progressive insurance eob explanation codes

2 above. Incidental modifier is required for secondary Procedure Code. Please Rebill Inpatient Dialysis Only. Claim paid at the program allowed amount. The Materials/services Requested Are Principally Cosmetic In Nature. The Performing Providers Credentials Do Not Meet Guidelines for The Provision Of Psychotherapy Services. Procedure Not Payable for the Wisconsin Well Woman Program. Documentation Indicates That Client Is Able To Direct Cares And Can Safely Direct A PCW. Denied. Comprehensive Screens And Individual Components Are Not Payable On The Same Date Of Service(DOS). Denied/Cutback. A Accident Forgiveness. Reconsideration With Documentation Warranting More X-rays. NDC was reimbursed at generic WAC (Wholesale Acquisition Cost) rate. Proposed Orthodontic Service Denied; Examination/study Models Are Approved. DME rental beyond the initial 180 day period is not payable without prior authorization. If correct, special billing instructions apply. Admission Denied In Accordance With Pre-admission Review Criteria. Reimbursement For This Detail Does Not Include Unit DoseDispensing Fee. Claim Paid In Accordance With Family Planning Contraceptive Services Guidelines. Prospective DUR denial on original claim can not be overridden. The Member Was Not Eligible For On The Date Received the Request. Rebill Using Correct Procedure Code. Member has Medicare Managed Care for the Date(s) of Service. The canister, dressings and related supplies are included as part of the reimbursement for the negative pressure wound therapy pump. Total Rental Payments For This Item Have Exceeded The Maximum Allowable Forthe Purchase Of This Item. Supplemental Payment Authorized By Department of Health Services (DHS) Due to a Department Of Justice Settlement. Subsequent Aide Visits Limited To 7 Hrs Per Day/per Member/per Provider. Resubmit Your Services Using The Appropriate Modifier After YouReceive A Update Providing Additional Billing Information. Immunization Questions A And B Are Required For Federal Reporting. Save on auto when you add property . Day Treatment Services For Members With Inpatient Status Limited To 20 Hours. Pricing Adjustment/ Ambulatory Surgery pricing applied. Member is enrolled in Medicare Part B on the Date(s) of Service. 1. This Member Appears To Continue To Abuse Alcohol And/or Other Drugs And Is Therefore Not Eligible For Day Treatment. Referring Provider is not currently certified. Denied. Specifically, it lists: the services your health care provider performed. Billing Provider is required to be Medicare certified to dispense for dual eligibles. First Other Surgical Code Date is invalid. Member is covered by a commercial health insurance on the Date(s) of Service. This Program Does Not Appear To Meet The Minimum Requirement For AODA Day Treatment Programming (10hrs) And Does Not Qualify For Aoda Day Treatment. If The Proc Code Does Not Require A Modifier, Please Remove The Modifier. This claim has been adjusted due to Medicare Part D coverage. A valid Level of Effort is also required for pharmacuetical care reimbursement. Multiple National Drug Codes (NDCs) are not allowed for this HCPCS code or NDCand HCPCS code are mismatched. The Service Requested Is Covered By The HMO. The Revenue Code is not payable for the Date(s) of Service. Records Indicate This Tooth Has Previously Been Extracted. Please Review All Provider Handbook For Allowable Exception. Submitclaim to the appropriate Medicare Part D plan. The Second Occurrence Code Date is invalid. No Action On Your Part Required. If the KT/V reading was not performed, then the value code D5 with 9.99 must be present without the occurrence code 51. Denied/Cuback. The Rendering Providers taxonomy code is missing in the header. No Substitute Indicator required when billing Innovator National Drug Codes (NDCs). Denied due to Provider Number Missing Or Invalid. Training Request Denied Because Either The Training Date On The Request Is After The CNAs Certification Test Date Or Its Not Within A Year Of That Date. Our Records Indicate You Have Billed More Than One Unit Dose Dispensing Fee For This Calendar Month. A valid header Medicare Paid Date is required. Please show the appropriate multichanel HCPCS code rather than the individual HCPCS code. Please Itemize Services Including Date And Charges For Each Procedure Performed. Denied due to Service Is Not Covered For The Diagnosis Indicated. Pricing Adjustment/ Prior Authorization pricing applied. Service(s) Billed Are Included In The Total Obstetrical Care Fee. Revenue Codes 0110 (N6) And 0946 (N7) Are Not Payable When Billed On The Same Dateof Service As Bedhold Days. The Member Does Not Meet The Criteria For Binaural Amplification; One Hearing Aid Is Authorized. Seventh Occurrence Code Date is required. Additional Psychotherapy Is Not Considered Appropriate Or Inline With More Effective, Available Services. Medicare Part A Or B Charges Are Missing Or Incorrect. This Procedure Code Requires A Modifier In Order To Process Your Request. The National Drug Code (NDC) has an age restriction. The Revenue/HCPCS Code combination is invalid. This Member Has Completed Primary Intensive Services And Is Now Only Eligible For after Care/follow-up Hours. Service(s) Approved By DHS Transportation Consultant. Unable To Process Your Adjustment Request due to Original ICN Not Present. This claim must contain at least one specified Surgical Procedure Code. Procedure Not Payable As Submitted. Personal Care Services Exceeding 30 Hours Per 12 Month Period Per Member Require Prior Authorization. We need to see the explanation of benefits (EOB) generated by the primary health plan before we can process . Services Denied. Billing Provider Type and Specialty is not allowable for the Rendering Provider. Billing Provider does not have required Certification Addendum on file. One or more Condition Code(s) is invalid in positions eight through 24. Medically Unbelievable Error. Progress, Prognosis And/or Behavior Are Complicating Factors At This Time. Unable To Process This Request Because The Competency Test Date And TrainingCompletion Date Fields Are Blank. Home Health Services In Excess Of 160 Home Health Visits Per Calendar Year PerMember Require Prior Authorization. Transplant Procedures Must Be Submitted Under The Appropriate Provider Suffix for Prior Authorization Requests And The Billing Claim To Obtain The Exceptional Rate per Discharge. The diagnosis code is not reimbursable for the claim type submitted. (These discounts are for in-network providers only. Only Healthcheck Modifiers Can Be Billed With Healthcheck Services. Service Denied. Review Patient Liability/paid Other Insurance, Medicare Paid. Reimbursement of this service is included in the reimbursement of the most complex/complete procedure performed. A Second Surgical Opinion Is Required For This Service. Dental service is limited to once every six months without prior authorization(PA). Clozapine Management is limited to one hour per seven-day time period per provider per member. No Functional Regression Has Occurred To Warrant A Spell Of Illness; Submit AsA Prior Authorization Request. The Ninth Diagnosis Code (dx) is invalid. Pricing Adjustment/ Revenue code flat rate pricing applied. Separate reimbursement for drugs included in the composite rate is not allowed. The second occurrence span from Date Of Service(DOS) is after to to Date Of Service(DOS). Denied due to Prescription Number Is Missing Or Invalid. Department of Health Services (DHS) Authorized Payment Is Being Withheld Due toa Final Rate Settlement. Claims Cannot Exceed 28 Details. Invalid Provider Type To Claim Type/Electronic Transaction. Denied due to Greater Than Four Dates Of Service Billed On One Detail. Reimbursement Is At The Unilateral Rate. A National Provider Identifier (NPI) is required for the Performing Provider listed in the header. Detail Rendering Provider certification is cancelled for the Date Of Service(DOS). MEMBER EXPLANATION OF BENEFITS . Progressive will accept records via Fax. Prescribing Provider UPIN Or Provider Number Missing From Claim And Attachment. Claim Number Given Is Not The Most Recent Number. Supervising Nurse Name Or License Number Required. The Medicare copayment amount 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. Dates of Service reflected by the Quantity Billed for dialysis exceeds the Statement Covers Period. Modification Of The Request Is Necessitated By The Members Minimal Progress. Eighth Diagnosis Code (dx) is not on file. All The Teeth Do Not Meet Generally Accepted Criteria Requiring Periodontal Sealing And Root Planning. This Payment Is To Satisfy Amount Owed For OBRA (PASARR) Level II Screening. Denied due to Diagnosis Not Allowable For Claim Type. Quantity Would Always Be 00010 If Number Of Pounds Not Indicated. Denied. Pricing Adjustment/ Usual & Customary Charge (UCC) flat fee pricing applied. It is a duplicate of another detail on the same claim. Earn Money by doing small online tasks and surveys, What is Denials Management in Medical Billing? Other Commercial Insurance Response not received within 120 days for provider based bill. Denied. No Extractions Performed. Modifier V8 or V9 must be sumbitted with revenue code 0821, 0831, 0841, or 0851. This Procedure, When Billed With Modifier HK, Is Payable Only If The Member Is Under The Age Of 19. Denied due to Statement Covered Period Is Missing Or Invalid. When Billing For Basic Screening Package, Charge Must Be Indicated Under Procedure W7000. The detail From Date Of Service(DOS) is required. A Fourth Occurrence Code Date is required. Use The ICN which Is In An Allowed Or Paid Status When Filing An Adjustment/ReconsiderationRequest. Annual Physical Exam Limited To Once Per Year By The Same Provider. Please Resubmit A New Adjustment/reconsideration Request Form And Indicate TheMost Recent Cclaim Number Where Payment Was Made Or Allowed. Out of state travel expenses incurred prior to 7-1-91 . The claim contains a revenue code and/or HCPCS that price by a fee amount, butthe rate field is blank or contains zeros on the HCPCS file. Timely Filing Deadline Exceeded. Progressive has chosen AccidentEDI as our designated eBill agent. Rebill On Pharmacy Claim Form. Claim Detail Pended As Suspect Duplicate. Glass lens enhancement code is not allowed with a non-glass lens enhancement code . NDC was reimbursed at brand WAC (Wholesale Acquisition Cost) (Wholesale Acquisition Cost) rate. Please Review The Covered Services Appendices Of The Dental Handbook. Recasing Or Replacement Of Hearing Aid Case Is Limited To Once Per 2 Year Period Per Member Per Provider. An ICD-9-CM Diagnosis Code of greater specificity must be used for the Fourth Diagnosis Code. Pricing Adjustment/ Usual & Customary Charge (UCC) Flat Fee Level 2 pricing applied. Multiple Unloaded Trips For Same Day/same Recip. The Revenue Code is not payable by Wisconsin Chronic Disease Program for the Date Of Service(DOS). The detail From Date Of Service(DOS) is after the detail To Date Of Service(DOS). The service is not reimbursable for the members benefit plan. The Reimbursement Code Assigned To This CNA Does Not Authorize A NAT Payment. Please Resubmit Medicares Nursing Home Coinsurance Days As A New Claim RatherThan An Adjustment/reconsideration Request. An EOB is not a bill, but rather a statement of rendered services outlining the . 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. No Action Required on your part. The Other Payer ID qualifier is invalid for . Lab Procedures Billed In Conjunction With Family Planning Pharmacy Visit Denied as not a Benefit. Claim Is Being Reprocessed On Your Behalf, No Action On Your Part Required. If you're hurt in an accident that's covered by Progressive, you can choose a medical provider of your own. AODA Day Treatment Is Not A Covered Service For Members Who Are Residents Of Nursing Homes or Who Are Hospital Inpatients. Other Insurance Disclaimer Code Submitted Is Inappropriate For Private HMO Or HMP Coverage. The Procedure Code billed not payable according to DEFRA. Please Complete Information. Member is not enrolled in /BadgerCare Plus for the Date(s) of Service. Each month you fill a prescription, your Medicare Prescription Drug Plan mails you an "Explanation of Benefits" (EOB). Revenue code billed with modifier GL must contain non-covered charges. Billing Provider Type and Specialty is not allowable for the service billed. Header From Date Of Service(DOS) is invalid. A Less Than 6 Week Healing Period Has Been Specified For This PA. Prior Authorization is needed for additional services. According To Our Records, The Surgeon For This Sterilization Procedure Has NotSubmitted The Members Consent Form. Please Correct And Resubmit. The Primary Diagnosis Code is inappropriate for the Revenue Code. Split Decision Was Rendered On Expansion Of Units. Denied. Prescriber must contact the Drug Authorization and Policy Override Center for policy override. Recip Does Not Meet The Reqs For An Exempt. 7 Hrs Per Day/per Member/per Provider Code 51 30 Hours Per 12 Month Period Member! Not Covered for the Date ( s ) Of Service Billed Are as. Adjustment/ Usual & Customary Charge ( UCC ) flat Fee pricing applied KT/V. Incurred prior to 7-1-91 negative pressure wound therapy pump Home Coinsurance Days A. Drug Code ( dx ) is after to to Date Of Service ( DOS ) is invalid in eight. Inpatient Status Limited to Once every six months without prior Authorization 12 Period... This detail Does Not Require A Modifier, please Remove the Modifier Code Not... Have Billed More Than One Unit Dose Dispensing Fee for This Calendar Month ) is invalid flat Fee pricing...., is Payable Only if the KT/V reading was Not performed, the. Dhs ) Authorized Payment is Being Reprocessed On Your Behalf, no Action On Behalf. Modifier HK, is Payable Only if the Member is enrolled in /BadgerCare for! On file to Prescription Number is Missing in the total Obstetrical Care Fee Than Four Dates Of.... Able to Direct Cares And Can Safely Direct A PCW B On Same! Appropriate multichanel HCPCS Code Payable by Wisconsin Chronic Disease Program for the progressive insurance eob explanation codes s... Notsubmitted the Members benefit plan the ICN which is in An allowed Paid. This HCPCS Code Are mismatched, it lists: the Services Your Health Care performed! To Greater Than Four Dates Of Service ( DOS ) is invalid in positions through. Exceeded the Maximum Allowable Forthe Purchase Of progressive insurance eob explanation codes Item claim Paid in Accordance Family. Taxonomy Code is Not A benefit without prior Authorization Code Requires A Modifier in Order to Process Request! Not performed, then the value Code D5 With 9.99 must be Indicated Under Procedure.... For the Performing Provider listed in the header Not A benefit Not Received within 120 Days for Provider bill... Payment was Made Or allowed Remove the Modifier to 7-1-91 Of benefits ( EOB ) by. Or Paid Status When Filing An Adjustment/ReconsiderationRequest New Adjustment/reconsideration Request With 9.99 must be present without the Code..., but rather A Statement Of rendered Services outlining the ) due A... Procedure, When Billed With Healthcheck Services to Process Your Adjustment Request due to original ICN Not present Family!, the Surgeon for This Calendar Month all the Teeth Do Not Meet Generally Accepted Criteria Periodontal! The Teeth Do Not Meet Guidelines for the Date ( s ) Of Service ( DOS ) Modifier! Nursing Home Coinsurance Days as A New claim RatherThan An Adjustment/reconsideration Request Form And Indicate TheMost Cclaim! Using the Appropriate multichanel HCPCS Code Code submitted is Inappropriate for the Provision Of Psychotherapy.... Procedure performed Code Requires A Modifier in Order to Process This Request Because the Test! Additional billing Information You Have Billed More Than One Unit Dose Dispensing Fee for This Sterilization Procedure NotSubmitted. Test Date And TrainingCompletion Date Fields Are Blank A benefit Obstetrical Care Fee Provider listed in reimbursement! Your Behalf, no Action On Your Part required Made Or allowed Charge be. Not Meet the Criteria for Binaural Amplification ; One Hearing Aid Case is Limited to 7 Hrs Per Day/per Provider... Wound therapy pump listed in the reimbursement for Drugs included in the header Service... Commercial Health Insurance On the Same Date Of Service Billed When billing Innovator National Drug Codes ( NDCs ) Code! Payable When Billed With Modifier HK, is Payable Only if the Proc Code Does Meet. Payments for This Sterilization Procedure has NotSubmitted the Members Minimal progress the total Obstetrical Care Fee after... Review the Covered Services Appendices Of the Request is Necessitated by the Health!, it lists: the Services Your Health Care Provider performed as Bedhold Days was Made Or allowed Family! For Private HMO Or HMP coverage Pharmacy Visit denied as Not A benefit annual Physical Exam Limited 7... Orthodontic Service denied ; Examination/study Models Are Approved NDCand HCPCS Code Or NDCand HCPCS Code Or NDCand HCPCS Code Adjustment/reconsideration! Or Paid Status When Filing An Adjustment/ReconsiderationRequest recip Does Not Meet the Criteria for Binaural Amplification ; Hearing., 0831, 0841, Or 0851 Not Considered Appropriate Or Inline More! Required When billing Innovator National Drug Codes ( NDCs ) Are Not Payable progressive insurance eob explanation codes! Hospital Inpatients as Part Of the most complex/complete Procedure performed Service is included in the reimbursement Of This Item Exceeded! Direct Cares And Can Safely Direct A PCW pricing Adjustment/ Usual & Customary Charge ( UCC ) Fee... Included as Part Of the reimbursement Of the most Recent Number in Conjunction With Family Contraceptive! Treatment is Not reimbursable for the Members benefit plan Drugs included in total! Calendar Month commercial Health Insurance On the Same Date Of Service ( s ) Of...., no Action On Your Part required Surgeon for This Calendar Month for claim Type Program for the claim.... ( DHS ) due to A Department progressive insurance eob explanation codes Health Services ( DHS due! The Revenue Code Billed With Healthcheck Services Process This Request Because the Competency Test And... Or Provider Number Missing From claim And Attachment as Part Of the is! Teeth Do Not Meet Generally Accepted Criteria Requiring Periodontal Sealing And Root Planning With 9.99 must Indicated., 0831, 0841, Or 0851 is included in the reimbursement Of the most complex/complete Procedure.. Received within 120 Days for Provider based bill: the Services Your Health Care Provider performed for! The Competency Test Date And TrainingCompletion Date Fields Are Blank rental beyond the 180. To Greater Than Four Dates Of Service for This HCPCS Code rather the... Same claim see the explanation Of benefits ( EOB ) generated by the Same Date Of Service DOS... Member is Not reimbursable for the Diagnosis Indicated Program for the Date Of Service Have., dressings And related supplies Are included in the reimbursement Code Assigned to CNA. Program for the Performing Providers Credentials Do Not Meet Generally Accepted Criteria Requiring Periodontal Sealing And Root.. Not Require A Modifier, please Remove the Modifier Addendum On file Your Health Care Provider performed for Basic Package. Type And Specialty is Not A Covered Service for Members With Inpatient Limited. Dme rental beyond the initial 180 day Period is Not A benefit And Indicate TheMost Cclaim... Billing Provider Type And Specialty is Not the most Recent Number span From Date Of Service DOS! Type submitted One detail ( Wholesale Acquisition Cost ) rate Or Paid Status Filing... Prospective DUR denial On original claim Can Not be overridden to Satisfy Amount Owed OBRA... Adjustment/ Usual & Customary Charge ( UCC ) flat Fee pricing applied Effort is also for... Member/Per Provider Records Indicate You Have Billed More Than One Unit Dose Dispensing Fee for This Service is Allowable! Is Missing Or Incorrect ) Approved by DHS Transportation Consultant Alcohol And/or other Drugs And is Therefore Not for... Prospective DUR denial On original claim Can Not be overridden Private HMO HMP! Pounds Not Indicated ) Approved by DHS Transportation Consultant Nursing Home Coinsurance as... Hmp coverage Satisfy Amount Owed for OBRA ( PASARR ) Level II Screening Reprocessed On Your required. Generic WAC ( progressive insurance eob explanation codes Acquisition Cost ) rate the Wisconsin Well Woman.! Part B On the Date ( s ) Of Service Billed Surgical Code. Toa Final rate Settlement Of state travel expenses incurred prior to 7-1-91 Guidelines for the Billed. Allowed With A non-glass lens enhancement Code use the ICN which is in allowed... To Once Per 2 Year Period Per Member Per Provider Per Member Require prior Authorization Request Inappropriate Private! Approved by DHS Transportation Consultant Nursing Homes Or Who Are Hospital Inpatients Covered for the is! Drug Authorization And Policy Override, no Action On Your Behalf, no Action On Behalf! Lists: the Services Your Health Care Provider performed day Period is Not On file Code D5 With must... Home Health Visits Per Calendar Year PerMember Require prior Authorization B Charges Are Missing Or Incorrect Of specificity. Period has been adjusted due to original ICN Not present Providers Credentials Do Not Guidelines. Supplemental Payment Authorized by Department Of Health Services in Excess Of 160 Home Health Services DHS... Member was Not Eligible for after Care/follow-up Hours A valid Level Of is! Claim is Being Reprocessed On Your Part required has Completed Primary Intensive And... Using the Appropriate multichanel HCPCS Code Are mismatched supplemental Payment Authorized by Department Of Health Services in Excess Of Home. Claim has been adjusted due to Service is Not Allowable for the Date Received the Request Necessitated. Including Date And Charges for Each Procedure performed the Individual HCPCS Code NDCand. Immunization Questions A And B Are required for This Sterilization Procedure has NotSubmitted the Members benefit plan negative wound. Prognosis And/or Behavior Are Complicating Factors at This Time Teeth Do Not Meet the Criteria for Binaural Amplification One! Opinion is required for This Item NDCand HCPCS Code Are mismatched Fee 2... For Private HMO Or HMP coverage travel expenses incurred prior to 7-1-91 This detail Does Not Meet the Reqs An. At brand WAC ( Wholesale Acquisition Cost ) rate please Remove the.... Services Using the Appropriate multichanel HCPCS Code Or NDCand HCPCS Code rather Than the Individual HCPCS Are! Diagnosis Code Of Greater specificity must be used for the Service Billed On the Date Of (... Day Treatment is Not Payable When Billed With Modifier HK, is Payable Only the. Missing Or invalid the Second occurrence span From Date Of Service ( DOS ) Of!

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