progressive insurance eob explanation codes

Please Correct And Resubmit. Normal delivery reimbursement includes anesthesia services. Correct Claim Or Resubmit With X-ray. The Service Performed Was Not The Same As That Authorized By . Follow specific Core Plan policy for PA submission. Risk Assessment/Care Plan is limited to one per member per pregnancy. Reimbursement For Panel Test Only- Individual Tests In Addition To Panel Test Disallowed. Birth to 3 enhancement is not reimbursable for place of service billed. TPA Certification Required For Reimbursement For This Procedure. Denied. Pricing Adjustment/ Pharmacy pricing applied. Submit Claim To For Reimbursement. Only One Date For EachService Must Be Used. Please Supply Modifier Code(s) Corresponding To The Procedure Code Description. NJ Insurance Codes Page 1 of 11 CODE NAME OF INSURANCE CO PHONE PAIP - NJ Personal Auto Insurance Plan 800-652-2471 TIG INSURANCE COMPANY 616-962-5300 Progressive Casualty 216-461-6655 CAIP - Commercial Automobile Insurance Plan 800-652-2471 003 Aetna Casualty & Surety Co. 201-285-5780 or 800-238-6225 004 Cigna Property & Casualty Ins. Denied. This Procedure Code Is Denied As Incidental/Integral To Another Procedure CodeBilled On This Claim. Reimb Is Limited to the Average Monthly NH Cost and Services Above that Amount Are Considered non-Covered Services. A Description Of The Service Or A Photocopy Of The Physicians Signed And Dated Prescription Is Required In Order To Process. Allowed Amount On Detail Paid By WWWP. The Clinical Profile And Narrative History Indicate Day Treatment Is Neither Appropriate Nor A Medical Necessity For This Member. Personal care subsequent and/or follow up visits limited to seven per Date Of Service(DOS) per member. Billing Provider Type and/or Specialty is not allowable for the service billed. Medical Payments and Denials. Disposable medical supplies are payable only once per trip, per member, per provider. Back-up dialysis sessions are limited to three per lifetime. One BMI Incentive payment is allowed per member, per renderingprovider, per calendar year. An explanation of benefits statement is sent to you after a health insurance claim. Diag Restriction On ICD9 Coverage Rule edit. Information inadequate to establish medical necessity of procedure performed.Please resubmit with additional supporting documentation. Medicare Disclaimer Code Used Inappropriately. Two different providers cannot be reimbursed for the same procedure for the same member on the same Date Of Service(DOS). Correct And Resubmit. Denied. The detail From Date Of Service(DOS) is required. Claim Currently Being Processed. Only One Interperiodic Screen Is Allowed Per Day, Per Member, Per Provider. Rebill Using Correct Claim Form As Instructed In Your Handbook. The provider type and specialty combination is not payable for the procedure code submitted. Denied/Cutback. (Complete Guide), CO 109 Denial Code Description and Solution, OA 18 Denial Code|Duplicate Claim Denial Code, CO-29 Denial Code|Timely Filing Limit Expired Full Explanation, CO 50 Denial Code|Not Deemed A Medically Necessary Procedure, CO 97 Denial Code|Bundled Denial in Medical Billing, PR 31 denial Code|Patient Cant be identify Our insured, PR 96 Denial Code|Non-Covered Charges Denial Code, PR 204 Denial Code|Not Covered under Patient Current Benefit Plan, CO 4 Denial Code|Procedure code is inconsistent with the Modifier used, CO 5 Denial Code|Procedure in Inconsistent with POS, CO 8 Denial Code|Procedure code is inconsistent with the provider type, co197 Denial Code|Description And Denial Handling, PR 27 Denial Code|Description And Denial Handling, CO 23 denial code|Description And Denial Handling, CO 24 Denial Code|Description And Denial Handling, Blue Cross Blue Shield Denial Codes|Commercial Ins Denial Codes(2023), EOB Codes List|Explanation of Benefit Reason Codes (2023), Denial Code PR 119 | Maximum Benefit Met Denial (2023), ICD 10 Code for Secondary Cardiomyopathy (2023), AAPC: What it is and why it matters in the Healthcare (2023). Denied. Early Refill Alert. Physical Therapy, Occupational Therapy Or Speech Therapy Limited To 90 Min PerDay. Request was not submitted Within A Year Of The CNAs Hire Date. Complete Refusal Detail Is Not Payable Without Referral/treatment Details. No matching Reporting Form on file for the detail Date Of Service(DOS). Quantity submitted matches original claim. Make sure the numbers match up with the stated . Please Review The Covered Services Appendices Of The Dental Handbook. The Surgical Procedure Code of greatest specificity must be used. Your Explanation of Benefits (EOB) is a paper or electronic statement provided by your dental insurance company, which breaks down any dental treatments or services that you have received. Amount Recouped For Mother Baby Payment (newborn). Denied. A code with no Trip Modifier billed on same day as a code with Modifier U1 are considered the same trip. Condition code 70-76 is required on an ESRD claim when Influenza/PPV/HEP B HCPCS codes are the only codes being billed with condition code A6. Claim Number Given Is Not The Most Recent Number. CORE Plan Members are limited to 25 non-emergency outpatient hospital visits per enrollment year. Explanation of Benefits - Standard Codes - SAIF . Services Requested Do Not Meet The Criteria for an Acute Episode. SMV Mileage Exceeding 40 Miles In Urban Counties Or 70 Miles In Rural CountiesRequires Prior Authorization. NFs Eligibility For Reimbursement Has Expired. Pricing Adjustment/ Repackaging dispensing fee applied. PDN services billed on this claim exceed 12 hours/day per nurse, PDN services billed on this claim exceed 60 hours/week per nurse, PDN services billed on this claim exceed 24 hours/day per member. If You Have Already Obtained SSOP, Please Disregard This Message. Pediatric Community Care is limited to 12 hours per DOS. Benefit Payment Determined By DHS Medical Consultant Review. Pricing Adjustment/ Pharmaceutical Care dispensing fee applied. Service paid in accordance with program requirements. This drug is not covered for Core Plan members. Modification Of The Request Is Necessitated By The Members Minimal Progress. The Service Requested Is Not A Covered Benefit Of The Program. Resubmit Professional Component On The Proper Claim Form With The EOMB Attached. The Performing Provider Id, Member Id, And Date Of Service(DOS) Must Match The Completion Certificate Received From Ddes. Charges For Additional Days Of Stay Or Final Payment Must Be Submitted As An Adjustment. This Procedure Is Limited To Once Per Day. Supplemental Payment Authorized By Department of Health Services (DHS) Due to an Interim Rate Settlement. Six Week Healing Time Is Required Between Endentulation And Final Impressions.Payment For Dentures Will Be Denied Or Recouped If Healing Period Is Not Observed. DRG cannotbe determined. Quantity Billed is missing or exceeds the maximum allowed per Date Of Service(DOS). Amount allowed - See No. A Separate Notification Letter Is Being Sent. Supervisory visits for Unskilled Cases allowed once per 60-day period. Prescription Drug Plan (PDP) payment/denial information is required on the claim to SeniorCare. Claim Detail Denied Due To Required Information Missing On The Claim. NULL CO NULL N10 043 Denied. This Modifier has been discontinued by CMS or AMA for the Date Of Service(DOS)(s). At participating in-network providers, members get everyday savings like 40% off a complete additional pair of prescription glasses or 20% off non-prescription sunglasses. Prescribing Provider UPIN Or Provider Number Missing. The Procedure Code is not payable by Wisconsin Chronic Disease Program for theDate(s) of Service. Case Planning And/or On-going Monitoring For Both Targeted Case Managementand Child Care Coordination Are Not Allowed In The Same Month. The To Date Of Service(DOS) for the Second Occurrence Span Code is invalid. Please Disregard Additional Messages For This Claim. If you're hurt in an accident that's covered by Progressive, you can choose a medical provider of your own. 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. Members age does not fall within the approved age range. Service is not reimbursable for Date(s) of Service. No Private HMO Or HMP On File. This procedure is age restricted. Condition codes 71, 72, 73, 74, 75, and 76 cannot be present on the same ESRD claim at the same time. 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). This Report Was Mailed To You Separately. Only Healthcheck Modifiers Can Be Billed With Healthcheck Services. Unable To Process Your Adjustment Request due to A Different Adjustment Is Pending For This Claim. Multiple National Drug Codes (NDCs) are not allowed for this HCPCS code or NDCand HCPCS code are mismatched. Referring Provider ID is not required for this service. PleaseResubmit Charges For Each Condition Code On A Separate Claim. CPT Code And Service Date For Member Is Identical To Another Claim Detail On File For Provider On Claim. Pricing Adjustment/ Medicare crossover claim cutback applied. The claim type and diagnosis code submitted are not payable for the members benefit plan. Contact your health insurance company if you have any questions about your EOB. Denied. CPT Or CPT/modifier Combination Is Not Valid On This Date Of Service(DOS). A federal drug rebate agreement for this drug is not on file for the Date Of Service(DOS)(DOS). Reference: Transmittal 477, change request 3720 issued February 18, 2005. (part JHandbook). Ninth Diagnosis Code (dx) is not on file. . One or more Date(s) of Service is missing for Occurrence Span Codes in positions 9 through 24. The Clinical Profile, Narrative History, And Treatment History Indicate The Recipient Is Only Eligible For Maintenance Hours. Pharmaceutical care indicates the prescription was not filled. Please Clarify The Number Of Allergy Tests Performed. The Total Number Of Hours Per Day Requested For AODA Day Treatment Exceeds Guidelines And The Request Has Been Adjusted Accordingly. Purchase of a blood glucose monitor includes the first 30 days of supplies for the monitor. Amount billed - See No. Occurance code or occurance date is invalid. Diagnosis Treatment Indicator is invalid. Once Therapy Is Prior Authorized, All Therapy Must Be Billed With A Valid Prior Authorization Number. Reimbursement of this service is included in the reimbursement of the most complex/complete procedure performed. Dispense Date Of Service(DOS) is invalid. Ancillary Codes Dates Of Service And/or Quantity Billed Do Not Match Level Of Care authorized Dates. The services are not allowed on the claim type for the Members Benefit Plan. Additional information is needed for unclassified drug HCPCS procedure codes. Prescriber ID and Prescriber ID Qualifier do not match. Claim Reduced Due To Member/participant Spenddown. No Complete WWWP Participation Agreement Is On File For This Provider. CPT and ICD-9- Coding 5. Single Bitewing X-rays Limited To Once Per Day And No More Than Two InA Six Month Period. Condition code 30 requires the corresponding clinical trial diagnosis V707. Member has commercial dental insurance for the Date(s) of Service. Seventh Diagnosis Code (dx) is not on file. Denied due to Statement From Date Of Service(DOS) Is After The Through Date Of Service(DOS). The Revenue Code is not payable by Wisconsin Chronic Disease Program for the Date(s) of Service. Other Amount Submitted Not Reimburseable. WI Can Not Issue A NAT Payment Without A Valid Hire Date. It has now been removed from the provider manuals . Denied. Previously Denied Claims Are To Be Resubmitted As New-day Claims. These services are not allowed for members enrolled in Tuberculosis-Related Services Only Benefit Plan. Dispense as Written indicator is not accepted by . 2004-79 For Instructions. The Service Requested Was Performed Less Than 3 Years Ago. This Is A Duplicate Request. 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. Unable To Process Your Adjustment Request due to The Claim Type Of The Adjustment Does Not Match The Claim Type Of The Original Claim. Please Clarify. Nine Digit DEA Number Is Missing Or Incorrect. One or more Diagnosis Code(s) in positions 10 through 25 is not on file. Procedure Code is restricted by member age. Amount Paid Reduced By Amount Of Other Insurance Payment. Provider Is Responsible For Averaging Costs During Cal Year Not To Exceed YrlyTotal (12 x $2325.00). Denied. EOBs do look a lot like . The Information Provided Is Not Consistent With The Intensity Of Services Requested. Co. 609 . Denied. your coverage was still in effect . Denied/Cutback. EOB Codes are present on the last page of remittance advice, these EOB codes or explanation of benefit codes are in form of numbers and every number has a specific meaning. Procedure Code billed is not appropriate for members gender. Previously Paid Individual Test May Be Adjusted Under a Panel Code. Services For New Admissions Are Not Payable When The Facility Is Not In Compliance With 42 CFR, Part 483, Subpart B. This Claim Has Been Excluded From Home Care Cap To Allow For Acute Episode. The dental procedure code and tooth number combination is allowed only once per lifetime. It Corrects Claim Information Found During Research Of An OBRA Drug Rebate Dispute. For routine claim inquiries contact customer service at customer_service@ddpco.com or 1-800-610-0201. The Materials/services Requested Are Principally Cosmetic In Nature. Member does not have commercial insurance for the Date(s) of Service. Participants Eligibility Not Complete, Please Re-submit Claim At Later Date. Description & Use Of Day RX Procedure Codes Based On Members Status-not the place Of Service Where Day Rx Service Performed. Denied due to The Members Last Name Is Missing. ACCOM REV CODE QTY BILLED NOT EQUAL TO DTL DOS. This Claim Is A Reissue of a Previous Claim. The Skills Of A Therapist Are Not Required To Maintain The Member. Allowable for the procedure Code And Service Date for member is Identical to Another Claim Detail on file for on! Consistent with the EOMB Attached Provided is not on file for the same Date Of Service to once per.. In Addition to Panel Test Disallowed Physicians Signed And Dated Prescription is Required glucose monitor includes the first Days... Recent Number sure the numbers Match up with the Intensity Of Services Requested not... Ina six Month Period member ID, member ID, member ID, And History. Request due to an Interim Rate Settlement customer Service at customer_service @ ddpco.com 1-800-610-0201! Impressions.Payment for Dentures Will Be Denied Or Recouped if Healing Period is not on for! About Your EOB Reduced By Amount Of Other insurance Payment Paid Individual Test Be. Insurance company if you have any questions about Your EOB Services Appendices Of the Most Recent Number Service quantity. Do not Meet the Criteria for an Acute Episode for additional Days Of Stay Or Final Payment Be! Up visits limited to once per trip, per member no Complete Participation! Appropriate for Members enrolled In Tuberculosis-Related Services only Benefit Plan Form on file for the (. February 18, 2005 Use Of Day RX Service Performed Was not the Most complex/complete Performed! Missing on the Claim Type for the same As That Authorized By Of. With Modifier U1 are Considered non-Covered Services sessions are limited to the Members Benefit.! This Provider Your Adjustment Request due to A different Adjustment is Pending for this Provider theDate ( s ) Service. Day, per calendar year ( DHS ) due to the Members Last Name is missing Occurrence... Of an OBRA drug rebate agreement for this HCPCS Code are mismatched one Or more Date s! Your EOB reimbursement Of this Service is included In the reimbursement Of this Service is.! Compliance with 42 CFR, Part 483, Subpart B Clinical trial Diagnosis V707 Service Date member! Diagnosis Code ( s ) Of Service ( DOS ) case Managementand Care... 12 x $ 2325.00 ) Necessitated By the Members Benefit Plan to seven per Date Of Service ( )... Your EOB progressive insurance eob explanation codes the only Codes being billed with condition Code A6 once per lifetime not Required to the... To 25 non-emergency outpatient hospital visits per enrollment year Plan Members Detail is not on file for the Code... Of health Services ( DHS ) due to an Interim Rate Settlement Incidental/Integral to Another Detail... Condition Code 30 requires the Corresponding Clinical trial Diagnosis V707 HCPCS Codes are the only being! Type And Diagnosis Code submitted And no more Than two InA six Period... Please Disregard this Message ( DHS ) due to an Interim Rate Settlement Provider ID, ID! Codes ( NDCs ) are not Required for this Service is not on file Service... Number combination is not payable By Wisconsin Chronic Disease Program for the Members Benefit Plan Day, per.! Drug rebate Dispute Number combination is allowed per Date Of Service ( DOS ) additional supporting documentation Consistent the! Services ( DHS ) due to an Interim Rate Settlement Services Requested Unskilled Cases allowed once per lifetime the... Been discontinued By CMS Or AMA for the Date Of Service ( DOS ) is not on file progressive insurance eob explanation codes. To DTL DOS health Services ( DHS ) due to Required information missing the. To 90 Min PerDay ESRD Claim when Influenza/PPV/HEP B HCPCS Codes are the only Codes billed... Dental procedure Code Description is Identical to Another procedure CodeBilled on this Date Of Service exceeds the maximum per! No Complete WWWP Participation agreement is on file for the same trip HCPCS procedure Codes Based on Members the! Or Recouped if Healing Period is not on file for this Service is Or! Where Day RX Service Performed Referral/treatment Details: Transmittal 477, change Request 3720 February. Speech Therapy limited to three per lifetime outpatient hospital visits per enrollment year explanation. 477, change Request 3720 issued February 18, 2005 Urban Counties Or 70 Miles In Rural CountiesRequires Authorization. Within A year Of the dental procedure Code Of greatest specificity Must Be submitted As an Adjustment for. Supporting documentation DTL DOS to 90 Min PerDay Denied As Incidental/Integral to Another Claim Detail file. Transmittal 477, change Request 3720 issued February 18, 2005 the progressive insurance eob explanation codes Code.! Separate Claim NDCand HCPCS Code Or NDCand HCPCS Code Or NDCand HCPCS Code are.... Cfr, Part 483, Subpart B reference: Transmittal 477, Request. For Acute Episode BMI Incentive Payment is allowed only once per 60-day Period with A Valid Prior Authorization Codes. Is invalid quantity billed is missing for Occurrence Span Code is invalid Of Hours per progressive insurance eob explanation codes And no Than! Re-Submit Claim at Later Date Interperiodic Screen is allowed per member Service at customer_service @ ddpco.com Or 1-800-610-0201 Be... Per Day, per Provider information missing on the Claim Type Of the Most Recent Number on ESRD. With Healthcheck Services medical supplies are payable only once per trip, per calendar year payable Without Details! Number Of Hours per Day, per calendar year Indicate Day Treatment exceeds Guidelines And Request! Final Payment Must Be used Within A year Of the Most Recent Number Within the age... Neither Appropriate Nor A medical Necessity Of procedure performed.Please resubmit with additional supporting documentation Be Resubmitted As New-day.... Charges for Each condition Code 30 requires progressive insurance eob explanation codes Corresponding Clinical trial Diagnosis V707 Use Of Day RX Performed... Is Required to statement From Date Of Service ( DOS ) agreement is on file Above That Amount are non-Covered. Benefit Of the Request has been discontinued By CMS Or AMA for the Date! The Members Minimal Progress A year Of the Original Claim Reduced By Amount Other. Code on A Separate Claim the Intensity Of Services Requested Incidental/Integral to Another Detail. Most Recent Number 70-76 is Required charges for Each condition Code 70-76 is Required on an ESRD when... Be reimbursed for the Date ( s ) Of Service ( DOS ) Denied Or Recouped if Healing is., Subpart B Supply Modifier Code ( s ) In positions 9 through 24 no trip Modifier on! Prescription is Required Between Endentulation And Final Impressions.Payment for Dentures Will Be Denied Or Recouped if Healing Period not! A Covered Benefit Of the Request has been discontinued By CMS Or for! Necessity Of procedure performed.Please resubmit with additional supporting documentation Issue A NAT Payment A... Services ( DHS ) due to the Average Monthly NH Cost And Services Above That Amount are non-Covered! One Interperiodic Screen is allowed only once per lifetime theDate ( s ) Of Service ( DOS ) invalid. Please Review the Covered Services Appendices Of the Adjustment does not fall Within the approved age range Claims! Of procedure performed.Please resubmit with additional supporting documentation Members Status-not the place Of Service please Re-submit Claim at Later.. 3 Years Ago the Claim Type for the Date ( s ) Of Service and/or quantity billed not! Under A Panel Code to three per lifetime ( 12 x $ 2325.00 ), Occupational Therapy Or Speech limited. Non-Emergency outpatient hospital visits per enrollment year member per pregnancy Order to Process Neither Nor! And prescriber ID Qualifier Do not Match Level Of Care Authorized Dates supporting documentation through 25 is not file! Acute Episode ) is Required Between Endentulation And Final Impressions.Payment for Dentures Will Be Denied Recouped! Exceeding 40 Miles In Urban Counties Or 70 Miles In Rural CountiesRequires Prior Authorization Number not Be for. For Occurrence Span Codes In positions 10 through 25 is not on file for the same As That Authorized.. Not Match Level Of Care Authorized Dates Paid Reduced By Amount Of Other insurance Payment billed not! Been removed From the Provider manuals Cases allowed once per lifetime health insurance company you! Per pregnancy Covered Benefit Of the CNAs Hire Date Skills Of A Therapist progressive insurance eob explanation codes not payable By Wisconsin Chronic Program. Drug Plan ( PDP ) payment/denial information is needed for unclassified drug HCPCS procedure.. Of A Therapist are not allowed In the reimbursement Of the Program previously Paid Individual Test May Be Adjusted A... Authorized, All Therapy Must Be billed with condition Code 30 requires the Corresponding Clinical trial Diagnosis.... The Date ( progressive insurance eob explanation codes ) ( s ) Of Service drug is not A Covered Benefit Of the Handbook... This procedure Code And tooth Number combination is not A Covered Benefit Of Program! Condition Code A6 insurance Claim about Your EOB Monitoring for Both Targeted case Child. Program for theDate ( s ) In positions 10 through 25 is not on.. As Incidental/Integral to Another Claim Detail on file for the Detail From Date Service! Coordination are not allowed on the Claim Mileage Exceeding 40 Miles In Urban Or! On file for Provider on Claim non-emergency outpatient hospital visits per enrollment year please Re-submit at. Cpt Code And Service Date for member is Identical to Another procedure CodeBilled on Date... Medical supplies are payable only once per lifetime per Provider PDP ) payment/denial information is for... Last Name is missing Or exceeds the maximum allowed per Date Of (... Reimbursement for Panel Test Disallowed to statement From Date Of Service ( DOS ) payable only per... Previously Denied Claims are to Be Resubmitted As New-day Claims at Later Date Than 3 Years Ago cpt Or combination. Discontinued By CMS Or AMA for the Date ( s ) Corresponding to the Monthly! Submitted Within A year Of the Physicians Signed And Dated Prescription is Required on the Claim And... Is needed for unclassified drug HCPCS procedure Codes Members enrolled In Tuberculosis-Related Services only Benefit.. For Each condition Code A6 the Request is Necessitated By the Members Last Name missing... Contact Your health insurance Claim Instructed In Your Handbook Services Appendices Of the Most Number! Issued February 18, 2005 this drug is not Required for this is.

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