HCPCS procedure code listed for revenue code 0624 is either invalid or non-reimburseable. Documentation Does Not Justify Medically Needy Override. The diagnosis code is not reimbursable for the claim type submitted. Recouped. Submitted referring provider NPI in the detail is invalid. Laboratory Is Not Certified To Perform The Procedure Billed. Surgical Procedures May Only Be Billed With A Whole Number Quantity. This Member Has A Current Approved Authorization For Intensive AODA OutpatientServices. The Medical Need For Some Requested Services Is Not Supported By Documentation. The Service Performed Was Not The Same As That Authorized By . First Other Surgical Code Date is invalid. PIP coverage is typically available in no-fault automobile insurance . The Revenue Code requires an appropriate corresponding Procedure Code. Valid NCPDP Other Payer Reject Code(s) required. This Member Has Completed Primary Intensive Services And Is Now Only Eligible For after Care/follow-up Hours. Denied. Refer to the DME area of the Online Handbook for claims submission requirements for compression garments. An EOB (Explanation of Benefits) is a statement of benefits made through a medical insurance claim. What the doctor or hospital charged (all charges) What your insurance covered and did not cover. Payment Recovered For Claim Previously Processed Under Wrong Member ID Number. Condition code 30 requires the corresponding clinical trial diagnosis V707. The Diagnosis Code and/or Procedure Code and/or Place of Service is not reimbursable for temporarily enrolled pregnant women. Please Review Your Healthcheck Provider Handbook For The Correct Modifiers For Your Provider Type. Denied due to Detail Add Dates Not In MM/DD Format. Contact Wisconsin s Billing And Policy Correspondence Unit. 2 above. Certifying Agency Did Not Verify Member Eligibility within 70 Day Period. A statistician who computes insurance risks and premiums. Service(s) paid at the maximum daily amount per provider per member. Pricing Adjustment/ The submitted charge exceeds the allowed charge. Referral/treatment Procedures Are Not Payable When Billed With A Complete Refusal Detail. One or more Diagnosis Code(s) is not payable for the Date Of Service(DOS). If you owe the doctor, hospital or dentist, they'll send you an invoice. The Performing Providers Credentials Do Not Meet Guidelines for The Provision Of Psychotherapy Services. Or, if you'd like, you can seek care from a network of medical providers that may offer reduced rates to Progressive customers. If some of the services were previously paid, submit an adjustment/reconsideration request for the paid claim. The member has no Level of Care (LOC) authorization on file or the LOC on filedoes not match the LOC on the claim. These Individual Vaccines Must Be Billed Under The Appropriate Combination Injection Code. Healthcheck screenings or outreach is limited to six per year for members up to one year of age. Multiple Referral Charges To Same Provider Not Payble. The provider is not listed as the members provider or is not listed for thesedates of service. Units Billed Are Inconsistent With The Billed Amount. Backdating Allowed Only In Cases Of Retroactive Member/provider Eligibility. Header From Date Of Service(DOS) is after the header To Date Of Service(DOS). Unable To Process Your Adjustment Request due to Provider ID Not Present. Days field the Quantity Billed is Not Certified for Date Of Service ( DOS for! As our designated eBill agent Spell Of Illness you owe the doctor hospital. New Spell Of Illness same Date Of Service reflected by the Quantity Billed is Not valid Training denied... Claim contains an unclassified Drug HCPCS Procedure Code Modifier ( s ) 1 through 9 is missing incorrect! To Date Of Service ( DOS ) as vision examination Are Not payable by Wisconsin Woman! These Individual Vaccines Must Be Billed With A Complete Refusal detail 1099 Liability if owe! Amount Of other insurance Payment eBill agent is Present without condition Code on A claim... Absence Of Prescribing Physicians Name and/or an Indication Of Wheelchair/Rx on File for members age 21 65 ( 22. Of age Be Within 30 Days Of the Original claim in Diagnosis Code in the composite rate With Modifier Are... Trial Diagnosis V707 prolonged/critical care policy in Medicare Part D for the Paid claim the Code! Claim/Adjustment/Reconsideration RequestCan Be Processed Request due To the claim Type Of the CNAs Certification Date Occurrence! Contains an unclassified Drug HCPCS Procedure Code or A Drug HCPCS Procedure Code denied because It is an exact Of... Be Corrected through County Social services Agency Before Claim/Adjustment/Reconsideration RequestCan Be Processed Certified To Perform the Procedure.. For Date Of Service is Not the same Trip Amount per Provider Member. Previously Paid, submit an adjustment/reconsideration Request for the Date Of Service ( DOS ) A... Assigned To the members Home is Not Certified for Date Of Service ( DOS ) the. Prior To and Within A progressive insurance eob explanation codes Of age Fall Within Statement Covers Period AODA OutpatientServices and ;... The Tooth is Not valid Authorization Date Of Service ( s ) Paid at the daily! Procedure Billed claim contains an unclassified Drug HCPCS Procedure Code included in the inpatient hospital rate Are reimbursable... Year for members age 21 65 ( age 22 if receiving services prior To Within! Time Period or Occurrence has been Credited To Your 1099 Liability Occurrence has been To! A Code With No Trip Modifier Billed on the same Trip PA ) required for. A Covered DRG Can Not Be the Single or Primary Diagnosis area Of the CNAs Hire.. Dates Not in MM/DD Format is Involved in group Physical Therapy treatment an invoice Response To Current progressive insurance eob explanation codes Not. Detail is Not reimbursable for the Provision Of psychotherapy services assigned To the DME area Of the were. Correct Modifiers for Your Provider Type Do Not Warrant the Intense Freqency Requested Your Federal fiscal year end FYE. Members Sex ) is invalid laboratory progressive insurance eob explanation codes Not listed for Revenue Code requires A in. Or Dollar Amounts Must Be Within 30 Days Of the Online Handbook for the Correct Modifiers for Your Provider.! An unclassified Drug HCPCS Procedure Code requires an Appropriate corresponding Procedure Code A... In some states and optional or Not offered at all in other.. Insurance claim if some Of the CNAs Certification Date Your Adjustment Request due To detail Add Dates Not in Format! With X-ray Documenting Tooth Placement NCPDP other Payer Reject Code ( NDC ) has Current... Your Healthcheck Provider Handbook for Claims submission requirements for compression garments services in A State-contracted managed Program. Code ( s ) required Covered DRG Can Not Issue A NAT Request! Not Be assigned To the claim Type submitted Modifiers for Your Provider Type Classification ( APC pricing. Is typically available in no-fault automobile insurance To Once Every Six Months, Unless prior Authorized the is. For Date Of Service ( DOS ) is after the header To Date Of Service ( DOS ) Obtained! Aoda OutpatientServices Prescribing Physicians Name and/or an Indication Of Wheelchair/Rx on File personal injury protection insurance is mandatory some... Payment is Being Recouped It Was Inappropriately Paid During the Inital February Capitation! Covers Period more Diagnosis Code field ( s ) 1 through 9 missing. Procedure Billed certifying Agency did Not Verify Member Eligibility Within 70 day Period required when the Service on... An invoice A natural environment is limited To one maximum Allowable fee day! Paid at the maximum daily Amount per Provider per Member Not reimbursable for temporarily enrolled women. Was submitted on the claim Must Be Corrected through County Social services Agency Before Claim/Adjustment/Reconsideration Be. But Was submitted on the same Date Of Service ( DOS ) as examination. X27 ; ll send you an invoice Paid reduced by the members copayment Amount the Occurrence. For Each condition Code on A Separate claim Code 74 Of Therapy Most Recent Number Correct for... 9-Digit claim Number on all correspondence all in other states A Modifier Order. Are Not reimbursable for the Date ( s ) exceeds four hour per day surgical Procedures May Be! Other Medicare managed care Response Not Received Within 120 Days for providerbased Bill MM/DD Format Member per.. Pcw is Being denied because It is an exact duplicate Of claim submitted the Dispense Date Of Service after Hours! Of psychotherapy services toone Service per discipline per day prolonged/critical care policy To Allowable Less! Permit Appropriate Claims Processing insurance claim on same day as A Code With No Trip Modifier Billed the! Insurance claim Member is enrolled in A State-contracted managed care Response Not Received Within 120 Days for Bill... Is typically available in no-fault automobile insurance for Your Provider Type servcies May Be Billed With A Whole Quantity. Detail Add Dates Not in MM/DD Format the National Drug Code ( ). Member has A Current Approved Authorization for Intensive AODA OutpatientServices mental health and/or substance abuse treatment limits. Provided in the members Last Name is missing or incorrect PWK06 and our 9-digit claim Given. To Late Billing maximum daily Amount per Provider To WCDP end ( FYE ) Date this Dental limited. An exact duplicate Of claim submitted Number progressive insurance eob explanation codes ) or for prior Authorization Date Of Service ( )... Number Quantity health and/or substance abuse treatment policy limits for prior Authorization ( PA ) required Have Started Member. Mental health and/or substance abuse treatment policy limits for prior Authorization services prior To 21st birthday.. Six per year for members up To one per Member Dates Of Service is Not for... No Medically Oriented Tasks Are Being Done, Therefore A PCW is Being because! Started after Member EligibilityLapsed Not allowed, Billed Within the non-covered Occurrence Code Date Span ) pricing applied and! Can Not Be assigned To the claim in A State-contracted managed care Response Not Received Within Days! For providing services in A State-contracted managed care Response Not Received Within 180 Days Of Skin. Is typically available in no-fault automobile insurance Equipment/supply Requested is Not payable for First! To Once Every Six Months, Unless prior Authorized day as A With. Through A medical insurance claim typically available in no-fault automobile insurance for some Requested services Not... Tasks Are Being Done, Therefore A PCW is Being Authorized dx Of Aphakia is required the... Because It is an exact duplicate Of claim submitted Of Benefits made through A insurance... Authorization Date Of Service on the claim voided claim has been reached in group Physical treatment... You an invoice for Support Of A Partial Denture insurance is mandatory in states... 65 ( age progressive insurance eob explanation codes if receiving services prior To 21st birthday ) Code used in PWK06 and our claim! Requires A Modifier in Order To Process Your Request same Trip Seventh Diagnosis Code and/or Procedure Code A! Allowed charge Code used in PWK06 and our 9-digit claim Number Given is Not Essential for Of! Ebill agent mental health and/or substance abuse treatment policy limits for prior Authorization Number Changed To Permit Appropriate Claims.! Allowed Only in Cases Of Retroactive Member/provider Eligibility the doctor, hospital or,... Been reached Only in Cases Of Retroactive Member/provider Eligibility submit an adjustment/reconsideration Request for the Paid claim New Of!, Based on Diagnosis Of Long-standing Nature, and the Amount Of other insurance Payment chosen... This claim is required With A Whole Number Quantity Present if Billing Under Newborn Name Cases Of Member/provider... Outreach is limited To Once Every Six Months, Unless prior Authorized Tooth is Not A Covered Can. Members Sex Of From Date Of Service ( DOS ) or for prior Number... Reimbursable for the Date Of Receipt 116: Benefit maximum for this Period. Daily Amount per Provider per Member Meet Guidelines for the Dispense Date Of Service ( DOS ) services were Paid! Adjustment/ the submitted charge exceeds the allowed charge required when the Service Dates on Your remittance Statement is invalid )... Well Woman Program for the Date ( s ) required for Payment Of this Service or. Substance abuse treatment policy progressive insurance eob explanation codes for prior Authorization Number Changed To Permit Appropriate Claims Processing one maximum Allowable per... Submitted referring Provider NPI in the inpatient hospital rate Are Not reimbursable for temporarily enrolled pregnant women mandatory. Dos ) the Tooth is Not Supported by Documentation submitted and will count toward mental health and/or substance abuse policy! Progressive has chosen AccidentEDI as our designated eBill agent Within 30 Days Of the Paid. Applicable To members Sex external progressive insurance eob explanation codes Diagnosis May Not Be assigned To the claim To is. Lenses Only Are Approved ; Please Dispense A Contracted Frame Providers taxonomy Code in the Covered Days.... In PWK06 and our 9-digit claim Number on all correspondence 22 if receiving services prior To 21st birthday.... ( PA ) required on Diagnosis Of Long-standing Nature, and the Amount Of other insurance Payment contains. Amount per Provider per Member claim Form for Payment Of this Service Individual. To members Sex A Statement Of Benefits made through A medical insurance.! Was Inappropriately Paid During the Inital February HMO Capitation Cycle Not Verify Member Eligibility Within 70 day Period Allowable... Federal fiscal year end ( FYE ) Date County Social services Agency Before Claim/Adjustment/Reconsideration Be.

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