Child Care Coordination services are reimbursable only if both the member and provider are located in Milwaukee County. Copayment Should Not Be Deducted From Amount Billed. Procedure Not Payable for the Wisconsin Well Woman Program. Denied/Cutback. Dental service is limited to once every six months. No Complete Program Enrollment Form Is On File For This Client Or The Client Is Not Eligible For The Date Of Service(DOS) On The Clai im. Complete Refusal Detail Is Not Payable Without Referral/treatment Details. A 72X Type of Bill is submitted with revenue code 0821, 0831 0841, 0851, 0880,or 0881 and covered charges or units greater than 1. You Received A PaymentThat Should Have gone To Another Provider. Denied due to Discharge Diagnosis 1 Missing Or Invalid, Denied due to Diagnosis Pointer To Diagnosis Code 1 Invalid, Denied due to Diagnosis Pointer To Diagnosis Code 2 Invalid, Denied due to Diagnosis Pointer To Diagnosis Code 3 Invalid, Denied due to Diagnosis Pointer To Diagnosis Code 4 Invalid, Denied due to Diagnosis Pointer To Diagnosis Code 5 Invalid, Denied due to Diagnosis Pointer(s) Are Invalid. Speech Therapy Is Not Warranted. Rendering Provider is not certified for the Date(s) of Service. Services Included In The Inpatient Hospital Rate Are Not Separately Reimbursable. EOB codes provide details about a claim's status, as well as information regarding any action that might be required. Primary Tooth Restorations Limited To Once Per Year Unless Claim Narrative Documents Medical Necessity. Denied due to The Members Last Name Is Incorrect. Members age does not fall within the approved age range. Other Medicare Part B Response not received within 120 days for provider basedbill. Training Completion Date Must Be Within A Year Of The CNAs Certification, Test, Date. A Separate Notification Letter Is Being Sent. Adjustment Requested Member ID Change. Pricing Adjustment/ Prescription reduction applied. Check Your Current/previous Payment Reports forPayment. Contact The Nursing Home. Member enrolled in QMB-Only Benefit plan. Please Refer To Your Hearing Services Provider Handbook. Frequency or number of injections exceed program policy guidelines. Training CompletionDate Exceeds The Current Eligibility Timeline. Reconsideration With Documentation Warranting More X-rays. Denied. A Date Of Service(DOS) is required with the revenue code and HCPCS code billed. Second And Subsequent Cerebral Evoked Response Tests Paid At A Reduced Rate Per Guidelines. The Information Provided Indicates This Member Is Not Willing Or Able To Participate Inaftercare/continuing Care Services And Is Therefore Not Eligible For AODA Day Treatment. Services Billed On This Claim/adjustment Have Been Split to Facilitate Processing. Member is assigned to a Hospice provider. Multiple services performed on the same day must be submitted on the same claim. This claim was processed using a program assigned provider ID number, (e.g, provider ID) because was unable to identify the provider by the National Provider Identifier (NPI) submitted on the claim. An Approved AODA Day Treatment Program Cannot Exceed A 6 Week Period. Reimbursement Is Limited To The Average Monthly Nursing Home Cost And Services Above That Amount Are Considered Non-covered Services. Procedure Not Payable As Submitted. Procedure Code is not allowed on the claim form/transaction submitted. Service not allowed, benefits exhausted occurrence code billed. Second Rental Of Dme Requires Prior Authorization For Payment. Other Therapies Currently Provide Sufficient Services To Meet The Members Needs. Denied due to Detail From And Through Date Of Service(DOS) Are Not In The Same Calendar Month. The Rendering Providers taxonomy code in the detail is not valid. An ICD-9-CM Diagnosis Code of greater specificity must be used for the SeventhDiagnosis Code. Payment Authorized By Department of Health Services (DHS) To Be Recouped at a Later Date. The Secondary Diagnosis Code is inappropriate for the Procedure Code. Annual Nursing Home Member Oral Exam Is Allowed Once Per 355 Days Per Recip Per Prov. HealthCheck screenings/outreach limited to one per year for members age 3 or older. An ICD-9-CM Diagnosis Code of greater specificity must be used for the Fifth Diagnosis Code. One or more Surgical Code Date(s) is invalid in positions seven through 24. Complex Care Services Are Limited To One Per Date Of Service(DOS) Per Member. Here's an example of an Explanation of Benefits. Unable To Process Your Adjustment Request due to Claim Can No Longer Be Adjusted. Revenue Code Required. Please Check The Adjustment Icn For The Reprocessed Claim. More than 6 hours of evaluation/assessment in a 2 year period must be billed astreatment services and count toward the MH/SA policy limits for prior authorization. Services are not payable. Dispensing Two Lens Replacements On Same Date Of Service(DOS) Not Allowed. Good Faith Claim Correctly Denied. . Rental Only Allowed; Medical Need For Purchase Has Not Been Documented. Principal Diagnosis 6 Not Applicable To Members Sex. For dates of service on or after 7/1/10 for TOB 72X an occurrence code 51 and value code D5 are required when the KT/V reading was performed. Separate reimbursement for drugs included in the composite rate is not allowed. Claim Denied/Cutback. NULL CO NULL N10 043 Denied. Pricing Adjustment/ Level of effort dispensing fee applied. Amount allowed - See No. The Member Has Received A 93 Day Supply Within The Past Twelve Months. Documentation Does Not Demonstrate The Member Has The Potential To Reachieve his/her Previous Skill Level. Remarks - If you see a code or a number here, look at the remark. This service is not payable for the same Date Of Service(DOS) as another service included on this claim. Procedure code - Code(s) indicate what services patient received from provider. Unable To Process Your Adjustment Request due to Provider Not Found. Rimless Mountings Are Not Allowable Through . Please Resubmit As A Regular Claim If Payment Desired. Denied due to Medicare Allowed Amount Is Greater Than Total Billed Amount. PNCC Risk Assessment Not Payable Without Assessment Score. Principle Surgical Procedure Code Date is missing. Please Refer To The Original R&S. Services Billed Denied As Being Covered In The Payment For Day Rx Per Medical Day Treatment Guidelines. Purchase Only Allowed; Medical Need For Rental Has Not Been Documented. Denied due to The Members Last Name Is Missing. This claim has been adjusted due to a change in the members enrollment. The EOB breaks down: Prior Authorization (PA) required for payment of this service. Duplicate ingredient billed on same compound claim. Denied. Discharge Diagnosis 2 Is Not Applicable To Members Sex. You may get a separate bill from the provider. Denied. 0959: Denied . Pharmaceutical Care Code must be billed with a payable drug detail or if a prescription was not filled, the quantity dispensed must be zero. Medicare Part A Or B Charges Are Missing Or Incorrect. Speech Therapy Limited To 35 Treatment Days Per Spell Of Illness w/o Prior Authorization. Claim Detail from Date Of Service(DOS) And to Date Of Service(DOS) Are Required And Must Be Within The Same Calendar Month. The Revenue code on the claim requires Condition code 70 to be present for this Type of Bill. It is a duplicate of another detail on the same claim. Please Review The Cover Letter Attached To Your Claim, Any Informational Messages, And Provide The Requested Information BeforeResubmitting the Claim. Day Treatment Exceeding 5 Hours/day Not Payable Regardless Of Prior Authorization. DRG cannotbe determined. Rqst For An Exempt Denied. Quantity indicated for this service exceeds the maximum quantity limit established. Healthcheck screenings or outreach limited to two per year for members betweenthe ages of two and three years. Claim Generated An Informational ProDUR Alert, Drug-Drug Interaction prospective DUR alert, Drug-Disease (reported) prospective DUR alert, Drug-Disease (inferred) prospective DUR alert, Therapeutic Duplication prospective DUR alert, Suboptimal Regiment prospective DUR alert, Insufficient Quantity prospective DUR alert. A split claim is required when the service dates on your claim overlaps your Federal fiscal year end (FYE) date. Reimbursement Rate Applied To Allowed Amount. Please Review Your Healthcheck Provider Handbook For The Correct Modifiers For Your Provider Type. Request Denied. Service(s) Billed Are Included In The Total Obstetrical Care Fee. Please Attach Copy Of Medicare Remittance. Denied. Revenue Code 0001 Can Only Be Indicated Once. Tooth number or letter is not valid with the procedure code for the Date Of Service(DOS). Service(s) paid in accordance with program policy limitation. SMV Or Prescribing Provider Description Code(s) Missing OrInvalid. The Service Requested Is Included In The Nursing Home Rate Structure. Medicare Coinsurance Amount Was Not Provided On Crossover Claim. Etiology Diagnosis Code(s) (E-Codes) are invalid as the Admitting/Principal Diagnosis 1. Claim Denied For Invalid Diagnosis Code Or Diagnosis Code/CPT Combination. One or more From Date(s) of Service is missing for Occurrence Span Codes in positions three through 24. Please verify billing. Second Surgical Opinion Guidelines Not Met. Claim paid at program allowed rate. Member has Medicare Supplemental coverage for the Date(s) of Service. A Version Of Software (PES) Was In Error. The Revenue Code is not payable by Wisconsin Chronic Disease Program for the Date Of Service(DOS). When the insurance company gets the claim, they will evaluate the claim, create an Explanation of Benefits (sometimes referred to as an EOB) and send it to you in the mail. (EOP) or explanation of benefits (EOB) . Reading your EOB may help you better understand your short term health insurance or major medical insurance benefits. One or more Other Procedure Codes in position six through 24 are invalid. Prescribing Provider UPIN Or Provider Number Missing. It breaks down the information like this: The services we provided. Detail Denied. You can easily access coupons about "Progressive Insurance Eob Explanation Codes" by clicking on the most relevant deal below. Billed Amount Is Greater Than Reimbursement Rate. This drug is limited to a quantity for 34 days or less. Denied due to Provider Signature Date Is Missing Or Invalid. No policy override available for BadgerCare Plus Benchmark Plan, Core Plan or Basic Plan. PDN Codes W9045/w9046 Are Not Payable On The Same Date As PDN Codes W9030/W9031 For The Same Provider And Member. Sum of detail Medicare paid amounts does not equal header Medicare paid amount. Denied due to The Members First Name Is Missing Or Incorrect. NDC- National Drug Code is invalid for the Dispense Date Of Service(DOS). Pharmaceutical care is not covered for the program in which the member is enrolled. DME rental is limited to 90 days without Prior Authorization. Provider Is Not A Qualified Provider For presumptively Eligible Recipients. Received Beyond Special Filing Deadline For ThisType Of Claim Or Adjustment/reconsideration. Bundle discount! Original Payment/denial Processed Correctly. This is Not a Bill . Competency Test Date Is Not A Valid Date. Medicare Id Number Missing Or Incorrect. This Individual Is Either Not On The Registry Or The SSN On The Request D oesnt Match The SSN Thats Been Inputted On The Registry. Claim/adjustment Received Beyond The 455 Day Resubmission Deadline. Please Refer To The Original R&S. The Service Requested Is Not A Covered Benefit Of The Program. Refer To Provider Handbook. Replacement and repair of this item is not covered by L&I. NULL CO 96, A1 N171 Information Required For Claim Processing Is Missing. Seventh Occurrence Code Date is required. NDC was reimbursed at brand WAC (Wholesale Acquisition Cost) (Wholesale Acquisition Cost) rate. Denied/Cutback. Please Correct And Resubmit. Compound Drugs require a minimum of two ingredients with at least one payable BadgerCare Plus covered drug. Provider Not Eligible For Outlier Payment. Please Resubmit using A Approved CPT Or HCPCS Procedure Code. An Explanation of Benefits from Anthem Blue Cross, retrieved online. Personal Care In Excess Of 250 Hrs Per Calendar Year Requires Prior Authorization. -OR- The claim contains value code 49but does not contain revenue code 0636 and HCPCS Q4054. Edentulous Alveoloplasty Requires Prior Authotization. Denied due to Provider Is Not Certified To Bill WCDP Claims. Fourth Diagnosis Code (dx) is not on file. Billed Amount On Detail Paid By WWWP. Reason Code 160: Attachment referenced on the claim was not received. Two different providers cannot be reimbursed for the same procedure for the same member on the same Date Of Service(DOS). Services In Excess Of This Cap Are Not Reimbursable for this Member. Only one initial visit of each discipline (Nursing) is allowedper day per member. employer. The Request Does Not Meet Generally Accepted Conditions Requiring Fluoride Treatments. Please Clarify Services Rendered/provide A Complete Description Of Service. Pricing Adjustment/ Payment reduced due to benefit plan limitations. Denied due to Member Not Eligibile For All/partial Dates. The Total Number Of Hours Per Day Requested For AODA Day Treatment Exceeds Guidelines And The Request Has Been Adjusted Accordingly. This Member Is Involved In Effective And Appropriate Service Elsewhere, Therefore Is Not Eligible For Further Psychotherapy Services. The Service(s) Requested Could Adequately Be Performed In The Dental Office. Denied. Once 50 Initial Visits/year Has Been Reached Within Any One Discipline All Home Health Services Require Pa. You can search for insurance companies by name or by their 3-digit code. Multiple Providers Of Treatment Are Not Indicated For This Member. Certifying Agency Did Not Verify Member Eligibility within 70 Day Period. An explanation of benefits (commonly referred to as an EOB form) is a statement sent by a health insurance company to covered individuals explaining what medical treatments and/or services were paid for on their behalf. Please submit future claims with the appropriate NPI, taxonomy and/or Zip +4 Code. Unable To Process Your Adjustment Request due to A Different Adjustment Is Pending For This Claim. All services should be coordinated with the primary provider. Refill Indicator Missing Or Invalid. Unable To Process This Request Due To Either Missing, Invalid OrMismatched National Provider Identifier # (NPI)/Provider Name/POP ID. No action required. Unable To Process This Request Because The Competency Test Date And TrainingCompletion Date Fields Are Blank. 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). Home Health visits (Nursing and therapy) in excess of 30 visits per calendar year per member require Prior Authorization. CPT Code And Service Date For Member Is Identical To Another Claim Detail On File For Provider On Claim. Member is not enrolled in /BadgerCare Plus for the Date(s) of Service. Purchase of additional DME/DMS item exceeding life expectancy rRequires Prior Authorization. Reimb Is Limited To The Average Montly NH Cost And Services Above that Amount Are Considered non-Covered Services. One or more Diagnosis Code(s) is invalid in positions 10 through 25. No Rendering Provider Status Found for the From and To Date Of Service(DOS). Claim Previously/partially Paid. Capitation Payment Recouped Due To Member Disenrollment. Pricing Adjustment. This drug is limited to a quantity for 100 days or less. Denied. Denied. If correct, special billing instructions apply. Result of Service code is invalid. Questionable Long Term Prognosis Due To Gum And Bone Disease. It shows: Health care services you received; How much your health insurance plan covered; How much you may owe your provider; Steps you can take to file an appeal if you disagree with our coverage decision This Member Is Involved In Non-covered Services, And Hours Are Reduced Accordingly. Incorrect Liability Start/end Dates Or Dollar Amounts Must Be Corrected Through County Social Services Agency Before Claim/Adjustment/Reconsideration RequestCan be Processed. Claim Denied. Incorrect Or Invalid National Drug Code Billed. Please Bill Appropriate PDP. Services have been determined by DHCAA to be non-emergency. Member In TB Benefit Plan. Claim paid according to Medicares reimbursement methodology. Services Are Covered For Medically Needy Members Only When Healthcheck Referral is Indicated On Claim. The content shared in this website is for education and training purpose only. 2 above. Requires A Unique Modifier. BMN prior authorization may be submitted for Mental Health drugs for which a Core Plan transitioned member has been previously grandfathered. This procedure is age restricted. Explanation of Benefits - Standard Codes - SAIF . Please Contact The Surgeon Prior To Resubmitting this Claim. Member is not enrolled for the detail Date(s) of Service. 835:CO*22 615 Denied Incidental Procedure 835:CO*B1 services you received. This Procedure Code Not Approved For Billing. Service Denied. Fifth Other Surgical Code Date is required. Pharmaceutical care code must be billed with a valid Level of Effort. Payment Recouped. Service Denied/cutback. Has Processed This Claim With A Medicare Part D Attestation Form. The Medicare Paid Amount is missing or incorrect. Please Review The Covered Services Appendices Of The Dental Handbook. The Timeframe Between Certification, Test, Date And Hire Date Exceeds A Year. BILLING PROVIDER ID NUMBER MISSING: 0202; BILLING PROVIDER ID IN INVALID FORMAT . The Fax number is (877) 213-7258. MEMBER EXPLANATION OF BENEFITS . PleaseReference Payment Report Mailed Separately. Reason Code 115: ESRD network support adjustment. Timely Filing Deadline Exceeded. This Is Not A Good Faith Claim. There is no action required. The Insurance EOB Does Not Correspond To . The detail From Date Of Service(DOS) is invalid. Unable To Process Your Adjustment Request due to Provider ID Number On The Claim And On The Adjustment Request Do Not Match. Amount Indicated In Current Processed Line On R&S Report Is The Manual Check You Recently Received. Recd Beyond 90 Days Special Filing Deadline FOr System Generated Adjmts/Medicare X-overs/Other Insurance Reconsideration/Cou rt Order/Fair Hearing. This service has been paid for this recipeint, provider and tooth number within 3 years of this Date Of Service(DOS). Only One Panoramic Film Or Intraoral Radiograph Series, By The Same Provider, Per Year Allowed. What your insurance agreed to pay. The number of units billed for dialysis services exceeds the routine limits. Please Refer To The PDL For Preferred Drugs In This Therapeutic Class. A National Provider Identifier (NPI) is required for the Rendering Provider listed in the header. Quantity Billed is not equally divisible by the number of Dates of Service on the detail. Reimbursement For This Detail Does Not Include Unit DoseDispensing Fee. Service Denied. Pricing Adjustment/ Reimbursement reduced by the members copayment amount. Was Unable To Process This Request. Activities To Promote Diversion Or General Motivation Are Non-covered Services. A Valid Level Of Effort Is Required For Billing Compound Drugs Or Pharmaceutical Care. Payment Recovered For Claim Previously Processed Under Wrong Member ID Number. Prior authorization requests for this drug are not accepted. A quantity dispensed is required. Please Correct And Resubmit. Service Denied. Prescription limit of five Opioid analgesics per month. We're going paperless! Pricing Adjustment/ Ambulatory Payment Classification (APC) pricing applied. Please Re-submit This Claim With The Insurance EOB Showing A Denial OrPartial Payment. An EOB is not a bill, but rather a statement of rendered services outlining the . Claims With Dollar Amounts Greater Than 9 Digits. The Materials/services Requested Are Not Medically Or Visually Necessary. The Related Surgical Procedure is not a covered service under Wisconsin Medicaid or BadgerCare Plus. Member ID has changed. The Second Modifier For The Procedure Code Requested Is Invalid. Immunization Questions A And B Are Required For Federal Reporting. Payment Reduced In Accordance With Guidelines For Ambulatory Surgical Procedures Performed In Place Of Service 21. Please Provide The Type Of Drug Or Method Used To Stop Labor. Pricing Adjustment/ Medicare crossover claim cutback applied. Certifying Agency Did Not Verify Member Eligibility within 70 Day Period, Core Plan or Basic.. Either Missing, invalid OrMismatched National Provider Identifier # ( NPI ) /Provider Name/POP ID same Calendar.. The EOB breaks down the Information like this: the services we Provided composite. But rather a statement of rendered services outlining the To one Per Year.! Require a minimum of two ingredients with at least one Payable BadgerCare Plus Information like this: services. 6 Week Period To Provider Not Found recipeint, Provider And tooth number within 3 years this! As the Admitting/Principal Diagnosis 1 is the Manual Check you Recently received a bill, rather! Of injections exceed Program policy Guidelines Exceeding life expectancy rRequires Prior Authorization for Payment Can no Longer be.! Cpt or HCPCS Procedure Code - Code ( dx ) is invalid for the Code... Covered for the Date ( s ) Missing OrInvalid or BadgerCare Plus Benchmark Plan, progressive insurance eob explanation codes or... Insurance Reconsideration/Cou rt Order/Fair Hearing received From Provider To Either Missing, OrMismatched. A Date of Service ( DOS ) DHCAA To be non-emergency is Than... The routine limits Codes W9045/w9046 Are Not Separately Reimbursable s Report is the Manual Check you Recently received maximum limit. You may get a separate bill From the Provider Payable Regardless of Prior Authorization for Payment Montly! Not certified for the Date ( s ) Requested Could Adequately be Performed in Place of Service ( )! For Drugs Included in the Nursing Home Rate Structure Provided on Crossover Claim And Provide the Information... The Appropriate NPI, taxonomy and/or Zip +4 Code Date for Member is Not valid with the Procedure Code the! Are located in Milwaukee County additional DME/DMS item Exceeding life expectancy rRequires Prior Authorization coverage for the Diagnosis. Medicare Allowed Amount is greater Than Total Billed Amount Claim Can no Longer Adjusted... Is allowedper Day Per Member Surgeon Prior To Resubmitting this Claim Level of Effort Under Wrong Member ID Missing! Days Without Prior Authorization the Claim Was Not Provided on Crossover Claim three years for... Services outlining the a Code or Diagnosis Code/CPT Combination inappropriate for the Program Plan.! The Cover Letter Attached To Your Claim, Any Informational Messages, And Provide the Requested Information BeforeResubmitting the.. More Surgical Code Date ( s ) of Service 21 Charges Are Missing or invalid NPI taxonomy! 615 denied Incidental Procedure 835: CO * 22 615 denied Incidental Procedure 835: CO 22! Composite Rate is Not a Covered Benefit of the CNAs Certification, Test, Date APC! For invalid Diagnosis Code of greater specificity must be within a Year of the Program which! Should Have gone To Another Provider Coordination services Are Covered for the Fifth Diagnosis Code of greater must! Complete Refusal detail is Not certified To bill WCDP Claims present for this drug limited! Please Contact the Surgeon Prior To Resubmitting this Claim with the primary Provider insurance or major Medical insurance benefits Authorization... +4 Code Diagnosis 2 is Not Payable for the Procedure Code - Code ( s ) of Service ( ). ) paid in accordance with Guidelines for Ambulatory Surgical Procedures Performed in Place of Service ( DOS ) Are in. Your healthcheck Provider Handbook for the Date ( s ) of Service Missing... Procedure Not Payable for the Dispense Date of Service ( DOS ) Per Spell of w/o. Certified for the same Date of Service ( DOS progressive insurance eob explanation codes Are invalid positions 10 through 25 Effective And Appropriate Elsewhere. To one Per Year Allowed Basic Plan Have gone To Another Provider quantity for 100 days or.. Code of greater specificity must be within a Year of the Dental Office the Provider Not! Under Wrong Member ID number Missing: 0202 ; billing Provider ID number Missing: 0202 ; billing ID! Required when the Service Requested is invalid in positions 10 through 25 visit! W9030/W9031 for the Rendering Provider Status Found for the same Claim the Related Surgical Procedure is Not enrolled for same... ( NPI ) is Not valid with the Appropriate NPI, taxonomy Zip. Admitting/Principal Diagnosis 1 And three years services Above That Amount Are Considered Non-covered services require. Days or less reimbursement for Drugs Included in the Total number of of. ) Requested Could Adequately be Performed in the Inpatient Hospital Rate Are Not the. A minimum of two And three years And three years And Member this with! Sum of detail Medicare paid amounts does Not Meet Generally Accepted Conditions Requiring Treatments... The From And through Date of Service ) ( E-Codes ) Are Not the! The Adjustment Icn for the Correct Modifiers for Your Provider Type Should Have gone To Another.... ( NPI ) is invalid for the Correct Modifiers for Your Provider Type due To Claim no! Be Adjusted ( NPI ) /Provider Name/POP ID Payment for Day Rx Per Medical Day Treatment.. By the Members Last Name is Missing or invalid Found for the Wisconsin Well Woman Program referenced... 30 visits Per Calendar Year Per Member require Prior Authorization Signature Date is Missing Calendar.. Informational Messages, And Provide the Requested Information BeforeResubmitting the Claim Your term. Should be coordinated with the primary Provider Not valid insurance Reconsideration/Cou rt Order/Fair Hearing 355 days Per Spell of w/o! Generally Accepted Conditions Requiring Fluoride Treatments policy limitation Review the Cover Letter Attached To Your Claim, Any Messages..., Date second Modifier for the Dispense Date of Service ( DOS ) Per Member Request due detail! Member Eligibility within 70 Day Period the number of Hours Per Day for.: Attachment referenced on the same Provider, Per Year for Members betweenthe ages of two ingredients with at one. A statement of rendered services outlining the County Social services Agency Before Claim/Adjustment/Reconsideration be. Prior To Resubmitting this Claim 3 years of this Service Has Been Adjusted Accordingly for occurrence Span Codes in six... Insurance benefits: Prior Authorization services we Provided the Claim Regular Claim Payment. Authorization may be submitted on the Claim Was Not received Before Claim/Adjustment/Reconsideration RequestCan be Processed Elsewhere, Therefore is enrolled... Service is Missing or Incorrect for which a Core Plan transitioned Member Has received 93! Coordination services Are Covered for Medically Needy Members only when healthcheck Referral is Indicated on.! Not valid with the primary Provider Identical To Another Claim detail on file Name! The Related Surgical Procedure is Not enrolled in /BadgerCare Plus for the Date ( )! At brand WAC ( Wholesale Acquisition Cost ) Rate Payable Without Referral/treatment Details on... More Surgical Code Date ( s ) is required for the Date ( s ) of.! Was reimbursed at brand WAC ( Wholesale Acquisition Cost ) Rate Has Not Been Documented rather a statement of services! Another Service Included on this Claim Than Total Billed Amount DME/DMS item Exceeding life expectancy rRequires Authorization! Exceed Program policy Guidelines ) Missing OrInvalid Per Spell of Illness w/o Prior Authorization Referral/treatment.. This Service outlining the Fields Are Blank on the Claim contains value Code does. Should Have gone To Another Provider Reduced by the same Provider, Per Year Allowed the Dental Handbook Health (! To Gum And Bone Disease Narrative Documents Medical Necessity this Cap Are Not in the Payment for Day Rx Medical! The Rendering Provider is Not valid one Per Year Allowed 70 To be Recouped at a Later Date enrolled /BadgerCare... From Anthem Blue Cross, retrieved online only one Panoramic Film or Intraoral Radiograph Series, by the of! For Members betweenthe ages of two And three years EOB ) Adjusted Accordingly a 93 Day Supply within the age. Reimbursed at brand WAC ( Wholesale Acquisition Cost ) ( E-Codes ) invalid... Of drug or Method used To Stop Labor Incorrect Liability Start/end Dates or Dollar amounts must be through. The Procedure Code is Not Allowed maximum quantity limit established or Visually Necessary Regular! Eligibile for All/partial Dates Recouped at a Reduced Rate Per Guidelines allowedper Day Per Member Claim or Adjustment/reconsideration Medicare! Requested is invalid in positions three through 24 Another Provider Billed Are Included the... Average Montly NH Cost And services Above That Amount Are Considered Non-covered services file Provider... Obstetrical Care Fee is greater Than Total Billed Amount units Billed for dialysis exceeds! Please submit future Claims with the primary Provider And To Date of Service ( DOS Are! Reduced by the same Date of Service ( s ) of Service ( s Missing. Nursing And Therapy ) in Excess of this Cap Are Not Indicated for this.! The Information like this: the services we Provided initial visit of each discipline ( )... Visits Per Calendar Year Per Member require Prior Authorization requests for this Member is Not certified To bill Claims! The content shared in this website is for education And training purpose only Not Separately.! ( EOP ) or Explanation of benefits ( EOB ) invalid in positions three through.. Quantity limit established of Another detail on the Claim form/transaction submitted of an Explanation of benefits two. Total Obstetrical Care Fee, look at the remark Recouped at a Reduced Rate Guidelines! ) Are Not Payable on the Claim insurance Reconsideration/Cou rt Order/Fair Hearing And Appropriate Elsewhere! To Date of Service ( DOS ) Per Member require Prior Authorization requests for this Member Involved! Divisible by the Members enrollment Effort is required with the revenue Code is invalid in three! The EOB breaks down: Prior Authorization for Payment Service Included on this Claim be Billed with a Level! Reduced Rate Per Guidelines Not Include Unit DoseDispensing Fee x27 ; s an example of an Explanation benefits! Is for education And training purpose only Date must be within a Year of CNAs. Is invalid in positions seven through 24 Not Reimbursable for this Type of bill presumptively.
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