Contact Wisconsin s Billing And Policy Correspondence Unit. You Must Either Be The Designated Provider Or Have A Refer. Please Refer To The All Provider Handbook For Instructions. They list the codes for each treatment or item as well as a short description of what the service entailed. Members Up To 3 Years Of Age Are Limited To 2 Healthcheck Screens Per 12 Months. No payment allowed for Incidental Surgical Procedure(s). Please Furnish Length Of Time For Services Rendered. Revenue codes 0822, 0823, 0825, 0832, 0833, 0835, 0842, 0843, 0845, 0852, 0853, or 0855 exist on the ESRD claim that does not contain condition code 74. Services are not payable. Multiple Carry Procedure Codes Are Not Payable When Billed With Modifiers. Claim Is Pended For 60 Days. Please Submit With Completed timely Filing Form In The All Provider Handbook And Supporting Documentation. Denied/Cutback. Amount billed - your health care provider charged this fee for. The Provider Type/specialty Is Not Recognized For These Date(s) Of Service. Incorrect Liability Start/end Dates Or Dollar Amounts Must Be Corrected Through County Social Services Agency Before Claim/Adjustment/Reconsideration RequestCan be Processed. The service was previously paid for this Date Of Service(DOS). Lab Procedures Billed In Conjunction With Family Planning Pharmacy Visit Denied as not a Benefit. Accommodation Days Missing/invalid. From Date Of Service(DOS) is before Admission Date. This claim is eligible for electronic submission. Click here to access the Explanation of Benefit Codes (EOBs) as of March 17, 2022. The Rendering Providers taxonomy code in the header is invalid. This Claim Is Being Returned. Check Your Current/previous Payment Reports forPayment. They might also make a digital copy available . Services For Members With Medical Status Code TR, SH, SJ, TS Or ST NotAllowed For Your Provider Type, Or For Your Provider Type without a TB Diagnosis. Effective 04/01/09, the BadgerCare Plus Core Plan will limit coverage for Brochodilators-Beta Agonists to Proventil HFA and Serevent. Repair services billed in excess of the amount specified in the Durable Medical Equipment (DME) handbook require Prior Authorization. Denied due to Per Division Review Of NDC. Second And Subsequent Cerebral Evoked Response Tests Paid At A Reduced Rate Per Guidelines. Homecare Services W/o PA Are Not Payable When Prior Authorized HomecAre Services Have Been Provided To The Same Member. Good Faith Claim Has Previously Been Denied By Certifying Agency. Denied. Your health plan's Explanation of Benefits, more commonly known as an EOB, may be confusing at first glance, but it doesn't have to be. The Revenue Code is not allowed for the Type of Bill indicated on the claim. New Prescription Required. This Procedure Is Denied Per Medical Consultant Review. Ninth Diagnosis Code (dx) is not on file. Recouped. A SeniorCare drug rebate agreement is not on file for this drug for the Date Of Service(DOS). the service performedthe date of the . Review Has Determined No Adjustment Payment Allowed. Routine foot care Diagnoses must be billed with valid routine foot care Procedure Codes. No Financial Needs Statement On File. The Diagnosis Is Not Covered By WWWP. Core Plan Denied due to Member eligibility file indicates BadgerCare Plus Core Plan member. 0001 01/01/1900 NOT USED - MEMBER'S DMAP I.D. A valid Level of Effort is also required for pharmacuetical care reimbursement. Training Completion Date Must Be Prior To And Within A Year Of The CNAs Certification Date. Service Denied A Physician Statement (including Physical Condition/diagnosis) Must Be Affixed To Claims For Abortion Services Refer To Physician Handbook. Effective 04/01/09, the BadgerCare Plus Core Plan will limit coverage for Hypoglycemics-Insulin to Humalog and Lantus. Ancillary Codes Dates Of Service And/or Quantity Billed Do Not Match Level Of Care authorized Dates. Case Planning And/or On-going Monitoring For Both Targeted Case Managementand Child Care Coordination Are Not Allowed In The Same Month. An ICD-9-CM Diagnosis Code of greater specificity must be used for the Diagnosis Code in posistion 10 through 24. Requests For Training Reimbursement Denied Due To Late Billing. We're going paperless! An antipsychotic drug has recently been dispensed for this member. Homecare Services W/o PA Are Not Payable When Prior Authorized Homecare Services have Been Provided To The Same Member. Denied/Cutback. Compound drugs not covered under this program. Gastrointestinal Surgery For The Purpose Of Weight Control Is Covered Only As An Emergency Procedure. Please Correct And Resubmit. Level And/or Intensity Of Requested Service(s) Is Incompatible With Medical Need As Defined In Care Plan. 107 Processed according to contract/plan provisions. NDC- National Drug Code is not covered on a pharmacy claim. Limited to once per quadrant per day. Claim Denied/Cutback. Service is reimbursable only once per calendar month. Member must receive this service from the state contractor if this is for incontinence or urological supplies. The Second Other Provider ID is missing or invalid. Service Not Covered For Members Medical Status Code. No Reimbursement Rates on file for the Date(s) of Service. Reimburse Is Limited To Average Monthly NHCost And Services Above That Amount Are Consider non-Covered Services. The Documentation Submitted Does Not Substantiate Additional Care. Providers May Only Bill For Assessments And Care Plans Twice Per Calendar Year. Explanation of Benefits List 277 Status Code 277 Description EOB Code EOB Description Entity Identifier Code Description . The procedure code is not reimbursable for a Family Planning Waiver member. Billing Provider Type and Specialty is not allowable for the Rendering Provider. All three DUR fields must indicate a valid value for prospective DUR. Patient Status Code is incorrect for Long Term Care claims. Please Indicate Anesthesia Time For Services Rendered. Missing or invalid level of effort submitted and/or reason for service, professional service, or result of service code billed in error. . The Type Of Psychotherapy Service Requested For This Member Is Considered To be Professionally Unacceptable, Unproven And/or Experimental. OFFHDR2014. Pricing Adjustment/ Pharmaceutical Care dispensing fee applied. Member is enrolled in a State-contracted managed care program for the Date(s) of Service. Quantity indicated for this service exceeds the maximum quantity limit established. Please Indicate Separately On Each Detail. Additional information is needed for unclassified drug HCPCS procedure codes. Note: The Group, Reason and Remark Codes are HIPAA EOB codes and are cross-walked to L&I's EOB codes. CODE DETAIL_DESCRIPTION EDI_CROSSWALK 030 Missing service provider zip code (box 32) 835:CO*45 . Denied due to Medicare Allowed Amount Required. Claim Denied In Order To Reprocess WithNew ID. 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. Treatment With More Than One Drug Per Class Of Ulcer Treatment Drug At The Same Time Is Not Allowed Through Stat PA. Claim Currently Being Processed. 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. CORE Plan Members are limited to 25 non-emergency outpatient hospital visits per enrollment year. Continuous home care and routine home care may not be billed for the same member on the same Date Of Service(DOS). (EOP) or explanation of benefits (EOB) . Supplemental Payment Authorized By Department of Health Services (DHS) Due to aAudit. Claim Denied. Service(s) Denied. Member Or Participant Identified As Enrolled In A Medicare Part D PrescriptionDrug Plan (PDP). It is a duplicate of another detail on the same claim. Third Other Surgical Code Date is required. The Total Billed Amount is missing or incorrect. Claims Cannot Exceed 28 Details. the V2781 to modify the meaning of the progressive. The From Date Of Service(DOS) and To Date Of Service(DOS) must be in the same calendar month and year. Contacting WorkCompEDI.com. Enter ZIP Code. Ulcerations Of The Skin Do Not Warrant A New Spell Of Illness. The provider is not listed as the members provider or is not listed for thesedates of service. The Primary Diagnosis Code is inappropriate for the Surgical Procedure Code. This Is A Manual Decrease To Your Accounts Receivable Balance. Time Spent In AODA Day Treatment By Affected Family Members Is Not Covered. Please Verify That Physician Has No DEA Number. Claim Paid In Accordance With Family Planning Contraceptive Services Guidelines. The Procedure Code is not payable by Wisconsin Well Woman Program for the Date(s) of Service. Reimbursement For This Service Has Been Approved. Please Bill Appropriate PDP. Please Refer To The Original R&S. Payment Reduced Due To Patient Liability. Consent Form Is Missing, Incomplete, Or Contains Invalid Information. Claim Detail Denied For Invalid CPT, Invalid CPT/modifier Combination, Or Invalid Type Of Quantity Billed. Payment has been reduced or denied because the maximum allowance of this ESRD service has been reached. There Is Evidence That The Member Is Not Detoxified From Alcohol And/or Other Drugs and is Therefore Not Currently Eligible For AODA Day Treatment. One or more Occurrence Span Code(s) is invalid in positions three through 24. Service Denied. Denied. Therapy Prior Authorization Requests Expire At The End Of A Calendar Month. If Required Information Is not received within 60 days, the claim detail will be denied. Does not reimburse both the global service and the individual component parts of the service for the same Date Of Service(DOS). The Procedure Requested Is Not Allowable For The Process Type Indicated On TheRequest. Purchase Of A DME/DMS Item Exceeding One Per Month Requires Prior Authorization. Independent RHCs Must Bill Codes W6251, W6252, W6253, W6254 Or W6255. Speech Therapy Evaluations Are Limited To 4 Hours Per 6 Months. It Must Be In MM/DD/YY Format AndCan Not Be A Future Date. Contact The Nursing Home. Modifier invalid for Procedure Code billed. The Member Is School-age And Services Must Be Provided In The Public Schools. A Trading Partner Agreement/profile Form(s) Authorizing Electronic Claims Submission Is Required. A NAT Reimbursement Request Must Be Submitted To WI Within A Year Of The CNAs Hire Date. NDC- National Drug Code is invalid for the Dispense Date Of Service(DOS). Resubmit With Original Medicare Determination (EOMB) Showing Payment Of Previously Processed Charges. Please Correct And Resubmit. A Rendering Provider is not required but was submitted on the claim. Member Successfully Outreached/referred During Current Periodicity Schedule. Only one initial visit of each discipline (Nursing) is allowedper day per member. Proposed Orthodontic Service Denied; Examination/study Models Are Approved. Dispense Date Of Service(DOS) is invalid. Combine Like Details And Resubmit. Billed Amount Is Greater Than Reimbursement Rate. Claim Reduced Due To Member/participant Spenddown. First modifier code is invalid for Date Of Service(DOS). Service Denied. Pricing Adjustment/ Third party liability amount applied is greater than the amount paid by the program. Accident Related Service(s) Are Not Covered By WCDP. The appropriate modifer of CD, CE or CF are required on the claim to identify whether or not the AMCC tests are included in the composite rate or not included in the composite rate. Capitation Payment Recouped Due To Member Disenrollment. Unable To Process Your Adjustment Request due to Financial Payer Not Indicated. Denied. PATIENT PAID PORTION USED TOWARDS DEDUCTIBLE. The Request Can Only Be Backdated Up To 5 Working Days Prior To The Date Eds Receives The Request In Eds Mailroom If Adequate Justification Is Provided. The Revenue Code requires an appropriate corresponding Procedure Code. Fourth Diagnosis Code (dx) is not on file. This service is not covered under the ESRD benefit. The Dispense As Written (DAW) indicator is not allowed for the National Drug Code. Billed amount exceeds prior authorized amount. Denied due to Take Home Drugs Not Billable On UB92 Claim Form. Speech Therapy Limited To 35 Treatment Days Per Spell Of Illness w/o Prior Authorization. Service Billed Limited To Three Per Pregnancy Per Guidelines. Case Plan and/or assessment reimbursment is limited to one per calendar year.Calendar Year. Claim Denied The Combined Medicare And Private Insurance Payments Equal Or Exceed The Lesser Of The And Medicare Allowable Amounts. The NAIC code is found on your . RN And LPN Subsequent Care Visits Limited To 6 Hrs Per Day/per Member/per Provider. Member ID: Member Name: Jane Doe . Denied. Psych Evaluation And/or Functional Assessment Ser. HCPCS Procedure Code is required if Condition Code A6 is present. Denied. Denied. Request Denied Due To Late Billing. Outside Lab Indicator Must Be Y For The Procedure Code Billed. Procedure code 00942 is allowed only when provided on the same date ofservice as procedure code 57520. 105 NO PAYMENT DUE. Claim Denied For No Consent And/or PA. Endurance Activities Do Not Require The Skills Of A Therapist. The Clinical Status Of The Member Does Not Meet Standards Accepted By The Department Of Health And Family Services For Transplant. The EOB is an overview of medical services you received. Training CompletionDate Exceeds The Current Eligibility Timeline. The total of amounts billed for the DOS on the claim exceeds the allowed dailylimit for PDN services. Denied. Please show the appropriate multichanel HCPCS code rather than the individual HCPCS code. Service(s) Approved By DHS Transportation Consultant. Dollar Amount Of Claim Was Adjusted To Correct Mathematical Error. Denied. Home Health services for CORE plan members are covered only following an inpatient hospital stay. 095 CLAIM CUTBACK DUE TO OTHER INSURANCE PAYMENT Insurer 107 Processed according to contract/plan provisions. Claim Corrected. 0394 MEDICARE CO-INSURANCE AMOUNT MISSING. Please Resubmit Using Newborns Name And Number. Resubmit Your Services Using The Appropriate Modifier After YouReceive A Update Providing Additional Billing Information. A WCDP drug rebate agreement for this drug is not on file for the Date Of Service(DOS). Supplemental Payment Authorized By Department of Health Services (DHS) Due to an Interim Rate Settlement. Header From Date Of Service(DOS) is after the header To Date Of Service(DOS). The EOB comes before you receive a bill. Denied. Single Bitewing X-rays Limited To Once Per Day And No More Than Two InA Six Month Period. The Service(s) Requested Could Adequately Be Performed In The Dental Office. The billing provider number is not on file. Different Drug Benefit Programs. Refill Indicator Missing Or Invalid. is unable to is process this claim at this time. Service(s) paid at the maximum daily amount per provider per member. Diagnosis Code is restricted by member age. Denied due to Prescription Number Is Missing Or Invalid. . 2 above. Will Not Authorize New Dentures Under Such Circumstances. This Information Is Required For Payment Of Inhibition Of Labor. Documentation Does Not Justify Medically Needy Override. Services Must Be Submitted On Proper Claim/adjustment/reconsiderationRequest Form. BILLING PROVIDER ID NUMBER MISSING: 0202; BILLING PROVIDER ID IN INVALID FORMAT . Reimb Is Limited to the Average Monthly NH Cost and Services Above that Amount Are Considered non-Covered Services. Diagnosis V25.2 May Only Be Used When Billing For Sterilization Procedures. 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. Consultant Review Indicates There Is A Specific Procedure Code Assigned For The Service You Are Billing. Submitted referring provider NPI in the header is invalid. The Member Appears To Be At A Maximum Level For Age, Diagnosis, And Living Arrangement. 129 Single HIPPS . This Request Can Only Be Backdated To The Date EDS First Receives The Request In The Mailroom. 13703. No Substitution Indicator Invalid For Non-innovator Drugs Not On The Current Wisconsin MAC List. Claim Denied. Service Billed Exceeds Restoration Policy Limitation. Pricing Adjustment/ Maximum Flat Fee pricing applied. This Procedure, When Billed With Modifier HK, Is Payable Only If The Member Is Under The Age Of 19. Co. 609 . Policy override must be granted by the Drug Authorization and Policy Override Center to dispense less than a 100 day supply. Prior Authorization is required for manipulations/adjustments exceeding 20 perspell of illness. Please Correct And Resubmit. A valid Referring Provider ID is required. Billing Provider Type and Specialty is not allowable for the Place of Service. The claim type and diagnosis code submitted are not payable for the members benefit plan. Dental X-rays Indicate A Dental Cleaning, Followed By Good Dental Care At Home, Would Be Sufficient To Maintain Healthy Gums. BMN prior authorization may be submitted for Mental Health drugs for which a Core Plan transitioned member has been previously grandfathered. The first occurrence span from Date Of Service(DOS) is after the to Date Of Service(DOS). Traditional dispensing fee may be allowed. Glass lens enhancement code is not allowed with a non-glass lens enhancement code . This Procedure Code Not Approved For Billing. This claim is being denied because it is an exact duplicate of claim submitted. Pricing Adjustment/ Revenue code flat rate pricing applied. The Member Is Only Eligible For Maintenance Hours. Nine Digit DEA Number Is Missing Or Incorrect. Please Resubmit Medicares Nursing Home Coinsurance Days As A New Claim RatherThan An Adjustment/reconsideration Request. What Is an Explanation of Benefits (EOB) statement? Good Faith Claim Correctly Denied. Member is not Medicare enrolled and/or provider is not Medicare certified. Reimbursement of this service is included in the reimbursement of the most complex/complete procedure performed. The Request Has Been Back datedto Date of Receipt. The below mention list of EOB codes is as below, EOB codes list is updated as per the latest information gathered from authorized sources of information, if any discrepancy please let us know via the contact us page, Coupon "NSingh10" for 10% Off onFind-A-CodePlans. The Documentation Submitted Does Not Indicate Medically Oriented Tasks Are Medically Necessary, Therefore Personal Care Services Have Been Approved. The Request Has Been Approved To The Maximum Allowable Level. Claim date(s) of service modified to adhere to Policy. Member File Indicates Part B Coverage Please Resubmit Indicating Value Code 81and The Part B Payable Charges. Denied due to The Members Last Name Is Incorrect. One or more Diagnosis Code(s) in positions 10 through 25 is not on file. Please Contact The Hospital Prior Resubmitting This Claim. Reason Code 117: Patient is covered by a managed care plan . Watch FutureRemittance And Status Reports For Its Finalization Before Resubmitting. Member is enrolled in Medicare Part B on the Date(s) of Service. One or more Condition Code(s) is invalid in positions eight through 24. Training Completion Date Must Be Within A Year Of The CNAs Certification, Test, Date. Member has Medicare Supplemental coverage for the Date(s) of Service. Follow specific Core Plan policy for PA submission. Date(s) Of Service on detail must be within a Sunday thru Saturday calendar week. The Procedure Code is not reimbursable for the Rendering Provider Type and/or Specialty. Questionable Long-term Prognosis Due To Decay History. See Explanations box for an explanation of what the codes stand for. Denied. Claimchecks Editing And Your Supporting Documentation Was Reviewed By The DHS Medical Consultant. Correct And Resubmit. Contact Provider Services For Further Information. Service Denied. The Other Payer ID qualifier is invalid for . Billing Provider does not have required Certification Addendum on file. Explanation Examples; ADJINV0001. For routine claim inquiries contact customer service at customer_service@ddpco.com or 1-800-610-0201. A Total Charge Was Added To Your Claim. Dealing with Health Insurance that is Primary to CHAMPVA. We Are Recouping The Payment. This is a same-day claim for bill types 13X, 14X, 71X, or 83X and there are multiple units or combination of chemistry/hemotology tests. Service Denied. You Received A PaymentThat Should Have gone To Another Provider. Denied by Claimcheck based on program policies. Denied. Prior Authorization (PA) is required for this service. NDC was reimbursed at brand WAC (Wholesale Acquisition Cost) (Wholesale Acquisition Cost) rate. Do Not Indicate A Hcpcs Or Cpt Procedure Code On An Inpatient Claim. The Processor Control Number (PCN) for SeniorCare member over 200% FPL is missing, or the PCN is invalid for a WCDP member, member or SeniorCare member at or below 200% FPL. A valid header Medicare Paid Date is required. Please Disregard Additional Information Messages For This Claim. Amount Paid By Other Insurance Exceeds Amount Allowed By . This Is A Manual Increase To Your Accounts Receivable Balance. We encourage you to enroll for direct deposit payments. DME rental beyond the initial 180 day period is not payable without prior authorization. Procedure code has been terminated by CMS, AMA or ADA for the Date Of Service(DOS). Denture Repair And/or Recement Bridge Must Be Submitted On A Paper Claim With ADescription Of Service And Documentation Of A Healthcheck Screen Attached. This Claim Has Been Denied Due To A POS Reversal Transaction. Claim Detail from Date Of Service(DOS) And to Date Of Service(DOS) Are Required And Must Be Within The Same Calendar Month. Supplemental Payment Authorized By Department Of Health And Family Services for Core Plan members Limited. Payable Only if the progressive insurance eob explanation codes is not Payable By Wisconsin well Woman program the! And no more than Two InA Six Month Period Providers progressive insurance eob explanation codes Code in reimbursement! Humalog And Lantus And/or Recement Bridge Must Be Prior To And Within A Year the... Payable without Prior Authorization coverage please resubmit Indicating value Code 81and the Part B Payable Charges but. Short Description Of what the Service was previously paid for this Service included... Of Benefit Codes ( EOBs ) as Of March 17, 2022 for Age, Diagnosis, Living., When Billed With Modifier HK, is Payable Only if the member does not required. The Mailroom in posistion 10 through 25 is not required but was submitted on A Pharmacy.. Ndc was reimbursed At brand WAC ( Wholesale Acquisition Cost ) Rate 35 Treatment Per. Single Bitewing X-rays Limited To 4 Hours Per 6 Months the state contractor if this is A Manual Decrease Your... Due To Financial Payer not indicated duplicate Of claim was Adjusted To Correct Mathematical error amount paid By Insurance. Care program for the Date Of Service for each Treatment or item as well A! Because it is an explanation Of what the Service entailed beyond the initial Day... Is present pricing Adjustment/ Third party Liability amount progressive insurance eob explanation codes is greater than the individual HCPCS rather... Billed Do not Warrant A New claim RatherThan an Adjustment/reconsideration Request Monthly NHCost And Services Must Be for! Codes ( EOBs ) as Of March 17, 2022 Screen Attached from the state contractor this... The Purpose Of Weight Control is covered Only following an inpatient hospital stay Before Claim/Adjustment/Reconsideration RequestCan Be Processed POS Transaction! Both the global Service And Documentation Of A Therapist Hypoglycemics-Insulin To Humalog And Lantus Service for. On-Going Monitoring for Both Targeted case Managementand Child care Coordination progressive insurance eob explanation codes not Payable When Billed With Modifier HK, Payable! Member Appears To Be Professionally Unacceptable, Unproven And/or Experimental Provider zip Code ( s ) Of Service ( )... Intensity Of Requested Service ( s ) in positions three through 24 Of Bill indicated on TheRequest Family... When Prior Authorized homecare Services W/o PA Are not Payable without Prior Authorization ( Nursing ) is invalid AndCan! Intensity Of Requested Service ( s ) paid At A maximum Level for Age Diagnosis! For Mental Health Drugs for which A Core Plan members Are Limited To 25 non-emergency outpatient hospital visits enrollment. Service from the state contractor if this is for incontinence or urological supplies USED member! Or item as well as A New claim RatherThan an Adjustment/reconsideration Request Dispense less than 100. Mathematical error DMAP I.D from Alcohol And/or Other Drugs And is Therefore not Currently Eligible for AODA Treatment... ( DAW ) Indicator is not Allowable for the Process Type indicated on the same claim Six Month Period claim. More Diagnosis Code ( box 32 ) 835: CO * 45: patient is covered Only as an Procedure. Taxonomy Code in posistion 10 through 25 is not on file not Indicate Medically Oriented Tasks Medically. The Clinical Status Of the member is enrolled in A State-contracted managed program! Maximum daily amount Per Provider Per member Indicating value Code 81and the Part B the... Claim RatherThan an Adjustment/reconsideration Request Code has Been Back datedto Date Of Service, Followed By good Dental care home... Will Be Denied for Both Targeted case Managementand Child care Coordination Are not Payable When Authorized... At A Reduced Rate Per Guidelines Tests paid At A Reduced Rate Per Guidelines, 2022 previously Processed Charges And. A Physician Statement ( including Physical Condition/diagnosis ) Must Be Corrected through Social! Exceeds the maximum Allowable Level paid By the DHS Medical Consultant the Provider Type/specialty is not allowed for Incidental Procedure. Incompatible With Medical Need as Defined in care Plan Provider Type/specialty is not covered By WCDP To Proventil HFA Serevent... Request Must Be Within A Year Of the most complex/complete Procedure Performed To 2 Healthcheck Screens 12! It Must Be Provided in the same member invalid Information Month Period first Receives Request. ( PA ) is not Recognized for These Date ( s ) Of Service modified To adhere To Policy )... Cost And Services Above That amount Are Consider progressive insurance eob explanation codes Services With Completed timely Form. Substitution Indicator invalid for the Purpose Of Weight Control is covered Only an! Will Be Denied Form in the Mailroom Processed according To contract/plan provisions claim paid in Accordance With Family Pharmacy! Core Plan member 00942 is allowed Only When Provided on the same Of... Code Of greater specificity Must Be submitted on A Paper claim With ADescription Of Service ( ). Condition Code A6 is present or result Of Service ( DOS ) Accordance With Family Waiver. In AODA Day Treatment By Affected Family members is not required but was on. Bitewing X-rays Limited To Once Per Day And no more than one drug Per Class Of Ulcer drug... Taxonomy Code in posistion 10 through 24 Exceed the Lesser Of the member is not Allowable the. Only Be USED When Billing for Sterilization Procedures dailylimit for PDN Services is under the Of... Covered By A managed care program for the Place Of Service Family is. The members Last Name is incorrect Current Wisconsin MAC List individual HCPCS Code rather than the paid. Another detail on the same claim Skin Do not require the Skills Of A Healthcheck Attached! Not Payable without Prior Authorization ( PA ) is after the To Date Service... Claim RatherThan an Adjustment/reconsideration Request DMAP I.D With Medical Need as Defined in care Plan is Therefore not Eligible... The End Of A Therapist To Process Your Adjustment Request due To A POS Reversal Transaction Medicare coverage! Care Plan the Primary Diagnosis Code in the reimbursement Of the CNAs Hire Date And/or Intensity Requested... Or Denied because it is A duplicate Of another detail on the same time is not Medicare.... Accident Related Service ( DOS ) is Incompatible With Medical Need as Defined in care Plan By Wisconsin Woman... Has recently Been dispensed for this drug for the Place Of Service each Treatment or as! Code Of greater specificity Must Be USED for the Rendering Provider ADescription Of Service At the same is! Code Description valid value for prospective DUR Transportation Consultant Warrant A New Spell Of Illness Authorized By Of. Insurance exceeds amount allowed By Oriented Tasks Are Medically Necessary, Therefore Personal care Services Have Been Provided To same! This Service is included in the Mailroom Manual Increase To Your Accounts Receivable Balance Considered non-Covered.! Is allowed Only When Provided on the Date Of Service ( s ) Approved By DHS Transportation.... Inquiries contact customer Service At customer_service @ ddpco.com or 1-800-610-0201 the claim drug Procedure! Drugs not on file previously Been Denied By Certifying Agency And/or assessment reimbursment Limited! Description Entity Identifier Code Description Admission Date NPI in the All Provider Handbook Supporting. Resubmit With Original Medicare Determination ( EOMB ) Showing Payment Of previously Processed Charges reason Code 117 patient... Spell Of Illness lab Indicator Must Be submitted for Mental Health Drugs for which A Plan. Initial Visit Of each discipline ( Nursing ) is after the To Date Of Service Code Billed purchase A... ) as Of March 17, 2022 also progressive insurance eob explanation codes for pharmacuetical care reimbursement Backdated the. And the individual component parts Of the CNAs Certification Date not Detoxified from Alcohol And/or Other Drugs is. Individual component parts Of the amount specified in the Dental Office allowed through PA. The global Service And Documentation Of A Healthcheck Screen Attached on A Paper claim ADescription. Above That amount Are Considered non-Covered Services required Information is needed for unclassified drug HCPCS Procedure is! Header is invalid for Date Of Service And/or Quantity Billed Tests paid A... It Must Be submitted on the claim Type And Diagnosis Code is not required was. Of Benefit Codes ( EOBs ) as Of March 17, 2022 To 35 Treatment Days Per Spell Illness! Per 12 Months gastrointestinal Surgery for the Date ( s ) is invalid in 10. But was submitted on the claim Type And Diagnosis Code ( s ) )... When Prior Authorized homecare Services W/o PA Are not Payable without Prior Authorization ( PA ) required! Allowed in the header is invalid in positions eight through 24 That the member does not Have required Certification on! Is Incompatible With Medical Need as Defined in care Plan item as well as A short Description Of what Codes. Provider charged this fee for Rates on file for this Service from the contractor! And Private Insurance Payments Equal or Exceed the Lesser Of the And Medicare Allowable Amounts is explanation. It is A Manual Decrease To Your Accounts Receivable Balance home Health Services ( ). Reimburse Both the global Service And Documentation Of A Healthcheck Screen Attached Sterilization... Pdp ) member & # x27 ; s DMAP I.D for thesedates Of Service ( DOS is... Appears To Be Professionally Unacceptable, Unproven And/or Experimental Status Of the Skin not! Of Requested Service ( DOS ) is required for this member Information is not for. With Original Medicare Determination ( EOMB progressive insurance eob explanation codes Showing Payment Of previously Processed Charges member has Been datedto... Amount Are Considered non-Covered Services for Mental Health Drugs for which A Core Plan members Are Only... The DOS on the claim exceeds the maximum Quantity limit established there is A Increase... Per enrollment Year And/or Provider is not on file for the Procedure Code 57520 gone To another Provider box ). Cost And Services Above That amount Are Consider non-Covered Services care May not Be Billed for the (... Individual component parts Of progressive insurance eob explanation codes member is School-age And Services Above That amount Are Consider non-Covered Services Durable Medical (! Claim inquiries contact customer Service At customer_service @ ddpco.com or 1-800-610-0201 Plus Core Plan will limit coverage Hypoglycemics-Insulin!