Value codes 48 Homoglobin Reading and 49 Hematocrit Reading, must have a zero in the far right position. Please Clarify. This Surgical Code Has Encounter Indicator restrictions. Copayment Should Not Be Deducted From Amount Billed. Non-preferred Drug Is Being Dispensed. Was Unable To Process This Request. The Revenue Code is not payable by Wisconsin Chronic Disease Program for the Date Of Service(DOS). Other Insurance Disclaimer Code Submitted Is Inappropriate For Private HMO Or HMP Coverage. A number is required in the Covered Days field. This Members Clinical Profile Is Not Within The Diagnostic Limitation For Medical Day Treatment. Detail Denied. This claim is a duplicate of a claim currently in process. The Member Has Been Totally Without Teeth And An Appliance For 5 Years. Out of state travel expenses incurred prior to 7-1-91 . Effective With Claims Received On And After 10/01/03 , Occurrence Codes 50 And 51 Are Invalid. This service was previously paid under an equivalent Procedure Code. Complete Refusal Detail Is Not Payable Without Referral/treatment Details. Services have been determined by DHCAA to be non-emergency. Denied. 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. Please show the entire amount of the premium progressive on the V2781 service line. This procedure is age restricted. Procedue Code is allowed once per member per calendar year. NDC was reimbursed at State Maximum Allowable Cost (SMAC) rate. Invalid Admission Date. This list was formerly published as Part 6 of the administrative and billing instructions in Subchapter 5 of your MassHealth provider manual. Unable To Process Your Adjustment Request due to Original Claim ICN Not Found. Assessment limit per calendar year has been exceeded. The Second Occurrence Code Date is invalid. Reimb Is Limited to the Average Monthly NH Cost and Services Above that Amount Are Considered non-Covered Services. Denied. Accommodation Days Missing/invalid. Keep EOB statements with your health insurance records for reference. Please Bill Medicare First. One or more To Date(s) of Service is missing for Occurrence Span Codes in positions three through 24. Medicare Disclaimer Code invalid. Denied. Occurrence Codes 50 And 51 Are Invalid When Billed Together. At Least One Of The Compounded Drugs Must Be A Covered Drug. Was Unable To Process This Request. Occupational therapy limited to 35 treatment days per lifetime without prior authorization. Claim Detail Denied. Denied due to Statement Covered Period Is Missing Or Invalid. Members I.d. DME rental beyond the initial 30 day period is not payable without prior authorization. Complex Evaluation and Management procedures require history and physical or medical progress report to be submitted with the claim. The Maximum limitation for dosages of EPO is 500,000 UIs (value code 68) per month and the maximum limitation for dosages of ARANESP is 1500 MCG (1 unit=1 MCG) per month. The detail From or To Date Of Service(DOS) is missing or incorrect. Please Submit A Separate New Day Claim For Copayment Exempt Days/services. Pricing Adjustment/ SeniorCare claim cutback because of Patient Liability and/or other insurace paid amounts. The Hearing Aid Recommended Is Not Necessary; The Member Could Be Adequately Fitted With A Conventional Aid. Referring Provider is not currently certified. Although an EOB statement may look like a medical bill it is not a bill. All ESRD clinical diagnostic laboratory tests must be billed individually to ensure that automated multi-chanel chemistry tests are paid in accordance with the Medicare Provider Reimbursement Manual (PRM) 2711. Progressive Casualty Insurance . Denied due to The Members Last Name Is Incorrect. The Ninth Diagnosis Code (dx) is invalid. The From Date Of Service(DOS) for the Second Occurrence Span Code is required. Pricing Adjustment/ Spenddown deductible applied. This claim is eligible for electronic submission. To Date Of Service(DOS) Precedes From Date Of Service(DOS). Documentation Does Not Justify Medically Needy Override. Prior Authorization (PA) is required for payment of this service. Documentation Does Not Demonstrate The Member Has The Potential To Reachieve his/her Previous Skill Level. Billing Provider is not certified for the detail From Date Of Service(DOS). This National Drug Code (NDC) is only payable as part of a compound drug. Outside Lab,element 20 On CMS 1500 Claim Form Must Be Checked Yes When Handling Charges Are Billed. The Dispense As Written (Daw) Indicator Is Not Allowed For The National Drug Code. Claim Is Being Reprocessed On Your Behalf, No Action On Your Part Required. Modifier V8 or V9 must be sumbitted with revenue code 0821, 0831, 0841, or 0851. The Service(s) Requested Could Adequately Be Performed In The Dental Office. Reconsideration With Documentation Warranting More X-rays. Additional servcies may be billed with H0046 and will count toward mental health and/or substance abuse treatment policy limits for prior authorization. Denied due to Diagnosis Code Is Not Allowable. Revenue codes 082X, 083X, 084X, 085X, 0800 or 0881 (X frequency not equal to 5) exist on an ESRD claim for a member who has selected method 1 or no method and the claim does not contain condition codes 71, 72, 73 ,74, 75, or 76. A valid Prior Authorization is required. Admit Diagnosis Code is invalid for the Date(s) of Service. It Corrects Claim Information Found During Research Of An OBRA Drug Rebate Dispute. This Modifier has been discontinued by CMS or AMA for the Date Of Service(DOS)(s). Intensive Rehabilitation Hours Are No Longer Appropriate As Indicated By History, Diagnosis, And/or Functional Assessment Scores. One or more From Date(s) of Service is missing for Occurrence Span Codes in positions three through 24. The Total Billed Amount is missing or incorrect. Denied. A Reimbursement Request For A Level I Screen Must Be Received At Within A Year Of The Screen Date. The NAIC code is found on your . Number On Claim Does Not Match Number On Prior Authorization Request. 3. The Service Requested Is Considered To Be Professionally Unacceptable, Unproven and/or Experimental. Each month you fill a prescription, your Medicare Prescription Drug Plan mails you an "Explanation of Benefits" (EOB). LTC hospital bedhold quantity must be equal to or less than occurrence code 75span date range(s). Previously Denied Claims Are To Be Resubmitted As New Day Claims. What is the 3 digit code for Progressive Insurance? Department of Health Services (DHS) Authorized Payment Is Being Withheld Due toan Interim Rate Settlement. Claim Reduced Due To Member/participant Spenddown. Questionable Long-term Prognosis Due To Decay History. Previously Denied Claims Are To Be Resubmitted As New-day Claims. Please Correct And Resubmit. Pricing Adjustment/ Maximum Allowable Fee pricing used. Eob Remark Codes And Explanations Medical Eob Codes Insurance Eob Reason Codes Eob Denial Codes Progressive Denial Code 202 CPT Code And Service Date For Member Is Identical To Another Claim Detail On File For Provider On Claim. Adjustment/reconsideration Denied, Provider Signature/date Was Not Provided OnThe Adjustment/reconsideration Request. Pharmaceutical care reimbursement for tablet splitting is limited to three permonth, per member. The Treatment Request Is Not Consistent With The Members Diagnosis. Supplemental Payment Authorized By Department of Health Services (DHS) Due to aAudit. Rendering Provider Type and/or Specialty is not allowable for the service billed. The value code 48 (Hemoglobin reading) or 49 (Hematocrit) is required for the revenue code/HCPCS code combination. Please Resubmit. Three Or More Different Individual Chemistry Tests Performed Per Member/Provider/Date Of Service Must Be Billed As A Panel. The service was previously paid for this Date Of Service(DOS). The Service Requested Does Not Correspond With Age Criteria. An ICD-9-CM Diagnosis Code of greater specificity must be used for the Third Diagnosis Code. Outpatient Services To Be Billed As Inpatient Ancillaries When Same Day Stay Occurs Please File An Adjustment/reconsideration Request To Correct Inpatiet Billing. General Assistance Payments Should Not Be Indicated On Claims. The General's NAIC number is the five-digit code given by the National Association of Insurance Commissioners (NAIC), which assigns numbers to authorized insurance providers in order to track customer complaints and ethics violations across state lines. Provider signature and/or date is required. Pricing Adjustment/ Payment reduced due to the inpatient or outpatient deductible. Denied. A Photocopy Of The PA Request Form Has Been Mailed Separately Identifying the Reimbursement Rate For The Procedure Codes Authorized. The Sixth Diagnosis Code (dx) is invalid. Second Rental Of Dme Requires Prior Authorization For Payment. This National Drug Code (NDC) has diagnosis restrictions. Review Of Adjustment/reconsideration Request Shows Original Claim Payment Was Max Allowed For Medical Service/Item/NDC. Private Duty Nursing Beyond 30 Hrs /Member Calendar Year Requires Prior Authorization. Payment may be reduced due to submitted Present on Admission (POA) indicator. Amount Paid Reduced By Amount Of Other Insurance Payment. Cannot bill for both Assay of Lab and other handling/conveyance of specimen. 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. Provider Is Not A Qualified Provider For presumptively Eligible Recipients. Claim Denied. An Explanation of Benefits, often referred to as an EOB, is a document that describes what costs a health insurance plan will cover for incurred healthcare and related expenses. A Hospital Stay Has Been Paid For DOS Indicated. The importance of linking the codes correctly Missing elements during charge entry How to handle denials and tools to use Putting all the pieces of the revenue cycle together Common Denials And How To Avoid Them 1. The Clinical Profile/Diagnosis Makes This Member Ineligible For AODA Services. Participant Is Enrolled In Medicare Part D. Beginning 09/01/06, Providers AreRequired To Bill Part D And Other Payers Prior To Seniorcare Or Seniorcare WillDeny The Claim. Principal Diagnosis 7 Not Applicable To Members Sex. We encourage you to enroll for direct deposit payments. Medicare paid amount(s) have been incorrectly applied to both the claim headerand details. This National Drug Code (NDC) has been terminated by CMS for the Date Of Service(DOS). Modifiers are required for reimbursement of these services. One or more Occurrence Code(s) is invalid in positions nine through 24. Quantity indicated for this service exceeds the maximum quantity limit established by the National Correct Coding Initiative. Will Not Authorize New Dentures Under Such Circumstances. Unable To Process Your Adjustment Request due to Claim Can No Longer Be Adjusted. Denied due to Provider Signature Date Is Missing Or Invalid. Paid In Accordance With Dental Policy Guide Determined By DHS. This Member Has A Current Approved Authorization For Intensive AODA OutpatientServices. Reimburse Is Limited To Average Monthly NHCost And Services Above That Amount Are Consider non-Covered Services. when they performed them. This Request Can Only Be Backdated To The Date EDS First Receives The Request In The Mailroom. Denied due to Provider Number Missing Or Invalid. 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. Revenue Code 082X is present on an ESRD claim which also contains revenue codes 083X, 084X, or 085X. Care Does Not Meet Criteria For Complex Case Reimbursement. Denied/Cutback. Claim Detail Is Pended For 60 Days. Continue ToUse Appropriate Codes On Billing Claim(s). A Procedure Code without a modifier billed on the same day as a Procedure Codewith modifier 11 are viewed as the same trip. Home Health Services In Excess Of 60 Visits Per Calendar Month Per Member Required Prior Authorization. The Diagnosis Does Not Indicate A Significant Change In the Members Condition. Does not reimburse both the global service and the individual component parts of the service for the same Date Of Service(DOS). The information on the claim isinvalid or not specific enough to assign a DRG. Service Billed Exceeds Restoration Policy Limitation. Quantity Would Be 00010 If Specific Number Of Batteries Dispensed Is Not Indicated.

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