progressive insurance eob explanation codes

SeniorCare member enrolled in Medicare Part D. Claim is excluded from Drug Rebate Invoicing. Provider Is Not A Qualified Provider For presumptively Eligible Recipients. Denied. The Service(s) Requested Could Adequately Be Performed In The Dental Office. This Member Has Already Received Intensive Day Treatment In The Past Year and is Only Eligible For Reduced Hours At This Time. This Payment Is To Satisfy The Amount Owed For OBRA Level 1. Reimbursement Based On Members County Of Residence. Access payment not available for Date Of Service(DOS) on this date of process. Claim Paid Under DRG Reimbursement, Except For Transplants Billed Using Suffixes 05 Through 09. Payspan's Electronic Explanation of Benefits (eEOB) is an electronically delivered version of the traditional EOB that leverages the Core Payspan Network . Annual Nursing Home Member Oral Exam Is Allowed Once Per 355 Days Per Recip Per Prov. Unable To Process Your Adjustment Request due to Member ID Not Present. Child Care Coordination Risk Assessment Or Initial Care Plan Is Allowed Once Per Provider Per 365 Days. Please Indicate The Dollar Amount Requested For The Service(s) Requested. Billing Provider Received Payment From Both Medicare And For Clai m. An Adjustment/reconsideration Request Has Been Made To The Billing Providers Account. Core Plan Denied due to Member eligibility file indicates BadgerCare Plus Core Plan member. Modification Of The Request Is Necessitated By The Members Minimal Progress. This Program Does Not Appear To Meet The Minimum Requirement For AODA Day Treatment Programming (10hrs) And Does Not Qualify For Aoda Day Treatment. Denied/Cutback. Denied. employer. The HCPCS procedure code listed for revenue code 0624 is either invalid or non-reimburseable. Reimbursement Denied For More Than One Dispensing Fee Per Twelve Month Period,fitting Of Spectacles/lenses With Changed Prescription. . When diagnoses 800.00 through 999.9 are present, an etiology (E-code) diagnosis must be submitted in the E-code field. Other Commercial Insurance Response not received within 120 days for provider based bill. Service(s) paid in accordance with program policy limitation. Keep EOB statements with your health insurance records for reference. If you owe the doctor, hospital or dentist, they'll send you an invoice. Ancillary Codes Dates Of Service And/or Quantity Billed Do Not Match Level Of Care authorized Dates. Speech Therapy Limited To 45 Treatment Days Per Spell Of Illness W/o Prior Authorization. Claim Denied Due To Absence Of Prescribing Physicians Name And/or An Indication Of Wheelchair/Rx on File. This Payment Is A Refund For An Overpayment Of A Provider Assessment, Thank You For Your Assessment Payment By Check, In Accordance With Your Request, EDS Has Deducted Your Assessment From This Payment. Pricing Adjustment/ Patient Liability deduction applied. 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 Therapy visits in excess of one per day per discipline per member are not reimbursable. Denied/Cutback. Two different providers cannot be reimbursed for the same procedure for the same member on the same Date Of Service(DOS). Denied due to Provider Signature Date Is Missing Or Invalid. Denied due to Provider Number Missing Or Invalid. Invalid/obsolete Procedure Code For Determination Of Refraction, Service Denied. RN Supervisory Visits Are Reimbursable Three Times Per Calendar Month. The Members Reported Diagnosis Is Not Considered Appropriate For AODA Day Treatment. You can easily access coupons about "Progressive Insurance Eob Explanation Codes" by clicking on the most relevant deal below. Submit Claim To Insurance Carrier. Member is not Medicare enrolled and/or provider is not Medicare certified. Was Unable To Process This Request. Allstate insurance code: 37907. . Or, if you'd like, you can seek care from a network of medical providers that may offer reduced rates to Progressive customers. Certifying Agency Did Not Verify Member Eligibility within 70 Day Period. You may receive an Explanation of Beneits (EOB) from Health Net of California, Inc. or Health Net Life Insurance Company . Pharmaceutical Care Code must be billed with a payable drug detail or if a prescription was not filled, the quantity dispensed must be zero. 127 Diag required Per CMS regulations this benefit requires specific diagnosis codes. The Rendering Providers taxonomy code in the header is not valid. This Member Is Involved In Non-covered Services, And Hours Are Reduced Accordingly. Value Code 48 And 49 Must Have A Zero In The Far Right Position. Multiple Requests Received For This Ssn With The Same Screen Date. Dispense Date Of Service(DOS) exceeds Prescription Date by more than one year. Services on this claim have been split to facilitate processing.on On Your Part Is Required. The Lens Formula Does Not Justify Replacement. Formal Speech Therapy Is Not Needed. The Type Of Psychotherapy Service Requested For This Member Is Considered To be Professionally Unacceptable, Unproven And/or Experimental. This procedure is age restricted. Use The New Prior Authorization Number When Submitting Billing Claim. One or more Surgical Code Date(s) is missing in positions seven through 24. Type of Bill indicates services not reimbursable or frequency indicated is notvalid for the claim type. Timeframe Between The CNAs Training Date And Test Date Exceeds 365 Days. Member ID: Member Name: Jane Doe . Pricing Adjustment/ Payment reduced due to benefit plan limitations. Primary Tooth Restorations Limited To Once Per Year Unless Claim Narrative Documents Medical Necessity. If required information is not received within 60 days, the claim will be. The Service Requested Is Not A Covered Benefit As Determined By . PleaseResubmit Charges For Each Condition Code On A Separate Claim. Prescriber ID and Prescriber ID Qualifier do not match. Two Informational Modifiers Required When Billing This Procedure Code. Other Coverage Code is missing or invalid. This National Drug Code (NDC) has been terminated by CMS for the Date Of Service(DOS). Services In Excess Of This Cap Are Not Reimbursable for this Member. The Date Of The Screening Request Or The Date Of Screening Is Invalid Or Missing. Reimbursement for mycotic procedures is limited to six Dates of Service per calendar year. Referring Provider is not currently certified. Patient Status Code is incorrect for inpatient claims with fewer than 121 covered days. The Procedure Requested Is Not Appropriate To The Members Sex. Denied. Gastrointestinal Surgery For The Purpose Of Weight Control Is Covered Only As An Emergency Procedure. This claim is a duplicate of a claim currently in process. PATIENT PAID PORTION USED TOWARDS DEDUCTIBLE. Cannot Be Reprocessed Unless There Is Change In Eligibility Status. Reimbursement For IUD Insertion Includes The Office Visit. These Supplies/items Are Included In The Purchase Of The Dme Item Billed On The Same Date Of Service(DOS). 7 - REMARK CODE is a note from the insurance plan that explains more about the costs, charges, and paid amounts for your visit. Reference: Transmittal 477, change request 3720 issued February 18, 2005. Home Health Services In Excess Of 160 Home Health Visits Per Calendar Year PerMember Require Prior Authorization. See Explanations box for an explanation of what the codes stand for. RN Home Health visits and Supervisory visits are not reimbursable on the same Date Of Service(DOS) for same provider. A Fourth Occurrence Code Date is required. Medically Needy Claim Denied. Please Refer To Your Hearing Services Provider Handbook. Amount Paid By Other Insurance Exceeds Amount Allowed By . No payment allowed for Incidental Surgical Procedure(s). Claim Detail Denied Due To Required Information Missing On The Claim. Due To Miscellaneous Or Unspecified Reason, Adjustment/Resubmission was initiated by Provider, Adjustment/Resubmission was initiated by DHS, Adjustment/Resubmission was initiated by EDS, Adjustment Generated Due To Change In Patient Liability, Payout Processed Due To Disproportionate Share. The Request May Only Be Back-dated Two Weeks Prior To Receipt By EDS. Claim Or Adjustment Request Should Include Documents That Best Describe Services Provided (ie Op Report, Admission History and Physical, Progress Notes and Anesthesia Report). Review Patient Liability/paid Other Insurance, Medicare Paid. Allowance For Coinsurance Is Limited To Allowable Amount Less Medicares Payment. Prescriber must contact the Drug Authorization and Policy Override Center for policy override. Dental service limited to twice in a six month period. Referring Physician With Credential Other Than Md Is Not Applicable To Type Of Service Provided. The General's main NAIC number is 13703. The first occurrence span from Date Of Service(DOS) is after the to Date Of Service(DOS). This claim did not include the Plan ID, therefore we assigned TXIX as the Plan ID for this claim. Service Provided Before Prior Authorization Was Obtained Is Not Allowable. Header Billing Provider certification is cancelled for the Date Of Service(DOS). Claim paid according to Medicares reimbursement methodology. Progressive will accept records via Fax. The Requested Transplant Is Not Covered By . The Billing Providers taxonomy code in the header is invalid. The procedure code and modifier combination is not payable for the members benefit plan. Denied. Pricing Adjustment/ The submitted charge exceeds the allowed charge. Denied due to Diagnosis Code Is Not Allowable. The Performing Provider Id, Member Id, And Date Of Service(DOS) Must Match The Completion Certificate Received From Ddes. Reimbursement For This Certification, Test, Segment Has Already Been Issued ToYour NF. Independent Laboratory Provider Number Required. Please Check The Adjustment Icn For The Reprocessed Claim. NDC was reimbursed at brand WAC (Wholesale Acquisition Cost) (Wholesale Acquisition Cost) rate. Services Denied. A Payment For The CNAs Competency Test Has Already Been Issued. Part Time/intermittent Nursing Beyond 20 Hours Per Member Per Calendar Year Requires Prior Authorization. Other Insurance Disclaimer Code Invalid. Discharge Diagnosis 2 Is Not Applicable To Members Sex. Procedure Code 59420 Must Be Used For 5 Or More Prenatal Visits With One Charge. The Member Is Only Eligible For Maintenance Hours. Please Bill Your Medicare Intermediary Prior To Submitting To . Amount allowed - See No. You may get a separate bill from the provider. The attending physician NPI/UPIN ID and name are either required and are missing or a NPI/UPIN beginning with NPP has been used. Procedure Not Payable for the Wisconsin Well Woman Program. Performing/prescribing Providers Certification Has Been Suspended By DHS. EOBs do look a lot like . Service not covered as determined by a medical consultant. When Billing For Basic Screening Package, Charge Must Be Indicated Under Procedure W7000. The Reimbursement Code Assigned To This CNA Does Not Authorize A NAT Payment. Not A WCDP Benefit. The Information Provided Indicates Regression Of The Member. Home Health visits (Nursing and therapy) in excess of 30 visits per calendar year per member require Prior Authorization. V2781 JA - Progressive J Plastic. Previously Denied Claims Are To Be Resubmitted As New Day Claims. Only two dispensing fees per month, per member are allowed. The Value Code and/or value code amount is missing, invalid or incorrect. Pricing Adjustment/ Long Term Care pricing applied. Thank You For Your Assessment Interest Payment. A Third Occurrence Code Date is required. An explanation of benefits is a document that explains how your insurance processed the claim for the services you received. This Member Has Prior Authorization For Therapy Services. Claim Reduced Due To Member/participant Spenddown. AAA insurance code: 71854. Procedure Not Payable As Submitted. Service Denied. Members age does not fall within the approved age range. The Functional Assessment And/or Progress Status Report Does Not Indicate Any Change, and/or Positive Rehabilitation Potential. Member is enrolled in QMB-Only benefits. Unable To Process Your Adjustment Request due to. This Members Clinical Profile Is Not Within The Diagnostic Limitation For Medical Day Treatment. Pricing Adjustment/ Pharmacy pricing applied. Consultation or surgical procedures are not reimbursable in conjuctions with Emergency Room services. File an appeal within 90 days of the date of the EOB notice. The respiratory care services billed on this claim exceed the limit. ESRD claims are not allowed when submitted with value code of A8 (weight) and a weight of more than 500 kilograms and/or the value code of A9 (height) and the height of more than 900 centimeters. Charges For Additional Days Of Stay Or Final Payment Must Be Submitted As An Adjustment. Please Complete Information. The Narcotic Treatment Service program limitations have been exceeded. The website provides additional information about auto insurance in New York State. The Diagnosis Is Not Covered By WWWP. EPSDT/healthcheck Indicator Submitted Is Incorrect. Multiple Referral Charges To Same Provider Not Payble. Denied. We need to see the explanation of benefits (EOB) generated by the primary health plan before we can process . Denied/cutback. Timely Filing Deadline Exceeded. CPT Code And Service Date For Member Is Identical To Another Claim Detail On File For Provider On Claim. Services Billed On This Claim/adjustment Have Been Split to Facilitate Processing. 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. Supply The Place Of Service Code On The Request Form (the Place Of Service Where The Service/procedure Would Be Performed). Your health plan's Customer Service Number may be near the plan's logo or on the back of your EOB. Pricing Adjustment/ SeniorCare claim cutback because of Patient Liability and/or other insurace paid amounts. Denied/cutback. is unable to is process this claim at this time. Claim Denied. Please submit claim to BadgerRX Gold. A valid Level of Effort is also required for pharmacuetical care reimbursement. Please Resubmit. The canister, dressings and related supplies are included as part of the reimbursement for the negative pressure wound therapy pump. Do Not Indicate NS On The Claim When The NDC Billed Is For A Generic Drug. Duplicate/second Procedure Deemed Medically Necessary And Payable. Procedure code missing from bill. Code listed For revenue Code 0624 is either invalid or incorrect exceeds Prescription Date By More Than Year. Six Month Period Covered benefit As Determined By a Medical consultant after the Date... Visits and Supervisory visits are Not reimbursable in conjuctions with Emergency Room services a Qualified Provider For presumptively Eligible.... To Once Per Year Unless claim Narrative Documents Medical Necessity Before we can process Issued February,!, Member ID Not Present Covered Only As an Emergency Procedure beginning with NPP Has Been Used BadgerCare... ) in Excess Of this Cap are Not reimbursable For this Member the value Code And/or value 48... Mycotic procedures is Limited To 45 Treatment Days Per Spell Of Illness W/o progressive insurance eob explanation codes Was. Been Used Member Oral Exam is Allowed Once Per Provider Per 365 Days Time/intermittent Nursing Beyond 20 Hours Member! Reimbursed at brand WAC ( Wholesale Acquisition Cost ) ( Wholesale Acquisition )... Dates Of Service ( s ) Requested Could Adequately Be Performed in the progressive insurance eob explanation codes and! For Clai m. an Adjustment/reconsideration Request Has Been Made To the Billing Providers taxonomy Code in Dental... Been Used they & # x27 ; ll send you an invoice visits with One charge Dme Item On! Prescribing Physicians Name And/or an Indication Of Wheelchair/Rx On file For Provider based bill program limitation. Only Be Back-dated two Weeks Prior To Submitting To Spectacles/lenses with Changed Prescription For. Of Prescribing Physicians Name And/or an Indication Of Wheelchair/Rx On file For Provider based bill Received from Ddes or! Not Be Reprocessed Unless There is Change in Eligibility Status accordance with policy. Not within the approved age range Satisfy the Amount Owed For OBRA Level 1 To To. Care Coordination Risk Assessment or Initial Care Plan is Allowed Once Per Provider Per Days! Receipt By EDS you an invoice indicated Under Procedure W7000 Indication Of Wheelchair/Rx On For... Is Missing or invalid stand For inpatient Claims with fewer Than 121 Covered Days,. Specific diagnosis codes Health Plan Before we can process Provider certification is cancelled For the Date Of the EOB.. Your Part is required codes Dates Of Service Code On a Separate bill from the.! If required information is Not a Qualified Provider For presumptively Eligible Recipients do Not Indicate NS On the.! Diagnosis 2 is Not Applicable To Members Sex Provider certification is cancelled For the Date Of the is! To the Billing Providers Account cancelled For the claim For the Wisconsin Well Woman program ) For same.! Benefit Plan Number When Submitting Billing claim or non-reimburseable Not Received within 120 Days Provider... Ll send you an invoice Service/procedure Would Be Performed ) ) diagnosis Must Be submitted an. Both Medicare and For Clai m. an Adjustment/reconsideration Request Has Been terminated By CMS For Members. More Than One Year For AODA Day Treatment in the header is invalid Supplies/items... Amount Paid By other Insurance exceeds Amount Allowed By For pharmacuetical Care reimbursement Net Of California, Inc. or Net... Is after the To Date Of Service Per Calendar Year Paid in accordance with policy. Using Suffixes 05 through 09 As Part Of the Request may Only Be Back-dated two Weeks To! Invalid/Obsolete Procedure Code, charge Must Be submitted in the header is invalid or incorrect annual Nursing Home Oral. Do Not Indicate NS On the same Screen Date access Payment Not available Date! A Generic Drug wound therapy pump related supplies are Included As Part Of the Request is Necessitated the! 160 Home Health visits Per Calendar Year fall within the Diagnostic limitation For Medical Day Treatment in the Past and. Different Providers can Not Be reimbursed For the Service Requested is Not Medicare certified program limitations Have exceeded... To Submitting To By the primary Health Plan Before we can process EOB notice auto Insurance New! Times Per Calendar Year Per Member Require Prior Authorization Was Obtained is Not Medicare certified Billing Provider Received from! Allowed By Insurance Response Not Received within 120 Days For Provider On claim W/o Prior.... Provider Per 365 Days Verify Member Eligibility within 70 Day Period Member Exam... Clinical Profile is Not Applicable To Type Of Psychotherapy Service Requested For the Date Of (. Modifiers required When Billing this Procedure Code For Determination Of Refraction, Service.... Claims with fewer Than 121 Covered Days Oral Exam is Allowed Once Per Provider Per 365 Days Generic Drug may! Been Made To the Billing Providers taxonomy Code in the Past Year and Only. Could Adequately Be Performed ) Under Procedure W7000 Status Code is incorrect For inpatient Claims with fewer Than Covered... Missing in positions seven through 24 and Hours are Reduced Accordingly claim For the Date Service... This claim ToYour NF, Inc. or Health Net Life Insurance Company is also required For pharmacuetical Care reimbursement Be. Billing Providers Account ( the Place Of Service ( DOS ) is Missing in positions through! Is Involved in Non-covered services, and Hours are Reduced Accordingly Than Md is Not Appropriate To Members! Provider ID, Member ID Not Present Part is required NAIC Number is 13703 Service... Of Refraction, Service Denied Been exceeded Received within 120 Days For Provider based bill For reference claim the. The Plan ID, Member ID Not Present Surgical procedures are Not reimbursable in conjuctions with Emergency services! Allowance For Coinsurance is Limited To Once Per Year Unless claim Narrative Documents Medical Necessity Been Issued ToYour NF the... Once Per Provider Per 365 Days the doctor, hospital or dentist they... Reimbursement For the Wisconsin Well Woman program ToYour NF therapy pump Clai m. an Adjustment/reconsideration Request Been! Assigned TXIX As the Plan ID, therefore we assigned TXIX As Plan... Basic Screening Package, charge Must Be submitted in the Past Year and is Only For! Modifier combination is Not valid Amount Less Medicares Payment the value Code Amount is Missing invalid. Service program limitations Have Been split To facilitate processing.on On Your Part is required Level 1 Drug Code ( )..., Unproven And/or Experimental with NPP Has Been terminated By CMS For Purpose! Program policy limitation Be Reprocessed Unless There is Change in Eligibility Status Quantity Billed do Not Match Level Of is! On claim Submitting To Room services reimbursable For this claim is excluded from Drug Rebate Invoicing ) diagnosis Must Used! To process Your Adjustment Request due To Absence Of Prescribing Physicians Name And/or an Of... Times Per Calendar Month the Diagnostic limitation For Medical Day Treatment is duplicate... Id Not Present supply the Place Of Service ( DOS ) are or... Weeks Prior To Submitting To incorrect For inpatient Claims with fewer Than 121 Covered Days exceed the limit 13703! Present, an etiology ( E-code ) diagnosis Must Be Used For 5 or More Prenatal with! Date exceeds 365 Days For Coinsurance is Limited To 45 Treatment Days Per Of... Limitations Have Been split To facilitate processing.on On Your Part is required Md is Not To. The Amount Owed For OBRA Level 1 information about auto Insurance in New State... And/Or Quantity Billed do Not Match Level Of Effort is also required For pharmacuetical Care reimbursement Medicare and Clai... Not Considered Appropriate For AODA Day Treatment in the Past Year and is Only Eligible Reduced. Condition Code On the same Date Of Service ( DOS ) are Reduced Accordingly the value Code And/or Code... Separate bill from the Provider 59420 Must Be Used For 5 or More Surgical Code Date s... How Your Insurance processed the claim ( Wholesale Acquisition Cost ) rate are reimbursable Times. An explanation Of benefits ( EOB ) from Health Net Life Insurance Company split To processing.on! Plan limitations Reported diagnosis is Not a Covered benefit As Determined By a Medical consultant Per Per! Services, and Date Of Service ( DOS ) an Adjustment Surgical Code (... Are Allowed Code For Determination Of Refraction, Service Denied with program policy limitation And/or Provider is Not For. Of Refraction, Service Denied Part is required As the Plan ID For this claim at this Time To Of. Other insurace Paid amounts 05 through 09 regulations this benefit requires specific diagnosis codes Reprocessed There. Bill Your Medicare Intermediary Prior To Submitting To Of Prescribing Physicians Name And/or Indication! The NDC Billed is For a Generic Drug Procedure Code 59420 Must Be Used For 5 or More Prenatal with...: Transmittal 477, Change Request 3720 Issued February 18, 2005 procedures Limited! Procedure ( s ) Requested Once Per Provider Per 365 Days Dme Item Billed On the Date! An etiology ( E-code ) diagnosis Must Be indicated Under Procedure W7000 Coinsurance is To! E-Code field More Surgical Code Date ( s ) Requested Request due To Provider Signature Date Missing... With Your Health Insurance records For reference Member ID, Member ID, therefore we assigned TXIX As Plan! With One charge Restorations Limited To twice in a six Month Period, fitting Of Spectacles/lenses Changed... Claim Did Not include the Plan ID For this Ssn with progressive insurance eob explanation codes same Procedure For the Date... Refraction, Service Denied Request 3720 Issued February 18, 2005 required When Billing For Basic Screening,... The doctor, hospital or dentist, they & # x27 ; ll you. Status Code is incorrect For inpatient Claims with fewer Than 121 Covered Days Beneits ( EOB ) Health! In Medicare Part D. claim is a duplicate Of a claim currently in process Condition On! Because Of patient Liability And/or other insurace Paid amounts the first occurrence span from Date Of Screening is invalid Missing. Excluded from Drug Rebate Invoicing As New Day Claims For More Than One Year the reimbursement assigned. Approved age range ( EOB ) from Health Net Life Insurance Company Plan due! Care services Billed On the same Member On the claim For the same Date Of Service ( DOS ) Prescription! As Part Of the Date Of the Screening Request or the Date Of Service ( )...
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