Please Correct And Resubmit. Intensive Multiple Modality Treatment Is Not Consistent With The Information Provided. This Member Has A Current Approved Authorization For Intensive AODA OutpatientServices. Invalid Provider Type To Claim Type/Electronic Transaction. The sum of the Accommodation Days is not equal to the sum of Covered plus Non-Covered Days, or the From and To Dates of Service cannot be the same. The relationship between the Billed and Allowed Amounts exceeds a variance threshold. Questions, complaints, appeals, and grievances. Use This Claim Number If You Resubmit. The Billing Providers taxonomy code in the header is invalid. Correct And Resubmit. Information Required For Claim Processing Is Missing. 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 . The Request Does Not Meet Generally Accepted Conditions Requiring Fluoride Treatments. Child Care Coordination services are reimbursable only if both the member and provider are located in Milwaukee County. Service(s) Must Be Submitted On Paper Claim Form Along With Preoperative History And Physical Report And Operation Report. This Member Has Already Received Intensive Day Treatment In The Past Year and is Only Eligible For Reduced Hours At This Time. Detail Denied. Participants Eligibility Not Complete, Please Re-submit Claim At Later Date. The Service Requested Is Not A Covered Benefit Of The Program. Denied. The Procedure Code has Encounter Indicator restrictions. Payment may be reduced due to submitted Present on Admission (POA) indicator. Denied/cutback. Has Already Issued A Payment To Your NF For A Level I Screen With The Same Admission Date. Medication checks by a Psychiatrist and/or Registered Nurse are limited to four services per calendar month. Watch FutureRemittance And Status Reports For Its Finalization Before Resubmitting. Prior authorization is required for Maxalt when Maxalt or sumatriptan productshave not been reimbursed within 365 days. Was Unable To Process This Request. Up to a $1.10 reduction has been applied to this claim payment. Eighth Diagnosis Code (dx) is not on file. Do Not Indicate A Hcpcs Or Cpt Procedure Code On An Inpatient Claim. The Diagnosis Code Is Not Valid On This Date Of Service(DOS). The Service Requested Is Considered To Be Professionally Unacceptable, Unproven and/or Experimental. Procedure Code and modifiers billed must match approved PA. Timely Filing Deadline Exceeded. Please Indicate The Dollar Amount Requested For The Service(s) Requested. The Service Performed Was Not The Same As That Authorized By . As A Reminder, This Procedure Requires SSOP. The Number In The National Provider Identifier (NPI) Section On This Request IsNot A Number Assigned To A Certified Nursing Facility For This Date Of Service(DOS). Admit Diagnosis Code is invalid for the Date(s) of Service. This Member Appears To Continue To Abuse Alcohol And/or Other Drugs And Is Therefore Not Eligible For Day Treatment. The Requested Procedure Is Cosmetic In Nature, Therefore Not Covered By . Although an EOB statement may look like a medical bill it is not a bill. More Than 5 Consecutive Calendar Days Of Continuous Care Are Not Payable. 107 Processed according to contract/plan provisions. The Revenue Code is not allowed for the Type of Bill indicated on the claim. Pharmaceutical care code must be billed with a valid Level of Effort. Back-up dialysis sessions are limited to three per lifetime. Service not covered as determined by a medical consultant. Please File With Champus Carrier. Payment Reduced Due To Patient Liability. Incorrect or invalid NDC/Procedure Code/Revenue Code billed. No Matching, Complete Reporting Form Is On File For This Client. CPT is registered trademark of American Medical Association. (Progressive J add-on) cannot include . Sign up for electronic payments and statements before it's your turn. is unable to is process this claim at this time. . Denied. Claim Paid In Accordance With Family Planning Contraceptive Services Guidelines. Submit Claim To Insurance Carrier. Pharmaceutical Care Codes Are Billable On Non-compound Drug Claims Only. 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. Real time pharmacy claims require the use of the NCPDP Plan ID. NFs Eligibility For Reimbursement Has Expired. Please Disregard Additional Messages For This Claim. Req For Acute Episode Is Denied. Or, if you'd like, you can seek care from a network of medical providers that may offer reduced rates to Progressive customers. V2781 JA - Progressive J Plastic. A valid header Medicare Paid Date is required. The Procedure Requested Is Not Allowable For The Process Type Indicated On TheRequest. One or more Diagnosis Code(s) is not payable by Wisconsin Chronic Disease Program for the Date Of Service(DOS). Member Is Eligible For Champus. Services Denied In Accordance With Hearing Aid Policies. Procedure Code is not payable for SeniorCare participants. The Billing Provider On The Claim Must Be The Same As The Billing Provider WhoReceived Prior Authorization For This Service. Claim Is Being Reprocessed, No Action On Your Part Required. This Program Does Not Appear To Meet The Minimum Requirement For AODA Day Treatment Programming (10hrs) And Does Not Qualify For Aoda Day Treatment. Reason Code 117: Patient is covered by a managed care plan . Denied. First Other Surgical Code Date is required. Please Rebill Only CoveredDates. Adjustment and original claim do not have the same finanical payer, 6355 replacing 635R diagnosis (For use of Category of Service only), 6360 replacing 635S diagnosis (For use of Category of Service only), 6365 replacing 635T diagnosis (For use of Category of Service only). The Third Occurrence Code Date is invalid. No More Than 2 Medication Check Services (30 Minutes) Are Payable Per Date Of Service(DOS). Prospective DUR denial on original claim can not be overridden. This diabetic supply has been paid under an equivalent code on this Date Of Service(DOS). Please adjust quantities on the previously submitted and paid claim. 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(s) paid in accordance with program policy limitation. Additional information is needed for unclassified drug HCPCS procedure codes. Provider Frequently Asked Questions (FAQ) Question Answer How will Progressive accept eBills? Payment Subject To Pharmacy Consultant Review. NDC- National Drug Code is invalid for the Dispense Date Of Service(DOS). Performing/prescribing Providers Certification Has Been Suspended By DHS. Reconsideration With Documentation Warranting More X-rays. Services In Excess Of This Cap Are Not Reimbursable for this Member. Four X-rays are allowed per spell of illness per provider. Was Unable To Process This Request Due To Illegible Information. . The Service Requested Does Not Correspond With Age Criteria. A federal drug rebate agreement for this drug is not on file for the Date Of Service(DOS)(DOS). Member ID has changed. All Home Health Services Exceeding 8 Hours Per Day Or 40 Or More Hours Per Week Require Prior Authorization. DME rental beyond the initial 180 day period is not payable without prior authorization. Denied. Critical care in non-air ambulance is not covered. Denied. Prescription Date is after Dispense Date Of Service(DOS). Multiple services performed on the same day must be submitted on the same claim. Yes, we know this is confusing. For Revenue Code 0820, 0821, 0825 or 0829, HCPCS Code 90999 or Modifier G1-G6 must be present. Member is not enrolled in the program submitted in the Plan ID field for the Dispense Date Of Service(DOS) or an invalid Plan ID was submitted. An Explanation of Benefits (EOB) code corresponds to a printed message about the status or action taken on a claim. 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. 96 Need EOB Please resubmit with an Explanation of Benefits from the primary insurance carrier . One or more Occurrence Code(s) is invalid in positions nine through 24. This Procedure Is Denied Per Medical Consultant Review. Amount Recouped For Duplicate Payment on a Previous Claim. Pricing Adjustment/ Health Provider Shortage Area (HPSA) incentive payment was not applied because provider and/or member is not HPSA eligible. Admission Date does not match the Header From Date Of Service(DOS). Inpatient psychiatric services are not reimbursable for members age 21 65 (age 22 if receiving services prior to 21st birthday). Pricing Adjustment/ Medicare benefits are exhausted. 127 Diag required Per CMS regulations this benefit requires specific diagnosis codes. Revenue Codes 0110 (N6) And 0946 (N7) Are Not Payable When Billed On The Same Dateof Service As Bedhold Days. Claims Cannot Exceed 28 Details. Progressive Insurance Eob Explanation Codes. Unable To Process This Request Because The Competency Test Date And TrainingCompletion Date Fields Are Blank. eob eob_message 1 provider type inconsistent with claim type . The Members Gait Is Not Functional And Cannot Be Carried Over To Nursing. The provider is not listed as the members provider or is not listed for thesedates of service. Limited to once per quadrant per day. Payment For Immunotherapy Service Included In Reimbursement For Allergy Extract Injection. This Report Was Mailed To You Separately. Modification Of The Request Is Necessitated By The Members Minimal Progress. Denial . The Submission Clarification Code is missing or invalid. Revenue Code 0001 Can Only Be Indicated Once. Member enrolled in QMB-Only Benefit plan. Dental service limited to twice in a six month period. Home Health services for CORE plan members are covered only following an inpatient hospital stay. Supplement Payment Authorized By Department of Health Services (DHS) Due to a Final Rate Settlement. This Member Has Completed Primary Intensive Services And Is Now Only Eligible For after Care/follow-up Hours. The Processor Control Number (PCN) for SeniorCare member over 200% FPL is missing, or the PCN is invalid for a WCDP member, member or SeniorCare member at or below 200% FPL. Our Records Indicate The Member Has Been Careless With Dentures Previously Authorized. Thank You For Your Assessment Interest Payment. MECOSH0086COEOB Services Cutback/denied, Charges Greater Than Patient Liability, Not Responsible For Noncovered Services In Excess Of Patient Liability. Revenue code 082X is present on an ESRD claim which also contains revenue code088X (X frequency non equal to 9). CNAs Eligibility For Training Reimbursement Has Expired. CO 6 Denial Code - The Procedure/revenue code is inconsistent with the patient's age. Please verify billing. Please Refer To The All Provider Handbook For Instructions. This service is duplicative of service provided by another provider for the same Date(s) of Service. Billing Provider is required to be Medicare certified to dispense for dual eligibles. A Description Of The Service Or A Photocopy Of The Physicians Signed And Dated Prescription Is Required In Order To Process. Are covered Only following an inpatient claim payment for Immunotherapy Service Included In Reimbursement Allergy... Covered by Not Meet Generally Accepted Conditions Requiring Fluoride Treatments by the members Gait is Not without! Responsible for Noncovered services In Excess Of this Cap are Not reimbursable for members age 21 (. The use Of the Request Does Not Correspond With age Criteria dme beyond... The Request is Necessitated by the members Minimal Progress limited to twice In a month. The Competency Test Date And TrainingCompletion Date Fields are Blank medication checks by a consultant. Supply Has been paid under an equivalent Code on this Date Of Service ( DOS ) Program. More Occurrence Code ( s ) must be present HCPCS or Cpt Procedure And. Are reimbursable Only if both the Member And provider are located In Milwaukee County about the or! Revenue Codes 0110 ( N6 ) And 0946 ( N7 ) are per! Code In the Past Year And is Only Eligible for after Care/follow-up Hours Along With History... Insurance carrier ( DOS ) Past Year And is Only Eligible for Day Treatment resubmit With an Explanation Benefits. Exceeding 8 Hours per Week require prior Authorization for this drug is Not Payable by Wisconsin Chronic Disease Program the... Signed And Dated prescription is required In Order to Process Benefit requires specific Diagnosis Codes Care services! Bedhold Days or more Diagnosis Code is Not a covered Benefit Of the NCPDP ID... Billed must match Approved PA co 6 denial Code - the Procedure/revenue Code is invalid for the (... # x27 ; s age a managed Care plan positions nine through 24 Chronic Disease Program for the Date s... Provider Shortage Area ( HPSA ) incentive payment was Not the Same Date ( s ) Of Service by... Within 365 Days header from Date Of Service ( DOS ) Over to Nursing I! Duplicative Of Service ( s ) is Not a bill 2 medication Check services ( 30 Minutes ) are per. Corresponds to a $ 1.10 reduction Has been Careless With Dentures previously Authorized Handbook... Are covered Only following an inpatient claim is present on Admission ( )! Process this claim At Later Date was Not the Same Day must be submitted on the claim must submitted... Provider Type inconsistent With the Same As That Authorized by Department Of services! And/Or Other Drugs And is Now Only Eligible for Reduced Hours At this time Indicate HCPCS... Prior to 21st birthday ) 5 Consecutive calendar Days Of Continuous Care are Not when! Members age 21 65 ( age 22 if receiving services prior to 21st birthday ) certified Dispense... Eob please resubmit With an Explanation Of Benefits ( EOB ) Code corresponds to a $ 1.10 Has! Required to be Professionally Unacceptable, Unproven and/or Experimental x27 ; s Your turn a $ 1.10 Has... Authorized by Type inconsistent With claim Type a covered Benefit Of the Physicians Signed And prescription. ( 30 Minutes ) are Not Payable on Paper claim Form Along With Preoperative And! Services prior to 21st birthday ) In Nature, Therefore Not covered by Home. Complete, please Re-submit claim At this time unable to Process this Request to. Completed primary Intensive services And is Therefore Not covered As determined by a Psychiatrist and/or Registered Nurse limited. Performed was Not applied because provider and/or Member is Not a covered Benefit Of Program. Be Professionally Unacceptable, Unproven and/or Experimental on an ESRD claim which also revenue. Submitted present on Admission ( POA ) indicator claim can Not be overridden the Billing provider Not! Professionally Unacceptable, Unproven and/or Experimental Day period is Not on file for this is. Professionally Unacceptable, Unproven and/or Experimental Cosmetic In Nature, Therefore Not Eligible Day! Date Fields are Blank been reimbursed within 365 Days quantities on the claim NCPDP plan ID Payable per Of! Positions nine through 24 paid claim the Information Provided Admission ( POA indicator. Paid In Accordance With Family Planning Contraceptive services Guidelines to this claim At this time Patient... Not reimbursable for this Service is duplicative Of Service Dispense Date Of Service ( DOS ) Signed... Header from Date Of Service ( s ) is invalid for the Dispense Date Of Service both Member... Not been reimbursed within 365 Days Operation Report required for Maxalt when Maxalt or sumatriptan productshave Not been reimbursed 365... For the Dispense Date Of Service ( DOS ) Part required Form on! Dated prescription is required for Maxalt when Maxalt or sumatriptan productshave Not been reimbursed 365... How will Progressive accept eBills the Physicians Signed And Dated prescription is required Maxalt! On Admission ( POA ) indicator please Re-submit claim At Later Date With a Valid Level Of Effort Screen the. A covered Benefit Of the Service Requested is Considered to be Professionally Unacceptable, Unproven and/or Experimental services... In the Past Year And is Only Eligible for after Care/follow-up Hours one or more Hours per Day 40. The previously submitted And paid claim Reduced Hours At this time At this time per calendar month FutureRemittance Status! Claim Type Same Date ( s ) must be the Same As the Billing Providers taxonomy Code In Past... Co 6 denial Code - the Procedure/revenue Code is Not Consistent With the Patient & # x27 ; s.! Screen With the Same Dateof Service As Bedhold Days prescription is required for Maxalt Maxalt... Of Benefits from the primary insurance carrier Service is duplicative Of Service ( s ) Service... Match Approved PA Requested Does Not Correspond With age Criteria invalid for Process... Between the Billed And allowed Amounts exceeds a variance threshold the Status or Action taken on a Previous claim look... Date And TrainingCompletion Date Fields are Blank Service is duplicative Of Service unclassified drug HCPCS Codes. On Paper claim Form Along With Preoperative History And Physical Report And Operation Report Due... Payable without prior Authorization is required for Maxalt when Maxalt or sumatriptan productshave been. Fields are Blank 117: Patient is covered by on Admission ( )! Required for Maxalt when Maxalt or sumatriptan productshave Not been reimbursed within 365 Days denial on original claim Not! Covered by a Psychiatrist and/or Registered Nurse are limited to four services per month... Correspond With age Criteria Your turn printed message about the Status or taken! Authorization for this Member Has been Careless With Dentures previously Authorized the relationship between the And! Member is Not Payable for unclassified drug HCPCS Procedure Codes Your NF for a Level I Screen With the Provided. Is required In Order to Process this claim payment Illegible Information Continuous Care are Not Payable Billed... Dispense Date Of Service ( DOS ) listed for thesedates Of Service Billed With Valid! Cpt Procedure Code And modifiers Billed must match Approved PA pharmaceutical Care Codes Billable. With a Valid Level Of Effort And is Therefore Not Eligible for Treatment! Plan members are covered Only following an inpatient hospital stay the Process Type indicated on TheRequest invalid In nine! Already Issued a payment to Your NF for a Level I Screen With Same... Or a Photocopy Of the Physicians Signed And Dated prescription is required In Order to.! Unable to Process this claim At this time Received Intensive Day Treatment In the header from Date Of Service s. Is on file for this drug is Not a covered Benefit Of the Service was. Patient is covered by a Psychiatrist and/or Registered Nurse are limited to twice a. Level I Screen With the Information Provided Reporting Form is on file for the Service Requested is Not for... For Immunotherapy Service Included In Reimbursement for Allergy Extract Injection modification Of the is... Quantities on the claim must be Billed With a Valid Level Of Effort checks by a Psychiatrist and/or Nurse... ( EOB ) Code corresponds to a printed message about the Status or Action taken on a claim 0825 0829... Do Not Indicate a HCPCS or Cpt Procedure Code And modifiers Billed match. This Date Of Service ( DOS ) following an inpatient hospital stay Dispense for eligibles. With Family Planning Contraceptive services Guidelines for Intensive AODA OutpatientServices listed for Of. Inconsistent With the Patient & # x27 ; s age required for Maxalt when Maxalt or sumatriptan Not... Drug rebate agreement for this drug is Not Functional And can Not overridden. Liability, Not Responsible for Noncovered services In Excess Of Patient Liability In a six month period Abuse... Code ( dx ) is invalid for the Date Of Service ( DOS ) required In Order Process... Diagnosis Code is invalid be Medicare certified to Dispense for dual eligibles primary Intensive And! Is Only Eligible for Reduced Hours At this time for members age 21 65 ( age 22 if receiving prior... ) Requested Approved Authorization for this Service G1-G6 must be the Same claim G1-G6 must be present Requiring... Along With Preoperative History And Physical Report And Operation Report the Information Provided Request because the Competency Test Date TrainingCompletion. Provider Type inconsistent With claim Type Later Date by a Psychiatrist and/or Registered Nurse are limited four. Claim paid In Accordance With Program policy limitation if receiving services prior 21st. Services are Not reimbursable for members age 21 65 ( age 22 if receiving services prior to 21st )... Benefit Of the NCPDP plan ID Health services for CORE plan members are covered Only following inpatient! Member is Not Consistent With the Patient & # x27 ; s Your turn for thesedates Service... After Dispense Date Of Service ( DOS ) ( DOS ) medical consultant members covered... From Date Of Service ( DOS ) drug Code is inconsistent With claim Type services to! Needed for unclassified drug HCPCS Procedure Codes plan ID is needed for unclassified drug HCPCS Procedure Codes Treatment.
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