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EOB (Explanation of Benefits) Codes and Description

EOB Code

0001 0002 0003 0004 0005 0006 0007 0008 0009 0010 0011 0012 0013 0014 0015 0016 0017 0018 0019 0020 0021 0022 0023 0024 0025 0026 0027 0028 0029 0030 0031 0032 0033 0034 0035 0036 0037 0038 0039 0040 0041 0042 0043 0044 0045 0046

EOB Description

PLEASE VERIFY THE DATES OF SERVICE. HEADER FROM DATE OF SERVICE IS MISSING OR INVALID. THE ADMITTING DATE OF SERVICE IS MISSING/INVALID OR LATER THAN THE FROM DOS VERIFY THE DATES OF SERVICE. THE TO DATE OF SERVICE IS INVALID, MISSING, FUTURE DATE OR LESS THAN THE FROM DATE OF SERVICE. PROCEDURE IS LIMITED TO ONE TIME IN A YEAR PERIOD. IF YOU BILLED FOR MORE THAN ONE UNIT ON THIS CLAIM, REBILL FOR ONE UNIT ONLY. EACH PROV IS LIMITED TO BILLING ONLY 1 OF THE FOLLOWING PROCEDURES (HOSP ADM, ER VIS, CONSULT, OV) MEMBER/SAME DOS. YOU HAVE ALREADY RECEIVED PAYMENT FOR 1OF THE DISCHARGE DATE IS MISSING OR INVALID TOTAL DAYS DO NOT EQUAL THE DIFFERENCE BETWEEN FROM AND TO DATES REQUEST FOR PAYMENT RECD PAST MEDICAID FILING LIMIT. CLAIM MUST BE FILED WITHIN 1 YR OF THE DOS OR WITHIN 6 MONTHS OF MEDICARE PD DATE. CLAIM DENIED. RESEARCH DATA UNAVAILABLE TO PROCESS CLAIM PLEASE RESUBMIT CLAIM WITH ITEMIZED BILL. SUMMARY STATEMENT FOR ENTIRE ADMISSION. CLAIM DENIED. PLEASE RESUBMIT CLAIM WITH ANESTHESIA REPORT NUMBER OF UNITS BILLED IS NOT EQUAL TO DATE SPAN ONLY ONE UNIT IS PAYABLE PER DATE OF SERVICE FOR THIS SERVICE. UNITS OF SERVICE CHANGED TO ONE. DISCHARGE DATE IS PRIOR TO THROUGH DATE OF SERVICE CODE INDICATING SUPERVISING PROFESSIONAL IS MISSING/INVALID CLAIM/DETAIL DETAIL DENIED. PROCEDURE IS LIMITED TO THE FOLLOWING CLAIM/DETAIL DENIED. PROCEDURE IS LIMITED TO TRAUMA RELATED INJURIES. LONG TERM CARE DAYS BILLED IS GREATER THAN THE NUMBER OF DAYS IN BILLING MONTH CLAIM DENIED. ACCOMMODATION/ANCILLARY CODE MISSING OR INVALID. CLAIM/DETAIL DENIED. PROCEDURE/NDC MISSING/INVALID. MEDICARE DOCUMENTATION NOT ATTACHED CLAIM DENIED. PHYSICIAN ON REPORT AND PHYSICIAN BILLING DO NOT MATCH. COVERED DAYS ARE NOT EQUAL TO ACCOMMODATION UNITS CLAIM DENIED. NO PHYSICIAN PATIENT CONTACT. THE DETAIL BILLED AMOUNT IS MISSING OR INVALID CLAIM SUBMITTED FOR INFORMATIONAL PURPOSE ONLY. NO PAYMENT IS TO BE MADE. CLAIM DENIED. LONG TERM CARE SUPPLEMENTAL BILLING MUST BE SUBMITTED AS AN ADJUSTMENT. CLAIM DENIED. RESUBMIT AN ADJUSTMENT ON RELATED PAID CLAIM. CLAIM/DETAIL DENIED. DATA ILLEGIBLE. PLEASE RESUBMIT. CLAIM REQUIRES DOCUMENTATION. PLEASE RESUBMIT ON PAPER. DEPENDENT ON SPECIFIC PROCEDURE CODE AND CRITERIA SET FOR REVIEW. MILEAGE RATE MISSING OR ZEROS CLAIM DENIED. LEVEL OF CARE MISSING. PLEASE CORRECT AND RESUBMIT. CLAIM DENIED. UNIT OF MEASURE INVALID. DOES NOT MATCH NDC UNIT OF MEASURE. NUMBER OF UNITS BILLED LESS THAN 30 FOR INSULIN SYRINGES DENIED BY MEDICARE DETAIL DENIED. THIS SERVICE NOT PAYABLE ON THIS DATE OF SERVICE CLAIM DENIED. ONLY 1 DATE OF SERVICE ALLOWED PER CLAIM FORM. MODEL WAIVER 1 MEMBER LIMITED TO 24 HOURS OF NURSING SERVICES PER DATE OF SERVICE. CLAIM DETAIL DENIED. REVENUE CODE INVALID FOR PLACE OF SERVICE. THIS PROCEDURE CODE IS LIMITED TO TWO UNITS OF SERVICE PER DATE OF SERVICE CLAIM/DETAIL DENIED. TYPE OF BILL INVALID OR MISSING. DRUG MANAGEMENT AND MEDICAL PSYCHOTHERAPY NOT ALLOWED FOR SAME DOS, PROVIDER, PROVIDER OR MEMBER CLAIM DENIED. COINSURANCE AND/OR DEDUCTIBLE GREATER ON CLAIM THAN EOMB. CLAIM DENIED. VOUCHER NUMBER MISSING OR INVALID. CLAIM DETAIL DENIED. REVENUE CODE MISSING OR INVALID. TYPE OF BILL INVALID FOR PROVIDER TYPE CLAIM DENIED. HCPCS CODE BILLED INVALID/OBSOLETE. RESUBMIT WITH CORRECT CODE.

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EOB (Explanation of Benefits) Codes and Description

EOB Code

0047 0048 0049 0050 0051 0052 0053 0054 0055 0056 0057 0058 0059 0060 0061 0062 0063 0064 0065 0066 0067 0068 0069 0070 0071 0072 0073 0074 0075 0076 0077 0078 0079 0080 0081 0082 0083 0084 0085 0087 0088 0089 0090 0091 0092 0093 0094 0095 0096 0097

EOB Description

PROFESSIONAL COMPONENT BILLED. CLAIM MANUALLY PRICED TO MAXIMUM ALLOWABLE CLAIM DENIED. MEDICARE PAID PATIENT, REFER TO DMS PROV SERVICES MANUAL AND RESU BMIT. CLAIM/DETAIL DENIED. MEDICARE PAID AMOUNT GREATER THAN OR EQUAL TO TOTAL BILLED AMOUNT. CLAIM DENIED. PLEASE CORRECT COVERED DAYS FIELD AND RESUBMIT PATIENT CONDITION/STATUS CODE MISSING, INVALID, OR INVALID FOR TYPE OF BILL ERROR ON CLAIM RELATED TO DOLLAR AMOUNTS -CLAIM IN PROCESS CLAIM/DENIED. NET BILLED NOT EQUAL TO TOTAL BILLED MINUS OTHER INSURANCE. CLAIM DENIED. OTHER INSURANCE AMOUNT MUST BE MANUALLY COMPUTED FOR THIS CLAIM CLAIM DENIED TOTAL DETAIL CHARGES NOT EQUAL TO TOTAL BILLED CLAIM/DETAIL DENIED. ASSISTANT SURGEON SERVICES NOT PAYABLE FOR A VAGINAL DELIV ERY. INVALID TYPE OF BILL FOR CORF/ORF PROVIDER SPECIALTY CLAIM/DETAIL DENIED. ONLY ONE DATE OF SERVICE ALLOWED PER DETAIL CLAIM/DETAIL DENIED. NET BILLED CHARGE MISSING OR INVALID CLAIM DENIED. LOCATION CODE INVALID. PAID IN FULL BY MEDICAID CLAIM DENIED. THE HOUR OF ADMISSION IS MISSING OR INVALID. CLAIM DENIED. AN 8-DIGIT LONG TERM CARE FACILITY NBR MUST BE ENTERED IN FORM LOCATOR NO.11. THE TIME OF PICK UP IS BEFORE THE TIME OF CALL IN DESTINATION CODE IS MISSING/INVALID PRO STICKER/INDICATOR MISSING OR INVALID FAMILY PLANNING INDICATOR INVALID AM/PM PICK-UP INDICATOR MISSING OR INVALID TIME OF CALL IN MISSING/INVALID TIME OF PICK UP IS MISSING OR INVALID DESTINATION CODE MISSING/INVALID PICK-UP LOCATION CODE MISSING OR INVALID REFERRED TO (OTHER) CODE INVALID ANCILLARY CHARGES NOT PAYABLE IN CONJUNCTION WITH VENTILATOR OR BRAIN INJURY PROGRAM REIMBURSEMENT CLAIM DENIED. QUANTITY DOES NOT MATCH PACKAGE SIZE OR A MULTIPLE OF THE PACKAGE SIZE. OTHER MEANS OF TRANSPORTATION CODE MISSING OR INVALID CLAIM DETAIL/DENIED. TIME OF CALL-IN AM/PM INDICATOR MISSING CLAIM/DETAIL DENIED. BASE RATE OR RATE PER MILE MISSING OR INVALID. CLAIM/DETAIL DENIED. DETAIL TOTAL BILL NOT EQUAL (RATE PER MILE X EXTRA MILES). PROVIDER TYPE INVALID FOR CATEGORY OF SERVICE CLAIM DENIED. NUMBER OF PERSONS SHARING RIDE INVALID. CLAIM DENIED. TYPE OF TRIP MISSING OR INVALID. CLAIM DENIED. SECONDARY SURGERY DATE MISSING/INVALID CLAIM DENIED. PRIMARY SURGERY DATE MISSING/INVALID. CLAIM DENIED/INVALID LINE ITEM PROVIDER LICENSE NUMBER CLAIM DENIED. TO DATE OF SERVICE EQUAL TO DATE OF RECEIPT. CLAIM DENIED. CLAIM INVOICE DATE MISSING/INVALID. DETAIL CHARGE MISSING OR INVALID CLAIM DENIED. EPSDT DISPOSITION CODE MISSING OR INVALID. CLAIM DENIED. YOU MUST INDICATE IN BLOCK 15 IF THIS WAS A PARTIAL, COMPLETE OR COMPLETION OF A PARTIAL EXAM FOR PROCESSING. THIS SERVICE DENIED. PLEASE RESUBMIT CLAIM WITH COPY OF PATHOLOGY REPORT. THIS SERVICE DENIED. PLEASE RESUBMIT WITH HISTORY AND PHYSICAL NOTES. PHYSICIAN SIGNATURE AND DATE ON CONSENT FORM MUST BE ON OR AFTER DATE OF SERVICE CONSENT FORM IS ILLEGIBLE. RESUBMIT LEGIBLE COPY WITH CLAIM TREATING PROVIDER NOT ELIGIBLE FOR DATE OF SERVICE DATES OF SERVICE ON CLAIM AND CONSENT FORM DISAGREE

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EOB (Explanation of Benefits) Codes and Description

EOB Code

0098 0099 0100 0101 0102 0103 0104 0105 0106 0107 0108 0109 0110 0111 0112 0113 0114 0115 0116 0117 0118 0119 0120 0121 0122 0123 0124 0125 0126 0127 0128 0129 0130 0131 0132 0133 0134 0136 0137 0138 0139 0140 0141 0142 0143 0144

EOB Description

DIAGNONSIS IS INCORRECT FOR ADULT HEALTH SCREEN (M-MCARE B CLAIM TYPE ONLY) INITIAL CYCLE OF CLAIM SUBMITTED BY AHCA DETAIL FROM DATE OF SERVICE MISSING OR INVALID DETAIL TO DATE OF SERVICE MISSING OR INVALID LAST DATE OF SERVICE AFTER BILLING DATE CLAIM HAS BEEN REVIEWED. REFER TO EOB 901-940 FOR DENIAL REASON. TPL IS INDICATED ON FILE. BUT DID NOT APPEAR ON CLAIM. YOUR CLAIM WAS DENIED AFTER AHCA REVIEW OF THE CLAIM AND ITS ATTACHMENT(S). DIAGNOSIS IS INCORRECT FOR ADULT HEALTH SCREEN MULTIPLE VISITS SAME DAY INCLUDED IN REIMBURSEMENT FOR OFFICE VISIT CONSENT FORM IS INCOMPLETE SURG SRV INCLUDES FOLLOW-UP HOSP AND OFFICE VISITS. IF VISIT CLAIM PAYS FIRST SURGERY WILL DENY. VOID VISIT PAYMENT THEN RESUBMIT SURGERY CLAIM. INVALID COMBINATION OF PROCEDURES OR REVENUE CODES. THIS IS A FATAL EDI EDIT DO NOT RESUBMIT. BOTH VISIT AND SURGERY NOT COVERED ON SAME DATE OF SERVICE CLAIM DENIED. DOCUMENTATION ATTACHED WAS INSUFFICIENT TO WAIVE ONE YR FILING LIMITATION. PLEASE CALL AHCA PROVIDER SERVICES FOR ASSISTANCE. CLAIM DENIED. REQUIRED DOCUMENTATION MISSING/INCOMPLETE. REQUIRED CONSENT FORM DOCUMENTATION WAS NOT COMPLETED PRIOR TO STERILIZATION PROCEDURE. CLAIM NOT PAYABLE BY MEDICAID. PAYMENT APPLIED TO RECEIVABLE DOCUMENTATION OF MEDICAL NECESSITY REQUIRED. CONSULT YOUR PROVIDER MANUAL CLAIM DENIED. THIS TYPE OF BILL NOT VALID FOR DRG-RELATED CLAIM ADMIT/DISCHARGE DATE CONFLICT INVALID NEWBORN OCCURRENCE DATE LAB PROCESSING CHARGE INCLUDED IN FLAT FEE MISSING PROVIDER NUMBER THIS SERVICE WAS NOT APPROVED BY MEDICARE. PLEASE RESUBMIT THIS SERVICE TO MEDICAID WITH A COPY OF THE MEDICARE EOMB. CLAIM DENIED. THIS CLAIM MAY NOT SPAN THE MEMBERS 1ST BIRTHDAY. PLEASE REFER TO THE BILLING INSTRUCTIONS IN YOUR PROVIDER MANUAL. INVALID DATE OF SERVICE THE TOOTH NUMBER IS MISSING OR INVALID ADMIT/DISCHARGE DATE CONFLICT LAST DATE OF SERVICE AFTER DATE RECEIVED THE TOOTH NUMBER IS MISSING OR INVALID PROVIDER IS NOT ELIGIBLE TO SUBMIT FEE-FOR-SERVICE CLAIMS CLAIM/DETAIL DENIED. THE DAILY LIMITATION FOR THIS PROCEDURE CODE HAS BEEN EXCEEDED. CLAIM/DETAIL DENIED. CERTAIN TITLE V PROC CODES ARE LIMITED TO A COMBINED TOTAL OF 12 HOURS PER DAY. TOTAL/SUBMITTED CHARGE MISSING SUBMITTED CHARGES/TOTAL CLAIM CHARGE CONFLICT MAP-34 FORM INCOMPLETE REVENUE CENTER CODE IS MISSING/INVALID CLAIM DENIED. SERVICES MUST BE BILLED IN CONJUNCTION WITH APPROPRIATE ROOM CHARGES. TYPE OF BILL IS INVALID CLAIM/DETAIL DENIED. ASSESSMENTS ARE LIMITED TO 20 UNITS PER CALENDAR YEAR, PER MEMBER. CLAIM PENDING REVIEW. MEMBER IS A POTENTIAL LOCK-IN MEMBER. UNITS BILLED ON REVENUE CODES 100-219 DO NOT MATCH COVERED DATE SPANS CLAIM EXCEEDS 12 MONTH FILING LIMIT CLAIM DETAIL DENIED. REVENUE CODE INVALID FOR PROVIDER TYPE. SHOULD BE BILLED BY PROVIDER OF SERVICE

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EOB (Explanation of Benefits) Codes and Description

EOB Code

0145 0146 0147 0148 0149 0150 0151 0152 0153 0154 0155 0156 0157 0158 0159 0160 0161 0162 0163 0164 0165 0166 0167 0168 0169 0170 0171 0172 0173 0174 0175 0176 0177 0178 0179 0180 0181 0182 0183 0184 0185 0186 0187 0188 0189 0190 0191

EOB Description

THIS PROCEDURE IS NOT CERTIFIED FOR THIS LABORATORY HCPC/REVENUE CODE MISSING. PROCEDURE CODE MISSING. PROCEDURE CODE IS NOT ALLOWED WITH PROVIDER TYPE MODIFIER THIS PROCEDURE IS NOT APPROPRIATE FOR THIS PLACE OF SERVICE THIS PROCEDURE/NDC IS NOT APPROPRIATE FOR THE MEMBERS AGE THIS PROCEDURE IS INVALID FOR THE MEMBERS SEX CLAIM DENIED. PROCEDURE INVALID FOR DATES OF SERVICE. PROCEDURE/NDC/REVENUE CODE MISSING OR NOT COVERED BY FLORIDA MEDICAID PROCEDURE CODE INVALID FOR DIAGNOSIS CODE PROCEDURE CODE INVALID FOR PROVIDER TYPE MODIFIER. PLEASE RESUBMIT WITH APPROPRIATE GROUP PROVIDER NUMBER IN CLINIC FIELD AND/OR INDIVIDUAL PROVIDER NUMBER IN BILLING FIELD THE INTERIM RATE FOR THIS PROCEDURE HAS NOT BEEN ESTABLISHED FOR THIS PROVIDER PROCEDURE CODE INVALID FOR PROVIDER SPECIALTY CLAIM DENIED DUE TO INJURY DIAGNOSIS MORE THAN ONE VISIT PER DETAIL DATE OF SERV NOT ALLOWED. EACH VISIT MUST BE BILLED AS SEPARATE LINE ITEMS. PROCEDURE INVALID FOR TOOTH NUMBER INDICATED CLAIM DETAIL DENIED. REVENUE CODE INVALID FOR DATE OF SERVICE. CLAIM DENIED. ANTINEOPLASTIC DRUGS AND CHEMOTHERAPY ADMIN ARE PAYABLE ONLY IF THE DIAGNOSIS IS MALIGNANCY. DIAGNOSIS CODE MISSING OR INCOMPLETE (OUTPATIENT HOSP: REV CODES 273 OR 279 NOT PAYABLE UNLESS DIAG IS INCLUDED IN RANGE 940.0-949.5) PRIMARY SURGICAL PROCEDURE CODE MISSING OR NOT ON FILE INVALID HOSPICE UNITS FOR REVENUE CODE 657 CLAIM/DETAIL DENIED. PRIMARY SURGICAL PROCEDURE CODE INVALID FOR MEMBERS AGE. PATIENT STATUS MISSING OR INVALID PRIMARY SURGICAL PROCEDURE CODE INVALID FOR MEMBERS SEX SECONDARY SURGICAL PROCEDURE CODE INVALID FOR MEMBERS SEX PLACE OF SERVICE IS INVALID SECONDARY SURGICAL PROCEDURE CODE INVALID FOR DATE OF SERVICE PROC CODE MISSING - OUTPATIENT REV CODES IN THE RANGE 300-319 MUST BE A BE ACCOMPANIED BY 5-DIGIT LAB PROC CODE RANGE 80000-89999 ADMISSION DATE/FROM DATE CONFLICT PROVIDER ON REVIEW FOR PRIMARY SURGICAL PROCEDURE FIRST SURGERY PROCEDURE CODE IS MISSING SURGICAL PROCEDURE CODE INDICATED AS ON REVIEW SECONDARY SURGICAL PROCEDURE CODE INDICATED AS ON REVIEW FIRST SURGICAL PROCEDURE REQUIRES PRIOR AUTHORIZATION. TOOTH SURFACE/QUADRANT REQUIRED INVALID ALPHA TOOTH NUMBER INVALID TOOTH SURFACE/MOUTH QUADRANT TOOTH NUMBER/LETTER REQUIRED RESUBMIT W/HYSTERECTOMY CONSENT FORM ATTACHED TOTAL/SUBMITTED CHARGE MISSING ADMISSION DATE OR ACTION CODE ARE MISSING STERILIZATION MUST BE 180 DAYS OR LESS FROM DATE CONSENT SIGNED BY MEMBER STAMPED SIGNATURES ARE UNACCEPTABLE CLAIM DENIED. DOCUMENTATION NEEDED FOR CLAIM PROCESSING INCLUDES AUDIOLOGIST RECOMMENDATION, MEDICAL CLEARANCE STATEMENT AND INVOICE. CONSENT FORM MUST BE SIGNED AND DATED AT LEAST 72 HOURS PRIOR TO STERILIZATION PROCEDURE IN CASES OF EMERGENCY SURGERY OR PREMATURE DELIVERY THE CLAIM DIAGNOSIS IS MISSING OR INVALID. PLEASE ENTER THE APPROPRIATE DIAGNOSIS CODE AND RESUBMIT THE CLAIM. CALCULATED NUMBER OF DAYS IS NOT EQUAL TO THE NUMBER OF DAYS BILLED

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EOB (Explanation of Benefits) Codes and Description

EOB Code

0192 0193 0194 0195 0196 0197 0198 0199 0200 0201 0202 0203 0204 0205 0206 0207 0208 0209 0210 0211 0212 0213 0214 0215 0216 0217 0218 0219 0220 0221 0222 0223 0224 0225 0226 0227 0228 0229 0230 0231 0232 0233 0234 0235 0236 0237 0238

EOB Description

THIS DIAGNOSIS IS NOT COVERED FOR THE MEMBERS AGE MISSING DATE OF SERVICE DIAGNOSIS IS INVALID FOR MEMBERS SEX THE SECONDARY DIAGONSIS IS INVALID FOR MEMBER SEX THE BILLED DIAGNOSIS IS ON REVIEW CLAIM/DETAIL DENIED. ROOT CANAL THERAPY LIMITED TO PERMANENT TEETH. DATES OF SERVICE FOR THIS CLAIM TYPE MUST ALL BE FROM THE SAME MONTH THIRD SURGERY DATE (FIELD 81) NOT WITHIN STATEMENT COVERS PERIOD - DATE SPAN (FIELD 6) CLAIM/DETAIL DENIED. PROVIDER ON REVIEW FOR THIS DIAGNOSIS INDIVIDUAL/CLINIC PROVIDER/NPI NUMBER(S) BILLED INCORRECTLY OR NOT ON FILE. DIAGNOSIS CODE NOT COVERED FOR BIRTH CENTER PROCEDURE CODE CLAIM/DETAIL DENIED. PROCEDURE CODE MODIFIER AG OR TYPE OF SERVICE 7 OR B NOT ALLOWED FOR DATES OF SERVICE AFTER 12/12/94. INVALID DIAGNOSIS CODE. CONTACT THE DEPARTMENT FOR MEDICAID SERVICES. DIAGNOSIS CODE INVALID FOR PROVIDER TYPE CLAIM DENIED. RENDERING PROVIDER IS NOT ELIGIBLE FOR THE DATE OF SERVICE. A SURGICAL PROCEDURE (WITHOUT A MODIFIER) IS BILLED WITHIN THE FOLLOW-UP OF A PREVIOUS SURGICAL PROCEDURE THIS PROCEDURE IS NOT COVERED FOR THIS DIAGNOSIS CLAIM DENIED. MOST ANESTHESIA SERVICES MUST BE BILLED USING ANESTHESIA PROCEDURE CODES BEGINING WITH 0. CLAIM/DETAIL DENIED. THIRD HEADER DIAGNOSIS ON REVIEW. CLAIM/DETAIL DENIED. THIRD DIAGNOSIS IS NOT ON FILE. CLAIM/DETAIL DENIED. DETAIL DIAGNOSIS INDICATOR INVALID. THE FOURTH DIAGNOSIS IS MISSING OR INVALID. PLEASE ENTER THE APPROPRIATE DIAGNOSIS CODE AND RESUBMIT THE CLAIM. CLAIM/DETAIL DENIED. SECONDARY HEADER DIAGNOSIS ON REVIEW. CLAIM DENIED - AGE RESTRICTION FOR COVERED DIAGNOSIS SERVICE DATE IS AFTER THE RECIPIENTS DATE OF DEATH THE FOURTH DIAGNOSIS IS NOT COVERED FOR THE MEMBERS AGE FOURTH DIAGNOSIS IS INVALID FOR MEMBERS SEX FOURTH HEADER DIAGNOSIS ON REVIEW CPHU ENCOUNTER LIMIT - CANNOT BILL MULTIPLE CPHU ENCOUNTERS FOR THE SAME SERVICE DATE THE PROVIDER IS NOT ELIGIBLE ON DATE(S) OF SERVICE THE PROVIDER IS NOT ELIGIBLE ON DATE(S) OF SERVICE THIS SERV CANNOT BE BILLED WITH A DATE SPAN THAT INCLUDES 2 OR MORE MONTHS. REBILL WITH ONE MONTH OF SERVICES PER CLAIM LINE. PARTIAL APPROVAL (MO) DATES ARE NOT WITHIN ADMIT/DISCHARGE DATES NO HISTORY MATCH FOUND, PLEASE RESUBMIT INVALID CONDITION CODE PATIENT STATUS MISSING OR INVALID THE PROVIDER IS NOT ELIGIBLE FOR DATE OF SERVICE BILLING PROVIDER NUMBER INVALID OR NOT ON PROVIDER FILE THERAPY NOT COVERED FOR RECIPIENT 21 YEARS OF AGE OR OLDER INVALID R.A.P. REFERRING PROVIDER NUMBER CLAIM/DETAIL DENIED. ACTION REASON CODE INDICATES PROVIDER IS ON REVIEW. RECIPIENT HAS OTHER INSURANCE COVERAGE ON MEDICAID 3RD PARTY LIABILITY FILE. PLEASE FILE WITH OTHER CARRIER OR ATTACH INSURANCE COMPANY DENIAL. CLAIM/DETAIL DENIED. REFERRING PROVIDER FLAG SET TO SUSPEND FOR REVIEW. SURGERY DATE IS BEFORE THE ADMIT DATE SURGERY DATE AFTER BILLING DATE CLAIM DENIED. CLINIC PROVIDER NUMBER NOT ON FILE CLAIM DENIED. BILLING PHYSICIAN/PROVIDER NOT LISTED AS MEMBER OF CLINIC.

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EOB (Explanation of Benefits) Codes and Description

EOB Code

0239 0240 0241 0242 0243 0244 0245 0246 0247 0248 0249 0250 0251 0252 0253 0254 0255 0256 0257 0258 0259 0260 0261 0262 0263 0264 0265 0266 0267 0268 0269 0270 0271 0272 0273 0274 0275 0276 0277 0278

EOB Description

DETAIL PROVIDER NUMBER INVALID OR NOT ON FILE PROCEDURE CANNOT BE BILLED INDEPENDENTLY PENDING CONFIRMATION OF PROVIDER ELIGIBILITY NO LEVEL 2 PRICING RECORD FOUND FOR MODIFIERS TC OR 26 PROCEDURE CODE Y2870 INVALID FOR DATES OF SERVICE 10/15/94 AND AFTER FOR THIS PROVIDER TYPE PROVIDER HAS NOT MET ALL REQUIREMENTS FOR BILLING OTHER LAB AND X-RAY SERVICES SVC DATES NOT ELIGIBLE 80022-ROUTINE VENIPUNCTURE SINGLE HOMEBOUND NURSING HOME OR SNF NOT ALLOWED SAME DOS/MEMBER/PROVIDER AS 80020-BLOOD COLLECTION VENIPUNCTURE PHYSICIAN ASSISTANT NUMBER MISSING/INVALID, NOT ELIG FOR THE DOS OR NOT LINKED TO AN INDIVIDUAL PHYSICIAN CLAIM DENIED. SURGEON AND ASSISTANT SURGEON BILLING NOT ALLOWED ON SAME FORM. PAYMENT REDUCED BECAUSE OUR RECORDS SHOW MEMBER WAS NOT IN FACILITY FOR ALL OF THE TOTAL BILLED DAYS RECIPIENT ID NOT ON FILE. BECAUSE UPDATE MAY ARRIVE FROM AHCA RECIPIENT. FILE RECHECKED WEEKLY FOR A MATCH. IF NUMBER INCORRECT, RESUBMIT NOW. INCORRECT MEMBER IDENTIFICATION NUMBER RECIPIENT IS NOT ACTIVE RECIPIENT INELIGIBLE FOR DOS WILL PEND FOR UP TO 14 DAYS AWAITING AHCA UPDATE RECIPIENT ELIG RECHECKED WEEKLY FOR ARRIVAL OF AHCA UPDATE THE MEMBER IS NOT ELIGIBLE ON THE CLAIM SERVICE DATES MEMBER HAS MEDICARE PART B. PLEASE BILL MEDICARE FOR THESE SUPPLIES OUR RECORDS INDICATE THAT THIS MEMBER MAY BE ELIG FOR MEDICARE. PLEASE BILL MEDICARE FIRST. IF MEDICARE DENIES THIS SERVICE, RESUBMIT WITH PROOF OF DENAL. OUR RECORDS INDICATE THAT THE MEMBER WAS OVER 21 YRS OLD ON THE DATE(S) OF SERVICE. THE MEMBER IS NOT ELIGIBLE FOR THE SERVICE(S) RECIPIENT ID NOT ON FILE. AN UPDATE MAY ARRIVE FROM AHCA. RECIPIENT FILE IS CHECKED WEEKLY FOR A MATCH. IF NUMBER INCORRECT, RESUBMIT NOW. DATE BILLED INVALID SERVICE NOT ALLOWED OUR RECORDS INDICATE THAT THE MEMBER WAS DECEASED PRIOR TO THE ENDING DATE OF SERVICE PROVIDER TYPE NOT ON TPL MATRIX CLAIM DENIED. MEMBER NOT ELIGIBLE FOR PORTION OF DATES OF SERVICE MEMBER NAME IS MISSING INCORRECT MEMBER IDENTIFICATION NUMBER MEMBER NOT ELIGIBLE FOR WAIVER SERVICES WAIVER PAYMENT AMOUNT REDUCED DUE TO MEMBER CONTINUING INCOME MEMBER ON REVIEW CLAIM DENIED. TARGETED CASE MANAGEMENT SERVICES ARE NOT PAYABLE TO MEMBERS ENROLLED IN A WAIVER OR HOSPICE PROGRAM. CLAIM DENIED. THIS SERVICE IS NOT PAYABLE FOR A MODEL WAIVER MEMBER. RECIPIENT INELIGIBLE FOR DOS. CLAIM WILL PEND FOR UP TO 14 DAYS AWAITING AHCA UPDATE. RECIPIENT ELIGIBLE RECHECKED WEEKLY FOR ARRIVAL OF AHCA UPDATE CLAIM/DETAIL DENIED. UNIT BILLED AMOUNT CANNOT BE GREATER THAN. RECIPIENT IS UNDER REVIEW. POSSIBLE PA FOR TRANSPLANT SERVICE SERVICE DATE IS AFTER THE RECIPIENTS DATE OF DEATH. INPATIENT HOSPITAL TREATMENT AUTHORIZATION NUMBER MISSING OR INVALID SOBRA - CLAIM REQUIRES MEDICAL REVIEW THE ATTACHED THIRD PARTY DOCUMENTATION IS NOT SUFFICIENT. CONTACT UNISYS PROVIDER RELATIONS FOR ASSISTANCE. CLAIM DENIED. CLAIM/DOCUMENTATION INDICATES THIRD PARTY PYMNT WAS RECEIVED BY MEMBER.

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EOB (Explanation of Benefits) Codes and Description

EOB Code

0279 0280 0281 0282 0283 0284 0285 0286 0287 0288 0289 0290 0291 0292 0293 0295 0296 0297 0298 0299 0300 0301 0302 0303 0304 0305 0306 0307 0308 0309 0310 0311 0312 0313 0314 0315 0316 0317 0318 0319 0320 0321 0322

EOB Description

ALIEN - CLAIM REQUIRES MEDICAL REVIEW. IF YOU DID NOT ATTACH MEDICAL TO THIS SUBMISSION, PLEASE DO SO AND RESUBMIT. CLAIM DENIED. YOUR CLAIM INDICATES THIS SERVICE IS DUE TO A WORK-RELATED ACCIDENT/INJURY. PLEASE BILL OTHER INSURANCE FIRST. ABORTION PROC OR CONDITION CODE A7 OR A8 IS PRESENT AND NO ABORTION CERTIFICATE IS PRESENT THE MEMBER HAS MEDICARE PART A PLEASE BILL MEDICARE OUR RECORDS INDICATE MEMBER HAS MEDICARE PART B: PLEASE BILL MEDICARE OUR RECORDS INDICATE THAT THIS MEMBER IS ELIGIBLE FOR HOSPICE COVERAGE BY MEDICARE. PLEASE BILL MEDICARE FIRST. RECIPIENT INELIGIBLE FOR DOS WILL PEND UP TO 14 DAYS AWAITING AHCA UPDATE. RECIPIENT ELIGIBLE RECHECKED WEEKLY FOR ARRIVAL OF AHCA UPDATE. THIS PROCEDURE CODE IS LIMITED TO ONE UNIT OF SERVICE PER DATE OF SERVICE PROFESSIONAL COMPONENT REV CODE MUST BE BILLED WITH CORRESPONDING TECHNICAL COMPONENT REVENUE CODE PROFESSIONAL COMPONENT REV CODE MUST BE BILLED WITH CORRESPONDING TECHNICAL REV CODE. CHARGES MOVED TO NON-COVERED. CLAIM DENIED. RENDERING PROVIDER NUMBER MISSING OR INVALID. PENDING CONFIRMATION OF MEMBER ELIGIBILITY PENDING POSSIBLE OTHER INSURANCE INVOLVEMENT CLAIM SUSPENDED FOR BUY-IN ELIGIBILITY REVIEW CLAIM SUSPENDED FOR ELIGIBILITY REVIEW BILLING OR REFERRING PROVIDER NUMBER IS MISSING PAY TO PROVIDER INELIGIBLE FOR DATE(S) OF SERVICE PAY TO PROVIDERS GROUP IS NOT VALID FOR THE TREATING PROVIDER MEMBER IS NOT ELIGIBLE FOR HOSPICE FOR BILLED DATES OF SERVICE HOSPICE MEMBER. OUR FILES SHOW MEMBER IS COVERED BY ANOTHER HOSPICE PROVIDER FOR BILLED DATE(S) OF SERVICE. TREATING PROVIDER NUMBER NOT ON FILE CLAIM DENIED. RENDERING PROVIDER NOT LISTED AS A MEMBER OF THE BILLING GROUP. DPR NUMBER IS NOT FOUND ON FILE THIS SERVICE MUST BE BILLED FOR A MINIMUM OF 8 UNITS PER DATE OF SERVICE PARTIAL APPROVAL (MO) DATES ARE NOT WITHIN ADMIT\DISCHARGE DATES TREATING PROVIDERS CLAIM DENIED AFTER DEPT OF HEALTH AND REHAB SRVS REVIEW A HOSPICE MEMBER - RECYCLE FOR EDIT 298 NO CLIA REGISTRATION ON FILE FOR THIS PROVIDER INVALID DATE OF SERVICE BILLING PROVIDER IS UNDER REVIEW CLAIM DENIED. NEW ADMISSION NOT PAYABLE BECAUSE OF NON-COMPLIANCE. CORRECTED PAYMENT PER ADJUSTMENT REQUEST PHYSICIANS-REFER PROV REQD FOR THIS PROC IN FIELD 17A/19. THERAPISTS, HOME HEALTH AND DME SUPPLIERS: SVC REQUIRES A SVC AUTH IN FIELD 17A/19. SPECIAL PROGRAM INDICATOR FIELD - ONLY VALID ENTRY IS (04) FOR FAMILY. LEAVE THIS FIELD BLANK UNLESS FAMILY PLANNING APPLICABLE. ASSISTIVE CARE SERVICE CLAIMS CANNOT SPAN MORE THAN ONE MONTH. PLEASE CHECK THE DATES OF SERVICE AND RESUBMIT THE CORRECTED CLAIM. TPL ON CLAIM, NOT ON RECIPIENT FILE CLAIM/DETAIL PAID. CLAIMS HISTORY REFLECTS THE TOOTH NUMBER PREVIOUSLY EXTRACTED. PLEASE CHECK RECORDS AND VERIFY TOOTH NUMBER. UNITS BILLED ON REVENUE CODES 100-219 DO NOT MATCH COVERED DATE SPANS MANUAL PRICE-REQUIRES REPORT INCORRECT PROVIDER NUMBER SUBMITTED - PAYMENT DELAYED CLAIM DENIED. EXCEEDS THERAPY LIMITS FOR DRUG CLASS. PROCEDURE CODE NOT ALLOWED FOR DATE OF SERVICE EPSDT RELATED PROC ARE NOT PAYABLE WITHIN 30 DAYS OF AN EPSDT SCREENING PROC

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EOB (Explanation of Benefits) Codes and Description

EOB Code

0324 0325 0326 0327 0328 0329 0330 0331 0332 0333 0334 0335 0336 0337 0338 0339 0340 0341 0342 0343 0344 0345 0346 0347 0348 0349 0350 0351 0352 0353 0354 0355 0356 0357 0358 0359 0360 0361 0362 0363 0364 0365 0366 0367 0368 0369 0370

EOB Description

DIAGNOSIS INCOMPATIBLE WITH RECIPIENTS SEX CLAIM/DETAIL DENIED. SCREENING PROCEDURE CODE INVALID FOR MEMBERS AGE CLAIM DENIED. BILL/INVOICE MUST ACCOMPANY CLAIM. PROCEDURE/NDC REQUIRES PRIOR AUTHORIZATION PRIMARY SURGICAL PROCEDURE REQUIRES PRIOR AUTHORIZATION SECONDARY SURGICAL PROCEDURE REQUIRES PRIOR AUTHORIZATION DETAIL DENIED. DETAIL UNITS BILLED EXCEED UNITS PRIOR AUTHORIZED PAYMENT REDUCED BY AMOUNT PREVIOUSLY PAID. POST OP INCLUDED IN PROCEDURE. MISSING OR INVALID AHCA ELIGIBILITY FORM FOR MEDICALLY NEEDY. PHOTOCOPIED FORM 2902 MUST CONTAIN DENIAL TCN IN TOP RIGHT WHEN RESUBMITTING NONSTEROIDAL ANTI-INFLAMMATORY DRUGS REQUIRE PRIOR AUTHORIZATION SUPPLY NOT COVERED ON RENTAL ITEM LACKS REPORT TO JUSTIFY HIGHER FEE INVALID PATIENT RESPONSIBILITY CATHETERIZATION PROC 8002, 80023 AND 80024 NOT ALLOWED SAME DOS/MEMBER/PROV FINANCIAL CLASS/PATIENT RESPONSIBILITY MISMATCH INSURANCE CODE 04 HAS BEEN SUBMITTED WITH THE CLAIM ONLY THREE FOLLOW UP EXAMS ALLOWED DURING THE SIX MONTH PERIOD FOLLOWING THE FITTING OF A HEARING AID AN OFFICE VISIT, ER VISIT OR CONSULTATION ARE NOT PAYABLE ON THE SAME DATE OF SERVICE AS A HOSPITAL ADMISSION OFFICE VISIT AND/OR ER VISIT ARE NOT PAYABLE ON THE SAME DOS AS A CONSULTATION CLAIM MASS ADJUSTED DUE TO A RETROACTIVE RATE CHANGE AN OFFICE VISIT IS NOT PAYABLE ON THE SAME DOS AS AN EMERG ROOM VISIT 80020-BLOOD COLLECTION VENIPUNCTURE NOT ALLOWED SAME DOS/MEMBER/PROVIDER AS 800 22ROUTINE VENIPUNCTURE SINGLE HOMEBOUND NURSING HOME OR SNF. INVALID NUMBER OF DAYS COVERED DENTURE RELATED EMERGENCY SERVICES AND UPPER OR LOWER DENTURE RELINE NOT PAYABLE ON SAME DATE OF SERVICE. ROOM CHARGES REDUCED TO SEMI PRIVATE RATE EMERGENCY DENTAL PROCEDURES AND EXTRACTION PROCEDURES NOT PAYABLE ON SDOS DETAIL DENIED. FILLINGS ARE NOT PAYABLE FOR THE SAME TOOTH AND THE SAME DOS SERVICE AS EMERGENCY SERVICES OR SEALANTS. ALLOW TO SUB PERCENT DIFF EX SUB TO ALLOW PERCENT DIFF EX INDIVIDUAL ALLERGY TESTING PROCEDURES ARE NOT PAYABLE WITH W0308-MAXIMUM ALLOWABLE PER ALLERGY TESTING OF SERVICE MANUAL PRICE INVALID OR NOT ACCOMPANIED BY A MANUAL PRICE EOB FEE ADJUSTED TO MAXIMUM ALLOWABLE AMOUNT CLAIM/DETAIL DENIED AFTER REVIEW BY MEDICAL CONSULTANTS CLAIM DENIED. INVOICE MUST HAVE ITEM BILLED NOTED. TREATING PROVIDER/REFERRING PROVIDER NUMBER ARE EQUAL REFER TO THE ADJUSTMENT REASON CODE FEE ADJUSTED PER CLAIM CREDIT PROCEDURE CODE NOT ON FILE MEDICARE DEDUCTIBLE GREATER THAN ALLOWED DEDUCTIBLE ROOT REMOVAL NOT PAYABLE ON SAME DATE OF SERVICE AS THE TOOTH EXTRACTION PAYMENT REDUCED BY OTHER INSURANCE FEE ADJUSTED TO MAXIMUM ALLOWABLE CLAIM DENIED. BILLED AMOUNT MAY NOT EXCEED $50.00 PER UNIT OF SERVICE THIS SERVICE PAID COINSURANCE AND/OR DEDUCTIBLE PROVIDER IS NOT ELIGIBLE TO BILL FOR HOME HEATLH SUPPLIES AND/OR VISITS ORIGINAL PSYCHIATRIC EVALUATION AND REGULAR HOSPITAL ADMISSION NOT PAYABLE ON SAME DATE OF SERVICE PAYMENT MODE NOT FOUND FOR BILLING PROVIDER

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EOB (Explanation of Benefits) Codes and Description

EOB Code

0371 0372 0373 0374 0376 0377 0378 0379 0380 0381 0382 0383 0384 0385 0386 0387 0388 0389 0390 0391 0392 0393 0394 0395 0396 0397 0398 0399 0400 0401 0402 0403 0404 0405 0406 0407 0408 0409 0410 0411 0412

EOB Description

REIMBURSEMENT RATE NOT FOUND FOR DATE OF SERVICE HOSPITAL FOLLOW-UP VISITS AND ORIGINAL PSYCHIATRIC DIAGNOSTIC EVAL AND/OR FOLLOW-UP PSYCHIATRIC CARE ARE NOT ALLOWED FOR SAME DATE OF SERVICE UNITS OF SERVICE HAVE BEEN REDUCED TO THE REMAINING PRIOR AUTHORIZED QUANTITY REPAYMENT PORTION OF THIS ADJUSTMENT HAS BEEN DENIED. RECOUPMENT IS UNDER FINANCIAL ITEMS. CLAIM DENIED. MAC FIELD INVALID. MEMBER INCOME/PATIENT LIABILITY DEDUCTION NOT APPLICABLE FOR THIS CLAIM CLAIM DETAIL DENIED. THIS PROCEDURE CODE IS NOT COVERED. PAID BY MEDICAID CO-PAY WAS DEDUCTED FROM REIMBURSEMENT CERTAIN SPECIFIED PROCEDURES ARE NOT REIMBURSABLE FOR SAME DATE OF SERV AS EMERGENCY ROOM VISIT DETAIL DENIED. BILLED AMOUNT FOR IMPLANTABLES MUST BE GREATER THAN $100.00. CERTAIN INCIDENTAL SURGERIES ARE NOT REIMBURSABLE FOR SAME DATE OF SERV AS ABDOMINAL SURGERY DETAIL DENIED. INVOICE MUST BE ATTACHED WHEN BILLING IMPLANTABLES. CERTAIN INCIDENTAL PROCEDURES ARE NOT REIMBURSABLE FOR THE SAME DATE OF SERVICE AS A D AND C PROCEDURE DETAIL DENIED. INVOICE AMOUNT MUST MATCH BILLED AMOUNT. CERTAIN INCIDENTAL SURGERIES AND PELVIC SURGERIES ARE NOT REIMBURSABLE FOR THE SAME DATE OF SERVICE THIS REVENUE CODE IS NOT PAYABLE WHEN BILLED WITH ALL INCLUSIVE ANCILLARY REVENUE CODE (240). CHARGES MOVED TO NON-COVERED. PAID CLAIM BASED UPON MEDICAL REVIEW CLAIM DENIED. DUPLICATE SERVICE BILLED DETAIL DENIED. PROCEDURE CODES X0091/97535 AND X0103/S5140 NOT PAYABLE ON SAME DATE OF SERVICE AS X0061/T2016, X0088/S5126 OR X0089/H0043. DETAIL DENIED. PROCEDURE CODES X0061, X0088 AND X0089 NOT PAYABLE ON THE SAME DATE OF SERVICE AS X0091 CLAIM DENIED. THE PRIMARY DIAGNOSIS CODE IS NOT VALID FOR THIS PROVIDER TYPE. HOURLY RESPITE SERV NOT ALLOWED FOR SAME DATE OF SERVICE AS DAILY RESPITE SERV AMOUNT PD BY OTHER INSURANCE EQUALS OR EXCEEDS AMOUNT OF MEDICAID REIMBURSEMENT FOR THIS SERV THE CLM IS PD IN FULL DAILY RESPITE SERVICES NOT ALLOWED FOR SAME DOS AS HOURLY RESPITE S ACCOMMODATION REVENUE CODES MUST BE BILLED ON AN INPATIENT CLAIM CLAIM/DETAIL DENIED. THE PROCEDURE CODE MODIFIER IS MISSING OR INVALID. CLAIM/DETAIL DENIED. THIS SERVICE NOT COVERED FOR THIS MEMBER. INVALID MODIFIER FOR ARNP. REGISTERED NURSE ANESTHETISTS CAN PROVIDE ONLY ANESTHESIA SERVICES - MODIFIER 48 NOT VALID. ELECTRONIC ADJUSTMENT/VOID CLAIM TYPES DO NOT MATCH A CLAIM FOR INPATIENT SERVICES COVERS MORE THAN 15 DAYS, THE RECIPIENT IS LESS THAN 21 YEARS OLD AND THE DIAGNOSIS CODE IS 290.00-316.99 PLEASE GIVE THE DATE(S) OF SURGERY AND RETURN THE INVOICE TO THIS OFFICE NURSING FACILITY PRIOR AUTHORIZATION NOT ON FILE - RECYCLE FOR EDIT 332 ADJUSTMENT EXCEEDS 12 MONTHS FROM DATE. SEE PROVIDER MANUAL FOR EXCEPTION CRITERIA DETAIL UNITS OF SERVICE MUST BE GREATER THAN ZERO PLACE OF SERVICE IS MISSING INVALID OR SPANNED HEADER DATES - OUTPATIENT BILLS MUST CONTAIN A SINGLE DATE OF SERVICE INVALID PROVIDER TYPE BILLED ON CLAIM FORM FORMAT INVALID FOR ELECTRONIC CLAIMS. DUE TO THE END OF YOUR FISCAL YEAR, PLEASE REBILL THESE MULTIPLE MONTHS OF SERVICE ON SEPARATE INVOICES - ONE INVOICE FOR EACH MONTH. DETAIL DENIED. ONLY ONE DATE OF SERVICE ALLOWED PER DETAIL.

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EOB (Explanation of Benefits) Codes and Description

EOB Code

0413 0414 0415 0416 0417 0418 0419 0420 0421 0422 0423 0424 0425 0426 0427 0428 0429 0430 0431 0432 0433 0434 0435 0436 0437 0438 0439 0440 0441 0442 0443 0444 0445 0446 0447 0448 0449 0450 0451 0452 0453

EOB Description

MEMBER NOT ENROLLED IN MANAGED CARE DURING DATES OF SERVICE MEMBER ENROLLED IN MANAGED CARE DURING DATES OF SERVICE FFS CLAIM HAS A MANAGED CARE PROVIDER TYPE CAPITATION RATE NOT WITHIN DATES OF SERVICE CLAIM DENIED. INVALID OR MISSING CAPITATION INDICATOR. CLAIM DENIED. INVALID ENCOUNTER TYPE. INDEPENDENT LABORATORY - INVALID PLACE OF SERVICE CLAIM DENIED. INVALID ENC PAYMENT AMOUNT. CLAIM DENIED. INVALID ENC PAYMENT DATE. CLAIM DENIED. INVALID ENC ADJUSTMENT TCN. CLAIM DENIED. INVALID MEMBER NOT ELIG FOR PHYSICAL. CLAIM DENIED. INVALID MEMBER NOT ELIG FOR BEHAVIORAL. DATE SPAN BILLING NOT ALLOWED FOR THIS PROC CODE. BILL EACH DATE OF SERV ON A SEPARATE CLAIM LINE. THE 36 MONTH MAXIMUM FOR THIS SERVICE HAS BEEN EXCEEDED. THE CLAIM DENIED. RESUBMIT AN ADJUSTMENT ON RELATED PAID CLAIM WITH JUSTIFICATION FOR DUPLICATED SERVICE. FFS NOT ALLOWED, MEMBER ELIGIBLE FOR BEHAVIORAL HEALTH MANAGED CARE CLAIM DENIED. PARTNERSHIP NUM MISMATCH CLAIM DENIED. ENCOUNTER, INVALID TCN TO CREDIT RESERVED FOR MANAGED CARE CLAIM DENIED. SEQ NO. MISMATCH ACROSS CLAIM. CLAIM DENIED. VOID/RESUB INVALID FOR XOVER. RESERVED FOR MANAGED CARE RESERVED FOR MANAGED CARE CLAIM DETAIL DENIED. THIS PROCEDURE CODE IS LIMITED TO 1 UNIT PER MEMBER, PER FIVE YEARS. CLAIM DENIED. CERTAIN OUTPATIENT HOSPITAL CHARGES ARE NOT PAYABLE WITHIN 3 DAYS PRIOR TO AN INPATIENT HOSPITAL ADMISSION AND VICE VERSA. CLAIM DETAIL DENIED. PROCEDURE CODE 90853 IS LIMITED TO 6 UNITS PER DAY, PER MEMBER, PER PROVIDER. INVALID RECIPIENT ID NUMBER CLAIM/DETAIL DENIED. REVENUE CODE 582 LIMITED TO 4 UNITS PER CALENDAR WEEK (SUNDAY THROUGH SATURDAY). CLAIM/DETAIL DENIED. PROCEDURE CODES 99244 AND 99245 ARE LIMITED CUMULATIVELY TO ONE UNIT PER DAY PER MEMBER. CLAIM/DETAIL DENIED. THIS PROCEDURE CODES IS NOT PAYABLE ON THE SAME DATE OF SERVICE AS PROCEDURE CODES 99244 AND 99245. CLAIM/DETAIL DENIED. PROCEDURE CODES 99244 AND 99245 ARE NOT PAYABLE ON THE SAME DATE OF SERVICE AS CERTAIN OTHER TITLE V PROCEDURE CODES. PLEASE CORRECT INVALID OR MISSING NDC NUMBER CLAIM/DETAIL DENIED. PROCEDURE CODE 99244 IS LIMITED TO ONE PER FIVE YEARS, PER MEMBER, PER PROVIDER. CLAIM/DETAIL DENIED. PROCEDURE CODE 99245 IS LIMITED TO ONE PER FIVE YEARS, PER MEMBER, PER PROVIDER. CLAIM/DETAIL DENIED. X0079 LIMITED TO 8 UNITS PER DAY. MEMBER NOT ON ELIGIBILITY FILE - SUSPEND FOR EDIT 250 THE MEMBER ELIGIBILITY NUMBER ON THE MEDICAID CARD ATTACHED WITH YOUR CLAIM IS INCORRECT. MOUTH QUADRANT REQUIRED CLAIM DETAIL DENIED. UNABLE TO APPLY ASSESSMENT PROC LIMITATION DUE TO NO CASE MANAGEMENT ON PRIOR AUTHORIZATION FILE. CLAIM/DETAIL DENIED. X0080/H0004 LIMITED TO 12 UNITS PER WEEK. CLAIM/DETAIL DENIED. X0061/T2016, X0088/S5126, X0089/H0043 AND X0103/S5140 LIMITED TO 1 UNIT, CUMULATIVELY, PER DAY.

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EOB (Explanation of Benefits) Codes and Description

EOB Code

0454 0455 0456 0457 0458 0459 0460 0461 0462 0463 0464 0465 0466 0467 0468 0469 0470 0471 0472 0473 0475 0476 0477 0478 0479 0480 0481 0482 0483 0484 0485 0486 0487 0488 0489 0490 0491 0492 0493 0494 0495 0496 0497 0498 0499

EOB Description

CLAIM/DETAIL DENIED. X0079/H0039 LIMITED TO 32 UNITS PER DAY. CLAIM/DETAIL DENIED. THIS PROCEDURE CODE LIMITED TO 48 UNITS PER DAY. CLAIM/DETAIL DENIED. THIS PROCEDURE CODE LIMITED TO 16 UNITS PER DAY. CLAIM/DETAIL DENIED. X0100/H0043 AND X0101/T2016 LIMITED TO ONE UNIT, CUMULATIVELY, PER DAY. CLAIM/DETAIL DENIED. RESPITE SERVICES ARE LIMITED TO $150.00 PER DAY. CLAIM/DETAIL DENIED. PROCEDURES WITH GT MODIFIER ARE LIMITED TO FOUR (4) PER CALENDAR YEAR. CLAIM/DETAIL DENIED. THIS PROCEDURE CODE LIMITED TO 16 UNITS PER DAY. CLAIM/DETAIL DENIED. XL307/97535 LIMITED TO 80 UNITS PER WEEK. PROVIDER TYPE/CLAIM TYPE NOT FOUND ON MATRIX OCCURRENCE SPAN FROM DATE IS GREATER THAN THE OCCURRENCE SPAN TO DATE PAY AND BILL TPL CLAIM MEMBER COVERED BY PRIVATE INSURANCE (NO ATTACHMENT) DETAIL DENIED. EARLY INTERVENTION AND CERTAIN EPSDT-SPECIAL SERVICES PROCEDURES ARE NOT PAYABLE ON THE SAME DATE OF SERVICE FOR THE SAME MEMBER. MEMBER HAS OTHER MEDICAL COVERAGE. BILL OTHER INSURANCE FIRST OR ATTACH DOCUMENTATION OF DENIAL FROM THE INSURANCE CARRIER. 837D CROSSOVER DENTAL CLAIM CLAIM/DETAIL DENIED. COMPANION CARE UNITS ARE LIMITED TO 200 PER WEEK. THE UNITS OF SERVICE BILLED WAS NOT WITHIN THE SPECIFIED RANGE ALLOWED RECIPIENT IS NOT ELIGIBLE FOR MEDICAID SERVICES, BUT MAY BE ELIGIBLE FOR MEDICARE. MEDICAID PRESCRIPTION SERVICES NOT COVERED. MEMBERS LIMITED TO ONE DRUG CLASS (GPPC) 681200 PRISCRIPTION/REFILL PER DOS MEDICAID REIMBURSEMENT FOR THIS DOS HAS ALREADY BEEN MADE. CLAIM PAYMENT SET TO ZERO ENCOUNTER PAY TO NOT WITHIN SUBMITTER PROVIDER NETWORK MEMBER IN AN INSTITUTIONAL SETTING DURING THE SAME DATE OF SERVICE MEMBER IN ANOTHER INSTITUTIONAL SETTING DURING THE SAME DATES OF SERVICE YOUR FACILITY HAS PREVIOUSLY BILLED AND RECEIVED PAYMENT FOR ALL OR A PORTION OF THESE DATES OF SERVICE NO CLIA REGISTRATION ON FILE FOR THIS PROVIDER PAY TO PROVIDER NOT AUTHORIZED FOR DIRECT PAYMENT. CONTACT PROVIDER ENROLLMENT FOR INSTRUCTIONS. CLAIM/DETAIL DENIED. DUPLICATE SERVICE BILLED. CLAIM/DETAIL DENIED. DUPLICATE SERVICE BILLED. DUPLICATE ANESTHESIA SERVICE BILLED BY PHYSICIAN AND NURSE ANESTHETIST ONLY ONE ANESTHESIA ALLOWED PER DOS PER MEMBER PAPER ATTACHMENT NOT RECEIVED WITHIN 21 DAYS DETAIL PLACE OF SERVICE NOT COVERED THROUGH THE PODIATRY PROGRAM ROUTINE FOOT CARE IS NOT PAYABLE FOR THIS DIAGNOSIS ABORTION CERTIFICATION MISSING CLAIM DENIED. THIS SERVICE WAS PREVIOUSLY PAID TO ANOTHER PROVIDER. CONSECUTIVE OUTPATIENT SERVICES ARE NON-PAYABLE DURING A HOSPITAL INPATIENT STAY. CLAIM DENIED. MEMBER IN ANOTHER INSTITUTIONAL SETTING DURING THE SAME DOS CLAIM HAS BEEN REVIEWED. REFER TO EOB CODES 901 - 940 FOR DENIAL REASON. CLAIM/DETAIL DENIED. DCBS MEMBERS MAY NOT RECEIVE THE SAME DCBS MENTAL HEALTH SERVICES FROM TWO DIFFERENT SUB-PROVIDERS ON THE SAME DATE OF SERVICE. DETAIL DENIED. THIS SERVICE IS NOT PAYABLE BEYOND THE BIRTH MONTH OF THE MEMBERS 18TH BIRTHDAY. INVALID HOSPICE REVENUE CODE OR INVALID COMBINATION OF HOSPICE REVENUE ONLY ONE (1) ANESTHESIA\IV SEDATION ALLOWED PER DATE OF SERVICE PER MEMBER CLAIM/DENIED. RESUBMIT AN ADJUSTMENT ON UNISYS ADJUSTMENT REQUEST FORM. CLAIM DENIED. ONLY ONE PAYMENT ALLOWED PER MEMBER, PER DATE OF SERVICE. CLAIM PENDING REVIEW OF HISTORY

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EOB (Explanation of Benefits) Codes and Description

EOB Code

0500 0501 0502 0503 0504 0505 0506 0507 0508 0509 0510 0511 0512 0513 0514 0515 0516 0517 0518 0519 0520 0521 0522 0523 0524 0525 0526 0527 0528 0529 0530 0531 0532 0533 0534 0535 0536 0537 0538

EOB Description

BIFOCAL OR SINGLE VISION LENSES LIMITED TO TWO SETS PER 12 MONTHS. PROFESSIONAL FEE-DISPENSING SERVICE ALLOWED ONE PER 12 MONTHS PER MEMBER ONE FAMILY PLANNING SERVICE PER DOS ANNUAL FAMILY PLANNING VISITS LIMITED TO 1 PER MEMBER PER NINE MONTHS PER CLINIC FAMILY PLANNING MEMBERS LIMITED TO ONE INITIAL VISIT PER PROVIDER PER THREE YEAR PERIOD MEMBER IN INSTITUTIONAL SETTING DURING SAME DATE OF SERVICE BILLED DATE GREATER THAN BATCH DATE PACKAGE OF 12 TESTS AND COMPONENTS NOT ALLOWED SAME DOS COMPLETE BLOOD COUNT AND COMPONENTS NOT ALLOWED SAME DOS MEMBERS ARE LIMITED ON INITIAL AND FOLLOW UP VISITS TO ONE PER YEAR, PER PROVIDER FOR DOS PRIOR TO SEPT 1, 1985 RECIPIENT LIMITED ON SELECTED INITIAL AND FOLLOW UP VISITS TO 1 PER DOS PAYMENT FOR REVISION OF ARTERIOVENOUS SHUNT IS INCLUDED IN FEE FOR INITIAL INSERTION WHEN REVISION IS PERFORMED WITHIN 21 DAYS OF ORIGINAL PROCEDURE. CLAIM DENIED. FOLLOW UP VISIT INCLUDED IN REIMBURSEMENT FOR DELIVERY. FOLLOW-UP HOSPITAL VISITS INCLUDED IN REIMBURSEMENT FOR C-SECTION. CAST APPLICATION/REMOVAL INCLUDED IN REIMBURSEMENT FOR SURGERY CLAIM DENIED. CULTURES/SMEARS NOT ALLOWED SAME DOS FOR SAME CONDITION. EXTRACTION OR EXPOSURE OF TOOTH DISALLOWED IF PREVIOUSLY EXTRACTED OR EXPOSED CLAIM DENIED. EMERGENCY SERVICES LIMITED TO ONE PER DOS PER MEMBER PER PROVIDER. CLAIM/DETAIL DENIED. INITIAL TOOTH EXTRACTION LIMITED TO ONE PER DOS/MEMBER/PROVIDER. USE PROCEDURE 07120 FOR EACH ADDITIONAL TOOTH EXTRACTED CLAIM DENIED. REIMBURSEMENT FOR CIRCUMCISION WITHIN TEN DAYS OF DELIVERY IS INCLUDED IN DELIVERY FEE. MAINTENANCE DRUG DAYS SUPPLY LESS THAN 30 DAYS COMPREHENSIVE CLIENT RE-EVALUATION NOT ALLOWED WITHIN 12 MONTHS OF COMPREHENSIVE CLIENT EVALUATION. COMPREHENSIVE CLIENT RE-EVALUATION LIMITED TO ONCE PER LIFE TIME RESIDENTIAL COMPONENT SERV NOT ALLOWED WITH IN-HOME SCL SERVICES ON SAME DOS MOTHER DISCHARGE DATE IS ZERO INPATIENT MEMBERS ARE LIMITED TO ONE ATTENDANCE AND ONE CONSULTATION PER ADMISSION INPATIENT MEMBERS WHO HAVE HAD ORAL SURGERY ARE LIMITED TO ONE ATTENDANCE AND/OR ONE CONSULTATION PER DATE OF SERVICE PER PROVIDER ADDITIONAL SERVICES TO THE SAME TOOTH ARE DISALLOWED IF THE TOOTH HAS BEEN PREVIOUSLY EXTRACTED ADDITIONAL SERVICES TO THE SAME TOOTH ARE DISALLOWED ON THE SAME DOS AS A CROWN PROCEDURE OR A FRACTURED INCISAL BUILD-UP CROWN AND BUILD UP PROCEDURES ARE DISALLOWED IF ADDITIONAL DENTAL SERVICES HAVE BEEN PAID FOR THE SAME TOOTH SAME DOS CLAIM PAID. CLAIM HAS BEEN REDUCED BY THE AMOUNT OF THE DISPENSING FEE. PURCHASE UNITS BILLED EXCEEDS MAXIMUM ALLOWED FOR THIS PRIOR AUTHORIZATION CHECK YOUR MAP-9 FORM RENTAL UNITS/CHARGES BILLED EXCEEDS MAXIMUM ALLOWED FOR THIS PRIOR AUTHORIZATION CHECK YOUR MAP-9 FORM CLAIM DENIED. PRIOR AUTHORIZATION NOT ON FILE OR DOES NOT MATCH CLAIM INFORMATION. CLAIM DENIED. PROCEDURE CODE X0064 CANNOT BE BILLED IN CONJUNCTION WITH OTHER PROCEDURE CODES. PLEASE BILL BABYS HOSPITAL STAY AFTER MOTHERS DISCHARGE ON SEPARATE CLAIM FORM, USING BABYS OWN NAME AND NUMBER THE MEDICARE EOMB INDICATES THIS IS A DUPLICATE BILLING. PLEASE SUBMIT THE ORIGINAL EOMB INDICATING THE DEDUCTIBLE AND CO-INSURANCE AMOUNTS. CLAIM/DETAIL DENIED. THIS PROCEDURE IS NOT PAID SEPARATELY WHEN THE GLOBAL SERVICE HAS BEEN REPORTED. CLAIM/DETAIL DENIED. THIS PROCEDURE REQUIRES PRIOR AUTHORIZATION NUMBER.

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EOB (Explanation of Benefits) Codes and Description

EOB Code

0539 0540 0541 0542 0543 0544 0545 0546 0547 0548 0550 0551 0552 0553 0554 0555 0556 0557 0558 0559 0560 0561 0562 0563 0564 0565 0566 0567 0568 0569 0570 0571 0572 0573 0574 0575 0576 0578

EOB Description

CLAIM/DETAIL DENIED. EPSDT RELATED SERVICES CLAIM EXCEEDS TOTAL UNITS OF SERVICE PRIOR AUTHORIZED. HOME HEALTH NURSING VISITS NOT REIMBURSED WHEN PRIVATE DUTY NURSING HAS BEEN AUTHORIZED THROUGH EPSDT SPECIAL SERVICES CAST APPLICATION OR REMOVAL HAS BEEN PAID SEPARATE OF SURGERY. RESUBMIT FOR ADJ WITH PAID RA OF CAST APPLICATION OR REMOVAL AND CORRECTED CLAIM DETAIL DENIED. IMPLANTABLES ARE LIMITED TO TWO UNITS OF SERVICE PER PROCEDURE, PER MEMBER, PER 90 DAYS. MULTIPLE SURGERIES FOR SAME DATE OF SERV MUST BE BILLED ON SAME CLAIM. YOUR CLAIM IS DENIED. INSTRUCTIONS FOR SUBMITTING AN ADJ ARE BEING FORWARDED. CLAIM/DETAIL DENIED. TELEHEALTH SERVICES ARE LIMITED TO 12 PER MEMBER PER 12 MONTHS. MULTIPLE MEDICAL/SURGICAL PROCEDURES FOR THE SAME DOS MUST BE BILLED ON THE SAME CLAIM. FILE AN ADJUSTMENT TO ADD ADDITIONAL PROCEDURES CLAIM/DETAIL DENIED. PRESCRIPTION NUMBER REFILL DATE IS GREATER THAN SIX (6) MONTHS OLD. CLAIM PAYMENT REDUCED. SPEND DOWN DEDUCTED. CLAIM/DETAIL DENIED. REVENUE CODE 235 MUST BE BILLED IN CONJUNCTION WITH REVENUE CODE 155, 183, AND/OR 185. PROCEDURE CODE 00140/D0140 CAN ONLY BE BILLED ALONE OR WITH MONITORED PROC CODES FOR THE SAME MEMBER, SAME PROVIDER, AND SAME DATE OF SERVICE. DISPENSING FEE DEDUCTED. IT WAS PAID WITH DISPENSING OF THE EMERGENCY SUPPLY. THE STAY DAYS BILLED EXCEEDS THE MAXIMUM NUMBER OF STAY DAYS FOR THIS INPATIENT HOSPITAL STAY. CLAIM DENIED. DRUG REQUIRES PRIOR AUTHORIZATION OR FIRST LINE THERAPY INITIATED. THE DATE OF SERVICE AND/OR DOLLAR AMOUNTS ON THE CLAIM AND MEDICARE EOMB DO NOT AGREE. PLEASE VERIFY AND RESUBMIT. DTL - CROSSOVER CLAIM EXCEEDS FILING LIMIT. LIMIT IS 12 MOS FROM MEDICARE EOMB DATE OR 36 MOS. FROM DATE OF SERVICE, WHICHEVER IS LATER. CLAIM/DETAIL DENIED. MEMBER MUST BE AN INPATIENT IN THE NURSING FACILITY. DTL - CROSSOVER CLAIM EXCEEDS FILING LIMIT. LIMIT IS 12 MONTHS FROM MEDICARE EOMB DATE OR 36 MOS FROM DATE OF SERVICE, WHICHEVER IS LATER. CLAIM DETAIL DENIED. H0039 LIMITED TO 32 UNITS PER DAY. CLAIM DENIED. THIS CLAIM EXCEEDS THE MONTHLY MAXIMUM UNITS FOR THIS NDC. DETAIL DENIED. PRIOR AUTHORIZED AMOUNT HAS BEEN EXCEEDED. INVALID NURSING HOME LEVEL OF CARE INVALID NURSING HOME LEVEL OF CARE INVALID LEVEL OF CARE PROV TYPE INVALID LOC FOR SNU PROVIDER THE SUM OF THE THIRD PARTY PAYMENT AMOUNTS ENTERED ON THE LINE ITEM(S) OF YOUR CLAIM IS NOT EQUAL TO THE AMOUNT ENTERED IN THE TPL TOTAL FIELD ELECTRONIC ADJUSTMENT/VOID SET TO DENY CLAIM DENIED. NO WAIVER LIABILITY BUCKET FOR MONTH OF SERVICE. DETAIL DENIED. PRIOR AUTHORIZED AMOUNT HAS BEEN EXCEEDED. DETAIL DENIED. PRIOR AUTHORIZED AMOUNT HAS BEEN EXCEEDED. DETAIL DENIED. PRIOR AUTHORIZED AMOUNT HAS BEEN EXCEEDED. CLAIM DENIED. PRIOR AUTHORIZATION REQUIRED IF 30 DAYS OF THERAPY EXCEEDED DURING A 365 DAY PERIOD. DETAIL DENIED. LEAD INVESTIGATION IN THE HOME LIMITED TO TWO (2) SERVICES PER SIX MONTHS. DETAIL DENIED. POST HAZARD ABATE IN HOME LIMITED TO ONE (1) SERVICE PER 12 MONTHS. CLAIM DENIED. PRIOR AUTHORIZED AMOUNT HAS BEEN EXCEEDED. 6TH SURGICAL PROCEDURE DATE INVALID ANCILLARY CHARGES NOT ALLOWED WITH PATIENT REVENUE CODES 180 OR 185 CLAIM DENIED. PRIOR AUTHORIZATION REQUIRED IF 60 DAYS OF THERAPY EXCEEDED DURING A 3 YEAR PERIOD.

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EOB (Explanation of Benefits) Codes and Description

EOB Code

0579 0580 0581 0582 0583 0584 0585 0586 0587 0588 0590 0591 0592 0593 0594 0595 0596 0597 0598 0599 0600 0601 0602 0603 0604 0605 0606 0607 0608 0609 0610 0611 0612 0613 0614 0615 0616 0617 0618 0619 0620 0621

EOB Description

CLAIM/DETAIL DENIED. REVENUE CODE 581 LIMITED TO 80 UNITS PER MEMBER PER CALENDAR WEEK (SUNDAY THROUGH SATURDAY). CLAIM/DETAIL DENIED. THE ANNUAL LIMITATION OF $1000.00 PER MEMBER FOR MINOR HOME ADAPTATIONS HAS BEEN EXCEEDED. CLAIM/DETAIL DENIED. UNIVERSAL PREVENTION PROCEDURE CODES ARE LIMITED TO A COMBINED TOTAL OF EIGHT UNITS PER MEMBER, PER PREGNANCY. CLAIM/DETAIL DENIED. SELECTIVE PREVENTION PROCEDURE CODES ARE LIMITED TO A COMBINED TOTAL OF 76 UNITS PER MEMBER, PER PREGNANCY. MULTIPLE ANESTHESIA PROC CODES (00100-01999) FOR THE SAME RECIPIENT, PROVIDER AND DATES OF SERVICE ARE NOT ALLOWED CLAIM/DETAIL DENIED. CERTAIN OUTPATIENT SERVICES ARE LIMITED TO A COMBINED TOTAL OF 32 UNITS PER MEMBER, PER WEEK (SUNDAY THRU SATURDAY) CLAIM/DETAIL DENIED. INTENSIVE OUTPATIENT NON-RESIDENTIAL SERVICES PROCEDURE CODES ARE LIMITED TO A COMBINED TOTAL OF 28 UNITS PER MEMBER, PER DAY. OCCURRENCE SPAN FROM DATE IS GREATER THAN THE OCCURRENCE SPAN TO DATE CLAIM/DETAIL DENIED. DAY REHABILITATION PROCEDURE CODES ARE LIMITED TO A COMBINED TOTAL OF 8 UNITS PER MEMBER, PER DAY. CLAIM/DETAIL DENIED. DAY REHABILITATION PROCEDURE CODES ARE LIMITED TO A COMBINED TOTAL OF 45 UNITS PER MEMBER, PER CALENDAR WEEK (SUNDAY THRU SATURDAY). 4TH SURGERY DATE/STAY CONFLICT 5TH SURGERY DATE/STAY CONFLICT 6TH SURGERY DATE/STAY CONFLICT 4TH SURGICAL PROCEDURE DATE INVALID 5TH SURGICAL PROCEDURE DATE INVALID THE CLAIM WAS CREATED BY A RESUBMISSION CLAIM DETAIL DENIED. OFFICE VISITS NOT ALLOWED WITHIN 10 DAYS FOLLOWING A SURGICAL PROCEDURE. CLAIM/DETAIL DENIED. THIS PROCEDURE IS NOT PAYABLE AFTER THE DATE OF DELIVERY. CLAIM DETAIL DENIED. ONLY ONE E AND M CODE ALLOWED PER DATE OF SERVICE. CLAIM PENDING REVIEW OF HISTORY EYE EXAM LIMITED TO OPTOMETRIST ONLY 3 FOLLOW UP EXAMS ARE ALLOWED PER 6 MONTHS CLAIM DENIED. LIMIT 2 ROUTINE ORTHODONTICS PER MEMBER, PER 12 MONTHS. CLAIM DENIED. EACH MEMBER ALLOWED ONE FULL MOUTH RADIOGRAPHY EVERY TWO YEARS PER PROVIDER. INVALID FINANCIAL CLASS CODE 6TH THRU 11TH DIAG CODE IS NOT FOUND 6TH DIAG CODE REQUIRES MED REVIEW 7TH DIAG CODE REQUIRES MED REVIEW 8TH DIAG CODE REQUIRES MED REVIEW 9TH DIAG CODE REQUIRES MED REVIEW 10TH DIAG CODE REQUIRES MED REVIEW 11TH DIAG CODE REQUIRES MED REVIEW 12TH - 24TH DIAG CODE REQUIRES MED REVIEW CLAIM HAS BEEN REVIEWED. REFER TO EOB 901-940 FOR DENIAL REASON. CLAIM HAS BEEN REVIEWED. REFER TO EOB 901-940 FOR DENIAL REASON. MAXIMUM OF 40 DAYS RESIDENTIAL RESPITE COMBINING DAILY AND HOURLY SERVICE PER MEMBER PER CALENDAR YEAR. MAXIMUM OF 60 DAYS IN-HOME RESPITE ALLOWED COMBINING DAILY AND HOURLY SERVICES PER MEMBER PER CALENDAR YEAR. MEMBER ALLOWED 1 INITIAL OFFICE VISIT WITH COMPLETE DIAGNOSIS PER 9 MONTHS 4TH SURGICAL PROCEDURES/SEX CONFLICT 5TH SURGICAL PROCEDURES/SEX CONFLICT 6TH SURGICAL PROCEDURES/SEX CONFLICT 4TH SURGICAL PROCEDURE NOT FOUND

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EOB (Explanation of Benefits) Codes and Description

EOB Code

0622 0623 0624 0625 0626 0627 0628 0629 0630 0631 0632 0633 0634 0635 0636 0637 0638 0639 0640 0641 0642 0643 0644 0645 0646 0647 0648 0649 0650 0651 0652 0653 0654 0655 0656 0657 0658 0659 0660 0661 0662 0664 0665 0666 0667 0668

EOB Description

5TH SURGICAL PROCEDURE NOT FOUND 6TH SURGICAL PROCEDURE NOT FOUND CLAIM DENIED. THIS PROCEDURE ALLOWED ONE PER DOS PER TOOTH PER PROVIDER. CLAIM DENIED/MEMBER ALLOWED 3 REPAIRS INCLUDING REPLACEMENTS OF ONE TOOTH PER 12 MONTHS. CLAIM DENIED. ONLY 14 DAYS SERVICE ALLOWED PER ADMISSION PER MEMBER. CLAIM HAS BEEN REVIEWED. REFER TO EOB 901-940 FOR DENIAL. CLAIM HAS BEEN REVIEWED. REFER TO EOB CODES 1901 - 1940 FOR DENIAL REASON CLAIM HAS BEEN REVIEWED. REFER TO EOB 901-940 FOR DENIAL REASON. UNITS OF SERVICE NOT COMPATIBLE WITH DATE SPAN BILLED. IF ONLY ONE DOS BILLED, A DATE SPAN MAY BE REQUIRED FOR NUMBER OF UNITS BILLED. MEMBERS ARE LIMITED TO ONE DENTURE RELINING PER 12 MONTHS FULL MOUTH DEBRIDEMENT IS ALLOWED ONCE PER MEMBER PER PREGNANCY DIAGNOSIS REQUIRES PRIOR AUTHORIZATION MAXIMUM $300.00 ALLOWED PER MONTH/MEMBER FOR TANK OXYGEN AIS/MR DAILY CODE LIMITED TO ONE UNIT PER DATE OF SERVICE PER MEMBER PROFESSIONAL FEE FOR DISPENSING INITIAL PAIR OF EYEGLASSES ALLOW - ONE PER 12 MOS, PER MEMBER. CLAIM DENIED. MEMBER LIMITED TO 3 FETAL TESTS/12 MONTHS. IF UNUSUAL CIRCUMSTANCES, SEND CLAIM DOCUMENTATION TO AHCA FOR REVIEW. ANNUAL FAMILY PLANNING VISITS ARE LIMITED TO ONE PER MEMBER PER 9 MONTHS PER CLINIC CANNOT AUTO DENY ADJUSTMENT THIS DETAIL WAS MANUALLY PRICED AFTER REVIEW BY CONSULTANTS PRIOR AUTHORIZATION DOES NOT MATCH FOR THIS CLAIM/DETAIL THIS PROCEDURE IS LIMITED TO ONE PER 12 MONTHS PER MEMBER PER PROVIDER. CANNOT AUTO DENY ADJUSTMENT MEMBERS ARE LIMITED TO ONE (1) OPTHAMOLOGICAL EXAMINATION PER PROVIDER PER 12 MONTHS NEW PATIENT HOME MEDICAL SERV LIMITED TO ONE PER MEMBER PER PROVIDER PER 12 MONTHS ESTABLISHED PATIENT MEDICAL SERVICES LIMITED TO ONE PER MEMBER PER PROVIDER PER 12 MONTHS PROVIDER NUMBER NOT ON FILE MEMBER ARE LMTD ON INITIAL PREVENTATIVE CARE VISITS TO 1 PER PROV PER 12 MONTHS. MEMBER LMTD 1 INITIAL OPTHALMOLOGICAL SERVICE PER PROV PER 12 MONTHS ROUTINE NEWBORN CARE IS PAYABLE ONLY ONCE PER INFANT WAITING FOR PAPER ATTACHMENT FROM PROVIDER CLAIM DENIED. BIFOCAL OR SINGLE VISION LENSES ARE LIMITED TO 4 PER 12 MONTHS. CLAIM/DETAIL DENIED. A PRESCRIPTION CAN ONLY BE BILLED 6 TIMES. MEMBER ALLOWED FILLINGS FOR UP TO FIVE SURFACES PER TOOTH PER DOS PER PROVIDER MAXIMUM OF 14 CONSECUTIVE HOSPITAL RESERVE DAYS ALLOWED PER MEMBER PER PROVIDER MAXIMUM OF 15 NON-HOSPITAL RESERVE DAYS ALLOWED PER MEMBER PER CALENDAR YEAR MAXIMUM OF 45 HOSPITAL RESERVE DAYS ALLOWED PER MEMBER PER CALENDAR YEAR MAXIMUM OF 15 CONSECUTIVE HOSPITAL RESERVE DAYS ALLOWED PER MEMBER PER PROVIDER. MAXIMUM OF 30 CONSECUTIVE RESERVE DAYS ALLOWED PER MEMBER PER PROVIDER CALCULATED PAYMENT EQUALS ZERO. OTHER INS PAID MORE THAN MEDICAID ALLOWABLE. SNU LEAVE DAYS PRESENT A MAXIMUM OF 14 INPATIENT HOSPITAL DAYS PER ADMISSION AND READMISSION PER MEMBER. PAY TO PROVIDERS MAIL IS UNDELIVERABLE. CONTACT PROVIDER ENROLLMENT FOR INSTRUCTIONS. VENIPUNCTURE/CATHETERIZATION PROCEDURES 80020, 80022, 80023, 80024 AND 36415 NOT ALLOWED SAME DOS/MEMBER/PROVIDER CLAIM/DETAIL DENIED. PROVIDER NOT CLIA CERTIFIED TO BILL NON-WAIVERED OR NON-MICROSCOPY LAB CODE. THIS PROCEDURE IS LIMITED TO ONE SERVICE PER MEMBER PER SAME DATE OF SERVICE PROVIDER/PROC CODE MOD/PLACE OF SERV CONFLICT. POST WITH ASC MOD 73 OR 74.

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EOB (Explanation of Benefits) Codes and Description

EOB Code

0669 0670 0671 0673 0674 0675 0676 0677 0678 0679 0680 0681 0682 0683 0684 0685 0686 0687 0688 0689 0690 0691 0692 0693 0694 0695 0696 0697 0698 0699 0700 0701 0702 0703 0704 0705

EOB Description

DAYS REDUCED. A MAXIMUM OF 14 CONSECUTIVE HOSPITAL RESERVE DAYS ALLOWED PER MEMBER, PER PROVIDER. DAYS REDUCED. A MAXIMUM OF 15 NON-HOSPITAL RESERVE DAYS ALLOWED PER MEMBER, PER PROVIDER, PER CALENDAR YEAR. CLAIM/DETAIL DENIED. MEDICAID WILL PAY FOR ONLY ONE CARDIAC CATHETER PROCEDURE PER DAY. CLAIM DENIED. CPT LEVEL CODE MISSING OR INVALID. PROCEDURE CODE V5020 IS LIMITED TO 3 PER MEMBER PER PROVIDER PER SIX MONTHS CLAIM DETAIL DENIED. PROCEDURE CODE W0030 IS LIMITED TO ONE UNIT PER MEMBER, PER PROVIDER, PER 60 DAYS. PROCEDURE W0030/V5011 CAN ONLY BE PERFORMED 150 TO 210 DAYS 5 TO 7 MONTHS AFTER PERFORMING PROCEDURE V5090 PROCEDURE CODE LIMITED TO ONE PER 60 DAYS MEMBERS ARE LIMITED TO A MAXIMUM OF 10 MONTHLY STABILIZATION VISITS DURING PHASE I TREATMENT CONTACT AHCA FOR FURTHER CONSIDERATION. CLAIM/DETAIL DENIED. ONLY ONE HANDS PROCEDURE CODE ALLOWED PER MEMBER PER DATE OF SERVICE. FAMILY AND/OR GROUP PSYCHOTHERAPY LMTD TO ONE PER DATE OF SERVICE PAY TO PROVIDER NONPARTICIPATING CLAIM DENIED. REIMBURSEMENT CANNOT EXCEED A MAXIMUM OF 14 DAYS PER ADMISSION. MODEL WAIVER MEMBERS ARE LIMITED TO 16 HOURS OF NURSING/ RESPIRATORY SERVICES PER DATE OF SERVICE MODEL WAIVER RESPIRATORY SERVICES ARE LIMITED TO ONE UNIT PER MEMBER PER DATE OF SERVICE CLAIM/DETAIL DENIED. A HOSPICE SERVICE HAS BEEN PAID FOR SAME MEMBER/SAME DATE(S) OF SERVICE. CLAIM/DETAIL DENIED. HOSPICE RESPITE SERVICES ARE LIMITED TO FIVE CONSECUTIVE DAYS PER MEMBER. UNITS BILLED EXCEED MAXIMUM FOR THIS PRIOR AUTHORIZATION MODEL WAIVER DOLLAR LIMIT HAS BEEN MET MEMBERS ARE LIMITED TO A MAXIMUM OF 365 ORAL CONTRACEPTIVE UNITS PER 12 MONTH PERIOD CLAIM DENIED. TARGETED CASE MANAGEMENT SERVICES ARE LIMITED TO 1 PER CALENDAR MONTH, PER MEMBER. CLAIM/DETAIL DENIED. CLIA ID MISSING OR INVALID CLAIM/DETAIL DENIED. PROVIDER NOT CLIA CERTIFIED TO BILL NON-WAIVERED LAB CODE. COMPREHENSIVE ORTHODONTIC EXAM LIMITED TO ONE PER MEMBER PER 12 MONTHS COMPREHENSIVE ORTHODONTIC EXAM LIMITED TO TWO (2) PER MEMBER PER LIFETIME MEMBERS ARE LIMITED TO A MAXIMUM OF 24 MONTHLY RETENTION VISITS PER LIFETIME CLAIM/DETAIL DENIED. PROFESSIONAL COMPONENT CHARGES MUST BE BILLED ON HCFA-150 MEMBERS ARE LIMITED TO ONE RETENTION VISIT PER 30 DAYS MEMBERS ARE LIMITED TO A MAXIMUM OF 10 POST TREATMENT STABILIZATION VISITS PER LIFETIME CLAIM/DETAIL DENIED. PROCEDURE CODE T2022 IS LIMITED TO $260.00 IN CLINIC PROVIDER IS INELIGIBLE FOR THIS CATEGORY OF SERVICE. CLAIM DENIED. BED RESERVE REVENUE CODES FOR MENTAL HOSPITAL AND ACUTE PSYCHIATRIC BED ARE LIMITED TO A COMBINATION OF 14 UNITS PER CALENDAR YEAR PER MEMBER CLAIM DENIED. BED RESERVE/OTHER REVENUE CODE IS LIMITED TO A TOTAL OF 21 UNITS PER CALENDAR 6 MONTHS PER MEMBER, PER PROVIDER. CLAIM DENIED. BED RESERVE/ACUTE REVENUE CODE IS LIMITED TO A TOTAL OF 14 UNITS PER CALENDAR 6 MONTHS PER MEMBER, PER PROVIDER. CLAIM DENIED. PSYCHIATRIC RESIDENTIAL TREATMENT FACILITY CLAIMS ARE LIMITED T O 30 CONSECUTIVE BED RESERVE DAYS PER MEMBER, PER PROVIDER. NEW PATIENT OPHTHALMOLOGICAL SERVICES LIMITED TO ONE PER MEMBER, PER PROVIDE R, PER 36 MONTHS/THREE YEARS

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EOB (Explanation of Benefits) Codes and Description

EOB Code

0706 0707 0708 0709 0710 0711 0712 0713 0715 0716 0717 0718 0719 0720 0721 0722 0723 0724 0725 0726 0727 0728 0729 0730 0731 0732 0733 0734 0735 0736 0737

EOB Description

NEW PATIENT OFFICE OR OUTPATIENT SERVICES LIMITED TO ONE PER MEMBER, PER PROVIDER, PER 36 MONTHS/THREE YEARS NEW PATIENT HOME MEDICAL SERVICES LIMITED TO ONE PER MEMBER, PER PROVIDER, PE R 36 MONTHS/THREE YEARS NEW PATIENT PREVENTATIVE CARE VISITS LIMITED TO ONE PER MEMBER, PER PROVIDER, PER 36 MONTHS/THREE YEARS CLAIM/DETAIL DENIED. PROCEDURE CODE 70320 LIMITED TO ONE PER YEAR, PER MEMBER, PER PROVIDER. CLAIM/DETAIL DENIED. ONLY ONE CHEMOTHERAPY ADMINISTRATION CODE IS PAYABLE PER DATE OF SERVICE. PROVIDER NOT APPROVED FOR ELECTRONIC BILLING SUBMIT MAP 380 PROVIDER AGREEMENT FORM PROCEDURE CODE/PROVIDER TYPE OF SERVICE CONFLICT (WAIVER PROGRAM AND CASE MANAGEMENT) DELIVERY, ROUTINE NEWBORN CARE, CIRCUMCISION ARE LIMITED TO ONE EACH PER EACH PER MEMBER PER DATE OF SERVICE CLAIM DENIED. PROCEDURE CODE X0064 LIMITED TO ONE UNIT OF SERVICE PER PROVIDER, PER MEMBER, PER TWO YEARS. CLAIM DENIED. PROCEDURE CODE X0074 LIMITED TO ONE UNIT OF SERVICE PER PROVIDER, PER MEMBER, PER TWO YEARS. CLAIM DENIED. PROCEDURE CODE X0075 LIMITED TO A TOTAL OF 76 UNITS OF SERVICE PER PROVIDER, PER MEMBER, PER TWO YEARS. CLAIM DENIED. PROCEDURE CODE X0076/T2022 LIMITED TO ONE UNIT OF SERVICE PER PROVIDER, PER MEMBER, PER CALENDAR MONTH. CLAIM DENIED. A MAXIMUM OF 60 RESPITE DAYS (COMBINING DAILY AND HOURLY SERVICES) ALLOWED PER PROVIDER, PER MEMBER, PER CALENDAR YEAR. MEDICARE COVERAGE IS PRESENT RECIP INELIG FOR DATE OF SRV - DENIED AFTER BEING PENDED FOR 14 DAYS AWAITING DCF UPDATE. IF YOU HAVE ELIG PROOF CONTACT DCF DISTRICT OFFICE. CLAIM/DETAIL DENIED. BUCCAL AND FACIAL TOOTH SURFACES NOR OCCLUSAL AND INCISAL TOOTH SURFACES NOT ALLOWED FOR SAME MEMBER, SAME PROV, SAME DOS. CLAIM/DETAIL DENIED. ONLY FOUR TOOTH SURFACES ALLOWED PER MEMBER, PER PROVIDER, PER DATE OF SERVICE, PER TOOTH NUMBER. CLAIM DETAIL DENIED. HOME MODIFICATIONS ARE LIMITED TO $1000.00 IN PAYMENTS PER SIX MONTHS. INDIVIDUAL PSYCHOTHERAPY IS LIMITED TO 12 UNITS OF SERVICE PER DAY, PER MEMBER, PER PROVIDER CLAIM/DETAIL DENIED. CEPHALOMETRIC X-RAY LIMITED TO ONE PER MEMBER, PER PROVIDER, EVERY TWO YEARS. CLAIM/DETAIL DENIED. DIALYSIS TRAINING LIMITED TO ONE (1) PER MEMBER, PER LIFE TIME. GINGIVECTOMY PROCEDURE IS LIMITED TO ONE PER MEMBER, PER PROVIDER, PER TOOTH NUMBER PER 12 MONTHS PIN RETENTION THERAPY TREATMENT IS LIMITED TO TWO PER MEMBER PER PERMANENT MOLAR PER LIFETIME PROCEDURE CODE 07880/D7880 LIMITED TO ONE PER LIFETIME PER MEMBER MEMBERS ARE LIMITED TO ONE RELINING OF THE LOWER DENTURE PER 12 MONTHS ALVEOPLASTY PROCEDURE CODES ARE LIMITED TO ANY COMBINATION OF THESE PROCEDURS WITH ONLY ONE PER QUADRANT, PER MEMBER, PER LIFETIME PROCEDURES ARE LIMITED TO ANY COMBINATION OF THESE PROCEDURES WITH ONLY ONE EACH PER QUADRANT, PER MEMBER, PER 12 MONTH PERIOD, PER PROVIDER CLAIM/DETAIL DENIED. PROCEDURE IS NOT ALLOWED TO THE SAME TOOTH ON THE SAME DATE OF SERVICE AS A SEALANT. CLAIM/DETAIL DENIED. SYRINGES LIMITED TO 125 UNITS PER 26 DAYS, PER MEMBER. CLAIM/DETAIL DENIED. VACCINE ADMINISTRATION LIMITED TO (3) PER MEMBER, PER PROVIDER, PER DATE OF SERVICE. INVALID PROCEDURE CODE AND MODIFIER

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EOB (Explanation of Benefits) Codes and Description

EOB Code

0738 0739 0740 0742 0743 0744 0745 0746 0747 0748 0749 0750 0751 0752 0753 0754 0755 0756 0757 0758 0759 0760 0761 0762 0763 0764 0765 0766 0767 0768 0769 0770 0771 0772 0773 0774 0775 0777 0778 0779 0781 0782 0783 0784 0785

EOB Description

CLAIM/DETAIL DENIED. SEALANTS ARE LIMITED TO THREE PER TOOTH PER LIFETIME PER MEMBER. CLAIM/DETAIL DENIED. SEALANTS ARE NOT ALLOWED TO A TOOTH THAT HAS RECEIVED AN OCCLUSAL FILLING. CLAIM/DETAIL DENIED. ONLY ONE UNIT OF SERVICE ALLOWED FOR THIS DENTAL PROCEDURE PER PRIOR AUTHORIZATION. DETAIL DENIED. INTRAORAL COMPLETE SERIES LIMITED TO ONE UNIT PER MEMBER, PER PROVIDER, PER 12 MONTHS. GINGIVECTOMY LIMITED TO 1 UNIT PER TOOTH, PER 12 MONTHS, PER MEMBER, PER PROVIDER CLAIM/DETAIL DENIED. SCHOOL-BASED HEALTH SERVICES ARE LIMITED TO 40 UNITS OF SERVICE PER DATE OF SERVICE. PLEASE CHECK THE UNITS OF SERVICE BILLED FOR ERRORS CLAIM/DETAIL DENIED. PROCEDURE CODE X0058 CANNOT BE BILLED BY A SCHOOL BASED PROVIDER AND A COMMUNITY MENTAL HEALTH PROVIDER ON THE SAME DATE OF SERVICE. REVENUE/PROCEDURE CODE INVALID FOR PROVIDER TYPE CLAIM DETAIL DENIED. PROCEDURE CODES X0079/H0039 AND X0098/97537, (ANY COMBINATION) ARE LIMITED TO FORTY HOURS PER SEVEN DAY PERIOD. REVENUE/PROCEDURE CODE INVALID FOR PLACE OF SERVICE CLAIM DETAIL DENIED. RESPITE CARE IS LIMITED TO 168 HOURS PER SIX MONTHS. DRUG/DRUG INTERACTION REVENUE/PROCEDURE CODE INVALID FOR DATE OF SERVICE REVENUE CODE MISSING/INVALID INVALID REVENUE CODE. CHARGES NOT ALLOWED. EARLY REFILL NON-REIMBURSABLE FOR THIS PROVIDER TYPE/DOS. EFFECTIVE FOR DOS 10/01/90 AND AFTER, DRUGS MUST BE BILLED BY MEDICAID PARTICIPATING PHARMACY. CLIA ID MISSING OR INVALID. CHARGES MOVED TO NON-COVERED. CHARGES MOVED TO NON-COVERED. RTSUP CAN ONLY BE REIMBURSED WHEN CHARGES FOR RT ARE BILLED FOR THE SAME DATES OF SERVICE. PROVIDER NOT CLIA CERTIFIED TO BILL NON-WAIVERED LAB CODE. CHARGES MOVED TO NONCOVERED. PROVIDER NOT CLIA CERTIFIED TO BILL NON-WAIVERED OR NON-MICROSCOPY LAB CODE. CHARGES MOVED TO NON-COVERED. INFERRED DRUG/DISEASE PRECAUTION DRUG/AGE PRECAUTION MEDICAL CONDITION ALERT SERVICES RENDERED DO NOT MEET DMS CRITERIA DIAGNOSIS AND DESCRIPTION OF TREATMENT ARE REQUIRED FOR SERVICES RENDERED THERAPEUTIC DUPLICATION REVENUE CODE PROCEDURE CODE COMBINATION INVALID. CHARGES MOVED TO NON-COVERED INGREDIENT DUPLICATION ALCOHOL PRECAUTION BREAST FEEDING PRECAUTION DRUG/FOOD INTERACTION DRUG/LAB CONFLICT CALL HELP DESK (1-800-807-1232) INVALID DUR CONFLICT CODE INVALID DUR INTERVENTION CODE INVALID DUR OUTCOME CODE CLAIM DENIED. PHARMACY CLAIMS MUST BE BILLED THROUGH POS VARIANCE LIMIT MET. CLAIM PENDING REVIEW. INVALID PROCEDURE CODE MODIFIER CLAIM/DETAIL DENIED. THE MEMBERS ANNUAL SPEECH THERAPY VISIT LIMIT. CLAIM/DETAIL DENIED. THE MEMBERS ANNUAL PHYSICAL THERAPY VISIT LIMIT. FULL MOUTH DEBRIDEMENT NOT ALLOWED ON SAME DATE OF SERVICE AS PROPHY OR PROPHY OR PERIODONTAL SCALING AND ROOT PLANNING NOT ALLOWED ON SAME DATE CLAIM/DETAIL DENIED. ONLY ONE DENTAL VISIT ALLOWED PER MEMBER PER

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EOB (Explanation of Benefits) Codes and Description

EOB Code

0786 0788 0789 0790 0791 0792 0793 0794 0795 0796 0797 0798 0799 0800 0801 0802 0803 0808 0810 0812 0814 0815 0816 0818 0821 0822 0824 0825 0826 0827 0828 0829 0830 0831

EOB Description

CLAIM/DETAIL DENIED. CAST PROCEDURES ARE LIMITED TO TWO PER 90 DAYS PER CLAIM/DETAIL DENIED. ADULT DAY TRAINING IS LIMITED TO FIVE (5) DAYS PER CLAIM/DETAIL DENIED. ADULT DAY TRAINING ON-SITE IS LIMITED TO EIGHT (8). CLAIM/DETAIL DENIED. ADULT DAY TRAINING IS LIMITED TO 255 DAYS PER CLAIM DETAIL DENIED. REVENUE CODE 580 IS LIMITED TO 45 UNITS (HOURS) PER WEEK (SUNDAY THROUGH SATURDAY). CLAIM DETAIL DENIED. ONLY ONE OBSTETRICAL VISIT ALLOWED IN AN EIGHT WEEK PERIOD. CLAIM DETAIL DENIED. ONLY ONE COMPREHENSIVE VISIT ALLOWED EVERY 50 WEEKS. CLAIM/DETAIL DENIED. EPIDURAL INJECTIONS FOR CONTROL OF PAIN SHALL BE LIMITED TO 3 INJECTIONS PER 6 MONTHS PER MEMBER. CLAIM/DETAIL REQUIRES PRIOR AUTHORIZATION. THE MONTHLY (CALENDAR MONTH) LIMITATION FOR THIS PROCEDURE CODE HAS BEEN EXCEEDED. CLAIM/DETAIL REQUIRES PRIOR AUTHORIZATION. THE ANNUAL (CALENDAR YEAR) LIMITATION FOR THIS PROCEDURE CODE HAS BEEN EXCEEDED. THE ANNUAL MAXIMUM FOR THIS SERVICE HAS BEEN EXCEEDED. THE ALLOWED PROCEDURE CODE XZ299 IS LIMITED TO $150.00 PER CALENDAR MONTH PER MEMBER, PER PROVIDER REVENUE CODE 270 CANNOT EXCEED $2,000 BILLED AMOUNT PER MONTH. PLEASE RESUBMIT WITH ITEMIZED INVOICE FOR SUPPLIES FOR ENTIRE MONTH. CLAIM DENIED. PROCEDURE CODES X0074 AND X0075 NOT PAYABLE ON SAME DATE OF SERVICE AS X0076. CLAIM DENIED. PROCEDURE CODE X0076 NOT PAYABLE ON THE SAME DATE OF SERVICE AS X0074 OR X0075. PROCEDURE CODE 00150/D0150 DISALLOWED BY SAME PROVIDER FOR SAME MEMBER ON THE SAME DATE OF SERVICE AS PROCEDURES 09110/D9110 OR 00140/D0140 MEMBER APPLIED INCOME NOT CURRENT FOR DOS - RECYCLE FOR EDIT 271 MONTHLY DIALYSIS PROCEDURE CODES ARE NOT REIMBURSEABLE FOR THE SAME OR OVERLAPPING DATE OF SERVICE AS DAILY DIALYSIS PROCEDURE CODES HEMODIALYSIS PROCEDURE CODES ARE NOT REIMBURSABLE FOR THE SAME OR OVERLAPPING DATES OF SERVICE AS EVALUATION AND MANAGEMENT PROCEDURE CODES. ADDITIONAL SURGICAL PROCEDURES ARE NOT PAYABLE ON SAME DATE OF SERVICE BY SAME PROVIDER FOR SAME MEMBER WHEN BILLING FOR SUTURE OF WOUND MEMBER ID NUMBER IS INVALID CLAIM DETAIL DENIED. THIS PROCEDURE CODE NOT PAYABLE ON THE SAME DATE OF SERVICE AS COMMUNITY RESIDENTIAL SERVICES. CAST REMOVAL OR REPAIR HAS BEEN PAID WITH APPLICATION OF CAST. IF UNRELATED PROC, SEND CLAIM WITH DOCUMENTATION OF UNRELATED PROC TO THE AHCA FOR REVIEW. VENIPUNCTURE OR ARTERIAL PUNCTURE IS NOT ALLOWED ON THE SAME DATE OF SERVICE AS OTHER MONITORED PROCEDURES CLAIM DETAIL DENIED. LIMITATION EXCEEDED, PRIOR AUTHORIZATION REQUIRED. X-RAY PROCEDURE NOT ALLOWED WITHIN 12 MONTHS OF INTRAORAL COMPLETE SERIES DETAIL DENIED. PROCEDURE CODE 08670 NOT PAYABLE WITHIN 24 MONTHS OF CERTAIN OTHER PROCEDURE CODES IF BILLED FOR THE SAME MEMBER BY THE SAME PROVIDER. DETAIL DENIED. THIS PROC CODE NOT PAYABLE WITHIN 24 MONTHS OF ORTHODONTIC TREATMENT IF BILLED FOR THE SAME MEMBER BY THE SAME PROVIDER. PROCEDURE CODE 09110/D9110 NOT PAYABLE IF PAYMENT HAS BEEN MADE FOR OTHER DENTAL PROCEDURE CODES FOR THE SAME DATE OF SERVICE THIS PROCEDURE IS NOT PAYABLE IF PAYMENT HAS BEEN MADE FOR PROCEDURE 09110/D0110 FOR THE SAME DATE OF SERVICE CLAIM/DETAIL DENIED. THIS REVENUE CODE IS NOT PAYABLE FOR THIS PROVIDER SPECIALTY CODE. CLAIM/DETAIL DENIED. PROVIDER NOT ELIGIBLE TO RECEIVE PAYMENT FOR SERVICES PROVIDED TO KCHIP PHASE III MEMBERS. CLAIM DENIED. NO DRG FOUND. CLAIM DENIED. DRG CANNOT USE DIAGNOSIS CODE.

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EOB (Explanation of Benefits) Codes and Description

EOB Code

0832 0833 0834 0835 0836 0837 0838 0839 0840 0841 0842 0843 0844 0845 0846 0847 0848 0849 0850 0851 0852 0853 0854 0856 0857 0858 0859 0860 0861 0863 0864 0865 0866 0867 0868 0872 0873 0874 0875 0876 0877 0878 0879 0880 0881 0882 0883 0884 0885 0886 0887 0888 0889

EOB Description

CLAIM DENIED. DRG CRITERIA NOT MET. CLAIM DENIED. DRG INVALID AGE. CLAIM DENIED. DRG INVALID SEX. CLAIM DENIED. DRG INVALID DISCHARGE STATUS. CLAIM DENIED. DRG INVALID PRINCIPLE DIAGNOSIS. CLAIM DENIED. DRG DENY 469 THROUGH 470. PROCEDURE CODE T2033 LIMITED TO ONE UNIT PER DAY PER MEMBER RESERVED FOR DRG PROCEDURE CODE HAS BEEN REBUNDLED BYPASS INDICATOR, GMIS INFORMATIONAL ONLY PROCEDURE CODE IS MUTUALLY EXCLUSIVE PROCEDURE CODE IS INCIDENTAL PROCEDURE CODE IS NOT INDICATED FOR SEPARATE REIMBURESMENT VISIT IS WITHIN ONE DAY PRE OP RANGE PROCEDURE CODE INCLUDES UNILATERAL AND BILATERAL PERFORMANCE PROCEDURE IS A BILATERAL OR DUPLICATE PLEASE PAY SPECIFIED PROCEDURE CODES PROCEDURE DOES NOT REQUIRE AN ASSISTANT SURGEON PROCEDURE CODE IS INVALID FOR PATIENTS AGE PROCEDURE CODE IS INVALID FOR PATIENTS SEX GMIS - INAPPROPRIATE PROCEDURE CODE FOR MEMBERS AGE PEDIATRIC PROCEDURE AGE SHOULD BE 1 TO 17 YEARS MATERNITY PROCEDURE AGE SHOULD BE 12 - 55 YEARS PROCEDURE NOT INDICATED FOR A MALE PROCEDURE NOT INDICATED FOR A FEMALE CLAIM DENIED. COSMETIC PROCEDURE. CLAIM DENIED. DUPLICATE PROCEDURE. CLAIM DENIED. EXPERMENTAL PROCEDURE. CLAIM DENIED. OBSOLETE PROCEDURE. PROCEDURE CODES DOES NOT REQUIRE AN ASSTANT SURGEON PROCEDURE CODE IS INVALID FOR LOCATION PROCEDURE CODE NEEDS TO BE REPLACED PROCEDURE NEEDS TO BE REPLACED FOR SURFACES BILLED PROCEDURE CODE NEEDS TO BE REPLACED FOR SURFACES BILLED CLAIM/DETAIL DENIED. PURCHASE OF PROCEDURE CODES E0607 AND E2100 IS FIRST DIAGNOSIS CODE NOT ON FILE SECOND DIAGNOSIS CODE NOT ON FILE SECOND DIAGNOSIS CODE INVALID THIRD DIAGNOSIS CODE NOT ON FILE CLAIM/DETAIL DENIED. HEARING AIDS ARE LIMITED TO $1400.00 PER EAR, PER CLAIM/DETAIL DENIED. CHILDRENS DENTAL PROPHYLAXIS AND FLOURIDE FOURTH DIAGNOSIS CODE NOT ON FILE CLAIM DENIED. PROCEDURE REQUIRES DOCUMENTATION CLAIM DENIED. PROCEDURE CODE IS FOR PATIENTS UP TO AGE 14 CLAIM DENIED. PROCEDURE CODE IS FOR PATIENTS OVER AGE 14. CLAIM DENIED. COSMETIC PROCEDURE NOT PAYABLE BY MEDICAID CLAIM DENIED. DUPLICATE PROCEDURE HAS BEEN PAID. CLAIM DENIED PROCEDURE IS CONSIDERED EXPERIMENTAL FIFTH DIAGNOSIS CODE NOT ON FILE FIFTH DIAGNOSIS CODE NOT ON FILE 6TH THRU 11TH DIAG CODE IS NOT FOUND 6TH THRU 11TH DIAG CODE IS NOT FOUND CLAIM/DETAIL DENIED. THIS PROCEDURE CODE IS NOT PAYABLE IF BILLED WITH A SUBSTANCE ABUSE DIAGNOSIS CODE.

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EOB (Explanation of Benefits) Codes and Description

EOB Code

0890 0891 0892 0893 0894 0896 0897 0898 0899 0900 0901 0902 0903 0904 0905 0906 0907 0908 0909 0910 0911 0912 0913 0914 0915 0916 0917 0918 0919 0920 0921 0922 0923 0924 0925 0926 0927 0928 0929 0930

EOB Description

CLAIM/DETAIL DENIED. THIS PROCEDURE IS NOT PAYABLE IF BILLED WITHOUT ONE OF THE DESIGNATED PREGNANCY DIAGNOSIS CODES. 6TH THRU 11TH DIAG CODE IS NOT FOUND 6TH THRU 11TH DIAG CODE IS NOT FOUND UNITS OF SERVICE GREATER THAN THE REMAINING PRIOR AUTHORIZED AMOUNT DETAIL DENIED. THE PRIOR AUTHORIZED AMOUNT FOR THIS PROCEDURE HAS BEEN MET. CLAIM HAS FAILED MORE THAN 24 ERROR CODES. PLEASE CORRECT AND RESUBMIT. 6TH THRU 11TH DIAG CODE IS NOT FOUND 6TH THRU 11TH DIAG CODE IS NOT FOUND 6TH THRU 11TH DIAG CODE NOT FOUND THE RX NUMBER MUST BE COMPLETED TO PROCESS YOUR CLAIM. PLEASE COMPLETE AND RESUBMIT YOUR CLAIM. DRUG QUANTITY IS REQUIRED. COMPLETE THE MISSING INFORMATION AND RESUBMIT YOUR CLAIM. CLAIM DENIED. DRUG QUANTITY BILLED FOR ESTABLISHED MINIMUM/MAXIMUM QUANTITIES. CLAIM DENIED. DRUG DAYS SUPPLY MISSING OR INVALID. CLAIM DENIED. NDC IS RATED DESI FOR CLAIM DATE OF SERVICE. ACKNOWLEDGMENT FORM MISSING ACKNOWLEDGEMENT FORM INVALID/INCOMPLETE CLAIM DENIED. NDC IS TERMINATED OR OBSOLETE. CLAIM\DETAIL IS DENIED. THE MEMBER IS IN A NURSING FACILITY ON THE DATE OF SERVICE CLAIM DETAIL DENIED. ANCILLARY SERVICES NOT AUTHORIZED BY THE PRO. CLAIM DENIED. SUBMITTED LEVEL OF CARE SERVICES NOT AUTHORIZED BY THE PRO. MODIFIER INVALID FOR PROCEDURE CODE BILLED CLAIM DENIED. OUTPATIENT HOSPITAL CLAIMS FOR MORE THAN 2 DAYS ARE NOT ALLOWED. CLAIM DENIED. OUTPATIENT HOSPITAL CLAIMS FOR MORE THAN TWO DAYS ARE NOT ALLOWED. PAPER CLAIM REQUIRED. SUBMIT WITH REPORT/ATTACHMENT IF INDICATED. CLAIM/DETAIL DENIED. THE NON-COVERED AMOUNT CANNOT BE GREATER THAN THE BILLED AMOUNT. EPSDT SPECIAL SERVICES/SCHOOL BASED HEALTH SERVICES CLAIMS NOT PAYABLE FOR THIS MEMBER CLAIM/DETAIL DENIED. SCREENING PROCEDURE CODE INVALID FOR MEMBERS AGE. CLAIM/DETAIL DENIED. THE DETAIL DATES OF SERVICE ARE NOT EQUAL TO OR WITHIN THE HEADER DATES OF SERVICE. CONSENT FORM INVALID. YOU MAY CORRECT ANY ITEM ON THE FORM EXCEPT SIGNATURE AND DATE OF PATIENT/PERSON OBTAINING CONSENT AND INTERPRETER. CLAIM DENIED. A PRESCRIPTION CAN ONLY BE BILLED 12 TIMES. CLAIM DENIED. THIRD PARTY LIABILITY AMOUNT IS EQUAL TO MEDICARE PAID AMOUNT OR GREATER THAN HEADER COINSURANCE PLUS HEADER DEDUCTIBLE. THIS SERVICE WAS NOT PAID BY MEDICARE. MEDICAID PAYMENT CAN ONLY BE MADE FROM A PAID MEDICARE EOMB. CLAIM DENIED. A NINE-BYTE, ALL-NUMERIC TAX ID-NUMBER MUST BE ENTERED IN THE PATIENTS ACCOUNT NUMBER FIELD ON THE CLAIM. CLAIM DENIED. DISPROPORTIONATE SHARE HOSPITAL CLAIMS WHICH SPAN A MEMBERS 6TH BIRTHDAY MUST BE SPLIT BILLED. CLAIM/DETAIL DENIED. VENIPUNCTURE AND ARTERIAL PUNCTURE NOT ALLOWED ON SAME DATE OF SERVICE AS OTHER MONITORED PROCEDURES. CLAIM/DETAIL DENIED. THIS SERVICE NOT PAYABLE ON THE SAME DATE OF SERVICE AS VENIPUNCTURE AND ARTERIAL PUNCTURE. CLAIM DENIED. THE CLINIC NUMBER MUST BE ENTERED. DETAIL DENIED. A VALID 5-DIGIT MODIFIER MUST BE ENTERED. CLAIM/DETAIL DENIED. ANESTHESIA LIMITED TO ONE PER MEMBER PER PROVIDER PER DATE OF SERVICE. CLAIM/DETAIL DENIED. MEMBER HAS THIRD PARTY LIABILITY (MEDICARE REPLACEMENT POLICY) COVERAGE ON FILE.

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EOB (Explanation of Benefits) Codes and Description

EOB Code

0931 0932 0933 0935 0936 0937 0938 0939 0941 0942 0943 0944 0945 0946 0947 0948 0949 0950 0951 0952 0953 0954 0955 0956 0957 0958 0959 0960 0961 0962 0963 0964 0965 0966 0967 0968 0969 0970 0971 0972

EOB Description

CLAIM DENIED. COMPOUND CODE MISSING OR INVALID. CLAIM/DETAIL DENIED. ONE DIALYSIS SERVICE ALLOWED PER RECIPIENT, PER PR CLAIM DENIED. UNIT DOSE INDICATOR MISSING OR INVALID. DRUG INCOMPATABILITY ALERT CLAIM DENIED. MEMBER IN ANOTHER INSTITUTIONAL SETTING DURING THE SAME DATE(S) OF SERVICE. CLAIM DENIED. PRESCRIPTION NUMBER REFILL DATE IS GREATER THAN ONE YEAR OLD. CLAIM/DETAIL DENIED. MAXIMUM OF TEN NON-HOSPITAL RESERVE DAYS ALLOWED CLAIM/DETAIL DENIED. MAXIMUM OF 14 HOSPITAL RESERVE DAYS ALLOWED PER CLAIM DENIED. CURRENT PROVIDER LICENSE NOT ON FILE. CLAIM DENIED. REVENUE CODE 129 IS NOT VALID WITH ANY OTHER ACCOMMODATION REVENUE CODE. CLAIM/DETAIL DENIED. FRAMES OR COMPONENTS OF FRAMES ARE LIMITED TO 2 LOW DOSE ALERT HIGH DOSE ALERT LATE REFILL MINIMUM DURATION ALERT MAXIMUM DURATION ALERT DRUG ALLERGY ALERT CLAIM DENIED. THIS SERVICE IS NOT PAYABLE FOR PSYCHIATRIC RESIDENTIAL TREATMENT FACILITY MEMBERS. THIS SERVICE IS NOT COVERED BY MEDICAID REIMBURSEMENT FOR THIS SERVICE IS INCLUDED IN THE TOTAL PAYMENT AMOUNT CONSENT FORM INCOMPLETE. YOU MAY COMPLETE ANY ITEM ON FORM EXCEPT, SIGNATURE AND DATE OF PATIENT PERSON OBTAINING CONSENT AND INTERPRETER. CLAIM DETAIL DENIED. THE PROCEDURE CODE MODIFIER IS MISSING OR INVALID. CLAIM/DETAIL DENIED. PROVIDER SPECIALITY INVALID FOR MODIFIER GT. THIS PROFESSIONAL CANNOT BILL THIS PROCEDURE CODE CMHC PROCEDURES X0054 OR X0152 PAYABLE ONLY WHEN BILLED WITH ANOTHER CMHC PROCEDURE CODE EFFECTIVE WITH DATES OF SERVICE ON OR AFTER 07-01-93, A FIVE DIGIT MODIFIER MUST BE BILLED ON COMMUNITY MENTAL HEALTH CENTER CLAIMS. PRIOR ADVERSE DRUG REACTION THIS REVENUE CODE IS NOT PAYABLE WHEN BILLED WITH ALL INCLUSIVE ACCOMMODATION REVENUE CODE 100. CHARGES MOVED TO NON-COVERED. THIS REVENUE CODE IS NOT PAYABLE WHEN BILLED WITH ALL INCLUSIVE REVENUE CODE 101 AND ALL INCLUSIVE ANCILLARY REVENUE CODE 240. CHARGES MOVED TO NON-COVERED. PREGNANCY ALERT. DRUG/GENDER ALERT CLAIM DENIED. PSYCHIATRIC RESIDENTIAL TREATMENT FACILITY SERVICES ARE NOT PAYABLE TO MEMBERS OVER AGE 21. CLAIM DENIED. CHILDRENS TARGETED CASE MANAGEMENT SERVICES ARE NOT PAYABLE TO MEMBERS OVER AGE 20. CLAIM DENIED. ADULT TARGETED CASE MANAGEMENT SERVICES ARE NOT PAYABLE TO MEMBERS UNDER AGE 18. CLAIM DENIED. REIMBURSEMENT FOR THIS REVENUE CODE IS LIMITED TO TWO UNITS OF SERVICE PER DAY. CLAIM DENIED. REIMBURSEMENT FOR THIS REVENUE CODE IS LIMITED TO ONE UNIT OF SERVICE PER DAY. THIS PROCEDURE CODE REQUIRES THE ENTRY OF A VALID QUADRANT CODE IN THE TOOTH NUMBER FIELD THIS PROCEDURE REQUIRES THE ENTRY OF A VALID ARCH CODE IN THE TOOTH NUMBER FIELD LITER FLOW PER MINUTE AND/OR NUMBER OF HOURS MISSING OR INVALID CLAIM DENIED. PROCEDURE CODES FOR MILEAGE, OXYGEN AND SUPPLIES MUST MATCH THE BASE RATE CATEGORY.

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EOB (Explanation of Benefits) Codes and Description

EOB Code

0973 0974 0975 0976 0977 0978 0979 0980 0981 0982 0984 0985 0986 0987 0988 0989 0990 0992 0993 0994 0996 0997 0998 0999 1000 1001 1002 1003 1006 1010 1011 1018 1020 1021 1022 1023 1024 1025 1026 1027 1028 1029 1030 1031 1032

EOB Description

PIN RETENTION THERAPY IS LIMITED TO ONE TOOTH PER DETAIL DUPLICATE TOOTH NUMBERS ARE NOT ALLOWED ON THE SAME DETAIL FOR GINGIVECTOMY PROCEDURE UNITS MUST EQUAL NUMBER OF TEETH PER DETAIL FOR PROCDURE GINGIVECTOMY PROCEDURE PIN RETENTION THERAPY IS LIMITED TO PERMANENT MOLARS ONLY TYPE OF BILL INVALID FOR PROVIDER TYPE CLAIM DENIED. ONLY ONE BASE RATE PROCEDURE CODE ALLOWED PER CLAIM. CLAIM DENIED. EMERGENCY TRANSPORTATION CLAIMS WITH DATES OF SERVICE ON OR AFTER 7/1/95 MUST BE SUBMITTED ON PAPER. COPAY FOR THIS SERVICE IS ADDITIVE. THE COPAY AMOUNT WAS CREDITED TO CLAIM DENIED. PAPER BILLING ONLY ALLOWED FOR MEMBERS IN CERTAIN COUNTIES, FOR CERTAIN PROCEDURE CODES, FOR DOS AFTER 11/30/02. CLAIM/DETAIL DENIED. VACCINE PROCEDURE CODE MUST BE BILLED USING MODIFIER 26 FOR ADMINISTRATION TO INDICATE VACCINE OBTAINED FROM PRIVATE SOURCE. MEDICARE EOMB DOES NOT INDICATE THAT COINSURANCE AND DEDUCTIBLE AMOUNTS ARE DUE. DETAIL DENIED. THIS PROCEDURE LIMITED TO TWO UNITS OF SERVICE. DETAIL DENIED. PROCEDURE CODE A0420 MUST ALSO BE BILLED WHEN AN EXTRA MILEAGE PROCEDURE CODE IS BILLED WITH A ROUND TRIP PROCEDURE CODE. DETAIL DENIED. PROCEDURE CODES A0070 AND A0422 LIMITED TO 1 UNIT OF SERVICE IF BASE RATE INDICATES ONE WAY TRIP. HEADER MEDICARE ALLOWED AMOUNT IS NOT EQUAL TO THE SUM OF THE DETAIL MEDICARE ALLOWED AMOUNTS CLAIM/DETAIL DENIED. RETURN MILEAGE NOT PAYABLE WHEN BILLING FOR ONE WAY TRIP. DETAIL DENIED. SERVICES NOT PAYABLE BEYOND THE MONTH OF THE MEMBERS THIRD BIRTHDAY. DETAIL DENIED. PROCEDURE CODE INVALID FOR PROVIDER TYPE 13. CLAIM/DETAIL DENIED. SERVICES NOT PAYABLE ON SAME DATE OF SERVICE AS AIR AMBULANCE. CLAIM/DETAIL DENIED. MILEAGE PROCEDURE CODES NOT PAYABLE SAME DATE OF SERVICE AS ADDITIONAL PASSENGER PROCEDURE CODES. NUMBER OF STUDENTS IN GROUP MISSING OR INVALID CLAIM PAID ZERO DUE TO INVALID PRESCRIBER LICENSE NUMBER. PLEASE RESUBMIT AN ADJUSTMENT WITH CORRECTED VALID PRESCRIBER LICENSE NUMBER. CLAIM TEMPORARILY SUSPENDED UNTIL NEW FEE UPDATE IS IMPLEMENTED PENDING FOR REVIEW INDIVIDUAL/BILLING PROVIDER(GROUP)/NPI NUMBER(S) BILLED INCORRECTLY OR NOT ON FILE. THERAPY NOT COVERED FOR RECIPIENTS UNDER 21 YEARS OF AGE PRESCRIBER NOT ACTIVE APD GATEKEEPER ADJUSTMENT FACILITY PROV NOT ELIG AT SERV LOC FOR PROG BILLED RENDERING PROVIDER NOT A MEMBER OF BILLING GROUP SYSTEM ERROR NO PRICING SEGMENT FOR LEVEL OF CARE SURGERY DATE AFTER BILLING DATE SURGERY DATE AFTER BILLING DATE SURGERY DATE AFTER BILLING DATE SURGERY DATE AFTER BILLING DATE SURGERY DATE AFTER BILLING DATE SURGERY DATE AFTER BILLING DATE SURGERY DATE AFTER BILLING DATE FIRST SURGICAL PROCEDURE CODE NOT ON FILE SECOND SURGICAL PROCEDURE NOT ON FILE THIRD SURGICAL PROCEDURE NOT ON FILE 4TH SURGICAL PROCEDURE NOT FOUND 5TH SURGICAL PROCEDURE NOT FOUND 6TH SURGICAL PROCEDURE NOT FOUND

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EOB (Explanation of Benefits) Codes and Description

EOB Code

1033 1034 1036 1037 1038 1039 1043 1050 1052 1053 1054 1055 1058 1059 1060 1061 1062 1063 1064 1065 1066 1067 1069 1070 1071 1072 1073 1074 1075 1076 1077 1079 1080 1081 1082 1083 1084 1085 1086 1090 1091 1092 1093 1094 1095 1096 1097 1098 1099 1100

EOB Description

FIRST SURGERY DATE (FIELD 80) NOT WITHIN (STATEMENT COVERS PERIOD) DATE SPAN (FIELD 6) SECOND SURGERY DATE (FIELD 81) NOT WITHIN (STATEMENT COVERS PERIOD) DATE SPAN (FIELD 6) 4TH SURGERY DATE/STAY CONFLICT FACILITY PROVIDER ID NOT ON FILE 5TH SURGERY DATE/STAY CONFLICT 6TH SURGERY DATE/STAY CONFLICT CLAIM HAS BEEN REVIEWED. REFER TO EOB CODES 1901 - 1940 FOR DENIAL REASON. SERVICE NOT REFERRED BY PRIMARY CARE CASE MANAGER DEPT OF HEALTH LICENSE NUMBER IS MISSING TAXONOMY CODE INVALID FOR PERFORMING PROVIDER DPR NUMBER IS NOT ON FILE DTL REFERRING PROV NOT ON FILE NO PAY TO PROVIDER RECORD FOR CROSSOVER CLAIM THIS SERVICE IS NOT A VALID ENCOUNTER UNLESS BILLED BY THE PCP/CM NO RENDERING PROVIDER FOR CROSSOVER CLAIM FILE INDICATES YOU ARE ENROLLED AS AN IN-STATE, NON-PARTICIP PROVIDER. CLAIM WAS REVIEWED. SRVS DEEMED NON-EMERGENCY AND NON-COVERED. FIRST SURGICAL PROCEDURE INVALID FOR RECIPIENT SEX SECOND SURGICAL PROCEDURE INVALID FOR RECIPIENT SEX THIRD SURGICAL PROCEDURE INVALID FOR RECIPIENT SEX 4TH SURGICAL PROCEDURES/SEX CONFLICT 5TH SURGICAL PROCEDURES/SEX CONFLICT 6TH SURGICAL PROCEDURES/SEX CONFLICT PROVIDER NOT AUTHORIZED TO TAPE BILL FIRST SURGICAL PROCEDURE CODE NOT ON FILE SECOND SURGICAL PROCEDURE NOT ON FILE THIRD SURGICAL PROCEDURE NOT ON FILE 4TH SURGICAL PROCEDURE NOT FOUND 5TH SURGICAL PROCEDURE NOT FOUND 6th SURGICAL PROCEDURE NOT FOUND PROVIDER TYPE NOT ON TPL MATRIX RECIPIENT IS UNDER REVIEW. POSSIBLE PA FOR TRANSPLANT SERVICE DIAGNOSIS NOT SPECIFIC RECIPIENT SEX ON FILE INCOMPATIBLE W/PRIMARY DIAG - IF BABY AND MOTHER INVOLVED, MAKE SURE YOU DID NOT USE BABY DIAG FOR MOTHER OR VICE VERSA RECIPIENT SEX ON FILE INCOMPATIBLE W/PRIMARY DIAG - IF BABY AND MOTHER INVOLVED, MAKE SURE YOU DID NOT USE BABY DIAG FOR MOTHER OR VICE VERSA THIRD DIAGNOSIS CODE INVALID FOR RECIPIENT SEX FOURTH DIAGNOSIS CODE INVALID FOR RECIPIENT SEX FIFTH DIAGNOSIS CODE INVALID FOR RECIPIENT SEX CLAIM MUST BE PROCESSED THROUGH THE PSN CLAIM MUST BE PROCESSED THROUGH PSN 1ST SURGICAL PROCEDURE DATE IS MISSING OR ZEROS 2ND SURGICAL PROCEDURE DATE IS MISSING OR ZEROS 3RD SURGICAL PROCEDURE DATE IS MISSING OR ZEROS 4TH SURGICAL PROCEDURE DATE INVALID 5TH SURGICAL PROCDURE DATE INVALID 6TH SURGICAL PROCEDURE DATE INVALID OCCUR SPAN TO DATE MISSING OCCURRENCE SPAN FROM DATE MISSING MISSING OCCURRENCE SPAN CODE AND DATES OCCUR SPAN FROM DATE MISSING REFERRING PROVIDER NUMBER REQUIRED

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EOB (Explanation of Benefits) Codes and Description

EOB Code

1101 1102 1103 1106 1112 1129 1130 1131 1132 1136 1137 1138 1139 1140 1143 1144 1145 1146 1147 1148 1149 1150 1152 1153 1154 1155 1156 1157 1158 1159 1160 1161 1162 1163 1164 1165 1166 1167 1168 1169 1170 1171 1172 1173 1174 1175 1176 1177 1178

EOB Description

OCCUR SPAN FROM DATE MISSING NURSING HOME PROVIDER NOT ALLOWED TO BILL REVENUE CODES MID-MONTH RATE CHANGE THIS GLOBAL CPT-4 PROCEDURE HAS BEEN ADDED TO MORE ACCURATELY REFLECT THE SERVICE PERFORMED. THE BILLED AMOUNT FOR THIS PROCEDURE WAS CALCULATED. DETAIL DENIED. THE PROCEDURE BILLED HAS BEEN REBUNDLED TO A GLOBAL CPT-4 CODE THAT MORE ACCURATELY REFLECTS THE SERVICE THAT WAS PERFORMED. DETAIL DENIED. PROCEDURE BILLED WAS PERFORMED WITH A PRIMARY PROCEDURE. IT IS CONSIDERED PART OF PRIMARY PROC. OCCUR SPAN TO DATE MISSING OCCUR SPAN TO DATE MISSING OCCURRENCE SPAN TO DATE IS MISSING RECIPIENT AGE ON FILE INCOMPATIBLE W/PRIMARY DIAG - IF BABY AND MOTHER INVOLVED, MAKE SURE YOU DID NOT USE BABY DIAG FOR MOTHER OR VICE VERSA RECIPIENT AGE ON FILE INCOMPATIBLE W/2ND DIAG - IF BABY AND MOTHER INVOLVED, MAKE SURE YOU DID NOT USE BABY DIAG FOR MOTHER OR VICE VERSA THIRD DIAGNOSIS CODE CONFLICTS WITH AGE LIMITATIONS FOURTH DIAGNOSIS CODE CONFLICTS WITH AGE LIMITATIONS FIFTH DIAGNOSIS CODE CONFLICTS WITH AGE LIMITATIONS KICK PAY-TO-PROVIDER AND SERV PROV ERR PROCEDURE NOT COMPATIBLE WITH PROV TYPE, PROCEDURE CANNOT BE BILLED ON THE CLAIM FORM USED OR NEW ANESTH CODE CONFLICTS WITH MODIFIER OR DOS FIRST DIAGNOSIS CODE NOT COVERED SECOND DIAGNOSIS NOT COVERED THIRD DIAGNOSIS CODE NOT COVERED FOURTH DIAGNOSIS CODE NOT COVERED FIFTH DIAGNOSIS CODE NOT COVERED PROV/PROC CODE MODIFIER/PLACE OF SERV CONFLICT. POST WITH ASC MOD 73 OR 74 CREDIT/ADJUSTMENT REQUIRES TCN NO MATCH ON RECIPIENT ID NO MATCH ON PROVIDER NUMBER CLAIM HAS ALREADY BEEN CREDITED/ADJUSTED ELECTRONIC ADJUSTMENT/VOID ADJUSTING A DENIED CLAIM CLAIM NOT ON HISTORY CANNOT ADJUST A CREDIT FIRST DIAGNOSIS IS SUB-CLASSIFIED SECOND DIAGNOSIS IS SUB-CLASSIFIED THIRD DIAGNOSIS IS SUB-CLASSIFIED FOURTH DIAGNOSIS IS SUB-CLASSIFIED FIFTH DIAGNOSIS IS SUB-CLASSIFIED SIXTH DIAGNOSIS IS SUB-CLASSIFIED SEVENTH DIAGNOSIS IS SUB-CLASSIFIED EIGHTH DIAGNOSIS IS SUB-CLASSIFIED NINTH DIAGNOSIS IS SUB-CLASSIFIED 10TH - 24TH DIAGNOSIS IS SUB-CLASSIFIED SIXTH DIAGNOSIS CODE NOT COVERED FIRST SURGICAL PROCEDURE NOT COVERED SECOND SURGICAL PROCEDURE NOT COVERED THIRD SURGICAL PROCEDURE NOT COVERED 4TH SURGICAL PROCEDURE NOT COVERED 5TH SURGICAL PROCEDURE NOT COVERED 6TH SURGICAL PROCEDURE NOT COVERED FIRST SURGICAL PROCEDURE NOT BILLED SECOND SURGICAL PROCEDURE NOT BILLED THIRD SURGICAL PROCEDURE NOT BILLED

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EOB (Explanation of Benefits) Codes and Description

EOB Code

1179 1180 1181 1182 1183 1184 1185 1186 1187 1200 1201 1202 1600 1601 1602 1603 1901 1902 1903 1904 1905 1906 1907 1908 1909 1910 1911 1912 1913 1914 1915 1916 1921 1922 1923 1937 1938 1938 1939 1941 1950 1951 1990 1995 1996 1997 1999 2000 2001 2002 2003 2004 2005

EOB Description

4TH SURGICAL PROCEDURE NOT BILLED 5TH SURGICAL PROCEDURE NOT BILLED 6TH SURGICAL PROCEDURE NOT BILLED FIRST DIAGNOSIS CODE NOT BILLED SECOND DIAGNOSIS NOT BILLED THIRD DIAGNOSIS CODE NOT BILLED FOURTH DIAGNOSIS CODE NOT BILLED FIFTH DIAGNOSIS CODE NOT BILLED SIXTH DIAGNOSIS CODE NOT BILLED PAY TO PROVIDER NUMBER IS NOT A GROUP PAY TO PROVIDER IS INACTIVE. CONTACT PROVIDER ENROLLMENT FOR INSTRUCTIONS X-OVER CLAIM TYPE NOT ALLOWED FOR PROVIDER TYPE INVALID GROUP NUMBER TPL IS INDICATED ON FILE, BUT DID NOT APPEAR ON CLAIM. YOUR CLAIM WAS DENIED AFTER AHCA REVIEW OF THE CLAIM AND ITS ATTACHMENT(S) TREATING PROVIDER IS A GROUP PROV PROVIDER NOT AUTHORIZED TO TAPE BILL ABORTION CERTIFICATE INVALID CONSENT FORM MISSING CONSENT FORM INCOMPLETE CONSENT FORM INVALID ACKNOWLEDGEMENT FORM MISSING ACKNOWLEDGEMENT FORM INVALID/INCOMPLETE INCIDENTAL PROCEDURE NOT COVERED PROCEDURE REQUIRES REVIEW REPORT CLAIM REQUIRES DOCUMENTATION PROCEDURE CODE/DESCRIPTION CONFLICT REPORT NOT ELIGIBLE DENIED AFTER MEDICAL REVIEW ABORTION CERTIFICATE MISSING HARD COPY CLAIM REQUIRED DIALYSIS STATEMENT MISSING INSUFFICIENT PRICING INFORMATION DENIED AT PROVIDERS REQUEST CLAIM BILLED WITH WRONG PROVIDER NUMBER NO RATE SHEET INCLUDED PERFORMING PROVIDER ID NOT ON FILE PRA FORM MISSING REFERRING PROVIDER NUMBER IS MISSING OR INVALID PRA FORM INVALID/INCOMPLETE OTHER PROVIDER ID NOT ON FILE PROCEDURE INCLUDED IN BUNDLED RATE HCPC IS REQUIRED OUT-STATE PROV NON-PARTICIPATING PERFORMING, FACILITY, DISPENSING PROV ID IN OLD FORMAT THE RENDERING PROVIDER IS NOT ENROLLED IN THE MEDICAID PROGRAM THIS CLAIM WAS BILLED WITH AN OLD RENDERING PROV NUMBER. PLEASE RESUBMIT WITH AFTER AHCA REVIEW OF THE CLAIM AND ITS ATTACHMENT(S) THE CURRENT PROVIDER NUMBER. BILLING PROVIDER ID SUMITTED UNDER OLD FORMAT RECIPIENT HAS OPTED OUT OF MEDICAID COVERAGE SURGICAL PROCEDURE CONFLICTS WITH AGE LIMITATIONS MEMBER NOT ELIGIBLE FOR HEADER DATE OF SERVICE MEMBER INELIGIBLE ON DETAIL DATE OF SERVICE PROCEDURE INCLUDED IN COMBINED PROCEDURE NO CASH PAYMENT FOR HCBS

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EOB (Explanation of Benefits) Codes and Description

EOB Code

2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033 2034 2035 2036 2037 2038 2039 2040 2041 2042 2043 2044 2045 2046 2047 2048 2049 2050 2051 2052 2053 2054 2055 2056 2057 2058 2059

EOB Description

RX-EXCEEDS DAYS SUPPLY LIMIT/REQUIRES PA PA NOT AUTHORIZED FOR DRUG THERCLASS 46 AND 47 EXCEEDS EMERGENCY ROOM VISITS FOR THIS DATE MEMBER INELIGIBLE ON DATE OF SERVICE NEWBORN OCCURRENCE CODE MISSING. WHEN ADMIT AND BIRTH DATES ARE EQUAL AND THE NEWBORNS LENGTH OF STAY EXCEEDS THE MOTHERS - USE OCCUR CODE 42. MATERNITY CLINIC/PHY CONFLICT FOR PRENATAL SERVICE MAXIMUM CRITICAL CARE VISITS EXCEEDED EXCEEDS 9 MO LIMIT FOR THIS LEVEL PRENATAL CARE EXCEEDS MONTHLY CLINIC VISIT LIMITS SCHOOL BASED YEARLY LIMIT EXCEEDED LIMIT OF HH VISITS HAS BEEN EXCEEDED FOR 1 YEAR LIMIT FOR CHMC SERVICE HAS BEEN EXHAUSTED DIABETIC SUPPLIES LIMITS EXCEEDED 12 MONTH LIMIT FOR THIS DENTAL SERVICE IS EXCEEDED YEARLY LIMIT FOR EYE GLASSES EXCEEDED 12 MONTH LIMIT FOR THIS DENTAL SERVICE IS EXCEEDED A CONFLICTING SERVICE HAS BEEN PAID FOR THIS DATE DEALER LIMITS EXCEEDED OTHER FED QUAL HEALTH CENTER SERV PAID THIS DATE EXCEEDS EARLY INTERVENTION SERVICES LIMITS EXCEEDS EPSDT CLINIC LIMITS EXCEEDS OB ULTRASOUND LIMIT FOR 9 MONTHS EXCEEDS NUTRITIONAL SERVICE FOR YEAR EXCEEDS HOME COM BASED WAIVERED SERVICE LIMITS SAME SERV WITH 91/92 HCPC HAS BEEN PAID THIS DATE EXCEPTION CODE 031 MAXIMUM RENTAL PAYMENT HIGHER CEREBRAL FUNCTION PREVIOUSLY PAID IN 12 MTS EXCEEDS YEARLY EARLY INTERVENTION CASE MAN LIMITS THE 2 PHY VISIT PER MONTH LIMIT HAS BEEN EXCEEDED ADDITIONAL HOURS OF TESTING REQUIRE PRIOR AUTHORIZATION MAXIMUM PAYMENT MADE EXCEEDS OXYGEN LIMITS-ONE PER MONTH TARGETED ULTRASOUND/AMNIOCENTISIS REVIEW THE MAMMOGRAM LIMIT HAS BEEN EXCEEDED EXCEPTION CODE 041 EXCEEDS ONCE PER MONTH LIMIT ONE NEWBORN EXAM HAS BEEN PAID FOR THIS CHILD PREVIOUSLY PAID-VISIT OR W3011-THIS DATE OF SERV. EXCEPTION CODE 045 EXCEPTION CODE 046 EXCEED PART A SKILLED NURSING FACILITY COINS LIMIT CONFLICTING DENTAL SERVICE SAME DAY EXCEEDS PSYCHOLOGICAL LIMIT PER MONTH EXCEPTION CODE 050 EXCEEDS 2 VISIT LIMIT NO LTC STAFFING SUBMITTED FOR SERVICE MONTH LTC EMC CLAIM INVALID WHEN STAFFING IS SENT PAPER PCS INELIGIBLE FOR CATEGORY OF SERVICE 2 RURAL HEALTH VISITS PER MONTH HAS BEEN EXCEEDED TRIGGER POINT INJECTION LIMIT HAS BEEN EXCEEDED OUTPATIENT MENTAL HEALTH LIMITS EXCEEDED YEARLY ASSISTATIVE TECHNOLOGY LIMIT EXCEEDED EXCEPTION CODE 059

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EOB (Explanation of Benefits) Codes and Description

EOB Code

2060 2061 2062 2063 2064 2065 2066 2067 2068 2069 2070 2071 2072 2073 2074 2075 2076 2077 2078 2079 2080 2081 2082 2083 2084 2085 2086 2087 2088 2089 2090 2091 2092 2094 2095 2096 2097 2098 2099 2100 2101 2103 2104 2105 2106 2110 2112 2114 2115 2116 2117 2118 2119 2120 2121

EOB Description

EXCEPTION CODE 060 EXCEPTION CODE 061 EXCEPTION CODE 062 EXCEPTION CODE 063 EXCEPTION CODE 064 EXCEPTION CODE 065 EXCEPTION CODE 066 EXCEPTION CODE 067 EXCEPTION CODE 068 EXCEPTION CODE 069 2 NURSING HOME VISITS PREVIOUSLY PAID THIS MONTH THIS SERV HAS BEEN PREVIOUSLY PAID FOR THIS MEMBER PREVIOUSLY PAID VISUAL EXAM IN 12 MONTHS EXCEPTION CODE 073 PREVIOUSLY PAID 3 PAP SMEARS IN 12 MONTHS EXCEPTION CODE 075 EXCEEDS YEARLY FAMILY PLANNING EXAM LIMIT EXCEPTION CODE 077 PREVIOUSLY PAID ONE VISIT ON THIS DAY EXCEPTION CODE 079 PREVIOUSLY PAID AUDITORY EXAM IN 12 MONTHS CHILDRENS DAYS EXCEEDED CHILDRENS DAYS EXHAUSTED CHILDRENS VISITS EXCEEDED CHILDRENS VISITS EXHAUSTED CHILDREN DAYS EXCEEDED FOR FISCAL YEAR PA REQUIRED CHILDREN DAYS EXCEEDED FOR FISCAL YEAR PA REQUIRED TB DRUG EXCEPTION CODE 088 EXCEPTION CODE 089 PCS - 1500 RECIPIENT SERVICES COVERED BY HMO PLAN ALIEN-NO REQUEST FOR AUTHORIZATION RECEIVED PROVIDER SPECIALTY REQUIRES THE BENEFICIARY BE ELIGIBLE FOR WAIVER RELATED PROC REVIEW INVALID CARRIER DENIED BATCH DDSD HAS DENIAL/SUSPEND EDIT COVERED IN PER DIEM HCBW WAIVER HAS DENY/SUSPEND EDIT MANUALLY SUSPEND FOR HCA RECIPIENT INELIGIBLE FOR MEDICAID ONLY SERVICES ADP WAIVER HAS DENY/SUSP EDIT PROCEDURE NOT COVERED WITH THIS PLACE OF SERVICE INVALID PROVIDER SPECIALTY FOR PROCEDURE INVALID DIAGNOSIS FOR PROCEDURE MEMBER NAME IS MISSING PCS CLAIM - MEMBER NOT PCS ELIGIBLE MISSING TOTAL CHARGE FOR NURSING HOME CLAIMS OUTPT HSP PRIOR TO 12/01/99-SUSPEND FOR REVIEW VISIT WITHIN NORMAL SURGERY FOLLOW-UP PERIOD EXCEPTION CODE 116 2 YEAR RESUBMISSION DEADLINE EXCEEDED DISCHARGE DATE IS LESS THAN ADMIT DATE DISCHARGE DATE IS LESS THAN LAST DATE OF SERVICE VISIT PAID IN NORMAL SURGERY FOLLOW-UP PERIOD CLAIM WAS FILED WITHOUT SERVICING PROVIDER

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EOB (Explanation of Benefits) Codes and Description

EOB Code

2122 2123 2124 2125 2126 2127 2128 2129 2130 2132 2133 2134 2136 2138 2140 2141 2142 2143 2144 2146 2148 2149 2150 2151 2152 2153 2154 2155 2156 2160 2163 2166 2167 2168 2170 2172 2173 2174 2175 2176 2178 2179 2180 2181 2182 2183 2184 2185 2186 2187 2189 2190 2191 2192 2193

EOB Description

INVALID/MISSING PROVIDER CHECK-DIGIT NUMBER INVALID/MISSING PAY-TO PROVIDER CHECK-DIGIT NUMBER MISSING FIRST DATE OF SERVICE ON CLAIM ONE YEAR TIMELY FILING DEADLINE EXCEEDED-FED REG FIRST DATE OF SERV GREATER THAN LAST DATE OF SERV DATE RECEIVED FOR PROCESSING-PRIOR TO DATE OF SERV DATE OF ACCIDENT IS GREATER THAN LAST DATE OF SERV MISSING MEMBER ID NUMBER ON CLAIM EXCEPTION CODE 130 MISSING TOTAL CLAIM CHARGE INVALID TOTAL CLAIM CHARGE INVALID NET CLAIM CHARGE MISSING/INVALID REVENUE CODE MISSING/INVALID TYPE OF BILL HCPC CODE IS INVALID FOR REVENUE CODE TOTAL DAYS LESS THAN COVERED DAYS 1 YR TIMELY FILE HAS BEEN OVERRIDDEN-TF ATTACHED REFILLS EXHAUSTED INVALID REFILL INDICATOR VALUE HCPC/REVENUE CODE MISSING PROCEDURE NOT PAYABLE THIS MEMBER PROC REQUIRES REVIEW CATEGORICALLY NEEDY MEMBER UNITS OF SERVICE ARE LESS THAN PROC ALLOWED UNITS MISSING PRESCRIBING PROVIDER NUMBER MISSING DRUG CODE INVALID DRUG CODE MISSING PRESCRIPTION NUMBER MISSING DRUG QUANTITY MISSING DAYS SUPPLY MISSING DIAGNOSIS INDICATOR MISSING DIAGNOSIS CODE MEMBER ELIGIBILITY PENDING DHS APPROVAL INVALID PATIENT STATUS INVALID SOURCE OF ADMISSION INVALID PLACE OF SERVICE CLAIM REQUIRES HCPC OR CPT-4 CODE ADMIT DATE GREATER THAN FIRST DATE OF SERVICE UNITS CANNOT BE LESS THAN DAYS SURGICAL PROCEDURE MISSING MEMBER NOT ON FILE PAY FROM STATE FUNDS PROCEDURE REQUIRES PRIOR AUTHORIZATION MISSING TOOTH SURFACE INVALID TOOTH NUMBER INVALID TOOTH SURFACE MISSING TOOTH NUMBER MISSING UNITS OF SERVICE MISSING CHARGE LTC MISSING ADMISSION DATE INVALID ADMISSION HOUR PROCEDURE NOT PAYABLE THIS MEMBER PROCEDURE REQUIRES MEDICAL REVIEW PROCEDURE REQUIRES PRIOR AUTHORIZATION ITEM DAYS NOT EQUAL TO COVERED DAYS ON CLAIM TOTAL DAYS ON CLAIM CONFLICT WITH DATES SHOWN MISSING COVERED DAYS

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EOB (Explanation of Benefits) Codes and Description

EOB Code

2194 2196 2197 2198 2199 2200 2201 2202 2203 2204 2205 2206 2207 2208 2209 2210 2213 2214 2215 2216 2222 2223 2224 2226 2227 2228 2230 2231 2233 2234 2235 2236 2237 2238 2239 2240 2241 2242 2244 2247 2249 2250 2252 2253 2254 2258 2259 2260 2262 2263 2265 2266 2268 2270 2271

EOB Description

AGE IS NOT COVERED INPATIENT PSYCHIATRIC SERVICES MISSING ADMISSION DATE INVALID INPATIENT REVENUE CODE MISSING ATTENDING SURGEON PRESCRIBER NUMBER DATE OF SURGERY IS MISSING INVALID TYPE OF ADMISSION PROCEDURE CODE IS NOT IN THE SCOPE OF PROGRAM SUB TYPE REQUIRED FOR THIS DIAGNOSIS CODE CLAIMANT SIGNATURE MISSING PROVIDER SIGNATURE IS MISSING PATIENT NOT CERTIFIED PRESCRIBING PROVIDER NUMBER NOT IN VALID FORMAT INVALID LEVEL OF CARE INVALID PICKUP LOCATION INVALID DESTINATION FACILITY PROVIDER SERVICE LOCATION IS MISSING PREGNANCY INDICATOR INVALID DATE PRESCRIBED IS INVALID DATE DISPENSED IS MISSING DATE DISPENSED IS INVALID MISSING OCCURRENCE DATE SERVICE DATES ARE NOT IN SAME MONTH INVALID OCCURRENCE DATE INVALID CONDITION CODE EXCEPTION CODE 227 MISSING MEDICARE PAID DATE NO CROSSOVER COINSURANCE OR DEDUCTIBLE DUE ESTIMATED DAYS SUPPLY INVALID INSURANCE DENIAL REQUIRED PROCEDURE REQUIRES PRIOR AUTHORIZATION SURGERY DATE CANNOT BE PRIOR TO ADMIT DATE SURGERY DATE CANNOT BE OUTSIDE DATE OF SERVICE FACILITY PROVIDER NOT IN VALID FORMAT ITEMIZED SERVICE DATE NOT IN ELIGIBILITY SPAN INVALID OCCURRENCE CODE THE DETAIL LINE (TO) DATE OF SERVICE IS MISSING XOVER DATA MISSING AT DETAIL LEVEL MISSING OCCURRENCE CODE INVALID PAY-TO PROVIDER NUMBER MAXIMUM NUMBER OF CLAIM DETAILS EXCEEDED CLAIM HAS NO DETAILS MEMBER IS NOT ON ELIGIBILITY FILE MEMBER IS NOT ELIGIBLE ALL DATES OF SERVICES ITEMIZED SERVICE DATE NOT IN ELIGIBILITY SPAN MEMBER NOT IN MANAGED CARE MEMBER IS NOT ON ELIGIBILITY FILE DATE BILLED IS INVALID SLIMB ONLY/NO MEDICAL ELIGIBILITY PROCEDURES NOT PAYABLE TB PROCEDURE REQUIRES REVIEW FOR TB MEMBER CLAIM HAS THIRD-PARTY PAYMENT REFERRING PHYSICIAN NUMBER IS MISSING INVALID PER DIEM AMOUNT INPATIENT TB NOT COVERED MEMBER IS NOT ELIGIBLE ON SERVICE DATE

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EOB (Explanation of Benefits) Codes and Description

EOB Code

2272 2273 2274 2276 2277 2278 2281 2282 2285 2287 2289 2290 2291 2292 2294 2295 2296 2297 2298 2300 2302 2303 2304 2305 2306 2307 2308 2309 2310 2311 2312 2313 2314 2315 2317 2318 2319 2321 2322 2323 2324 2326 2327 2328 2329 2331 2332 2335 2336 2337 2338 2341 2342 2345 2346

EOB Description

ITEMIZED SERVICE DATE NOT IN ELIGIBILITY SPAN SUSPENDED FOR MEMBER REVIEW CLAIM INDICATES MEMBER EXPIRED NEWBORN-HCA REVIEW LTC ELIGIBILITY ERROR DISCHARGE DTE UNEQ TO LTC ELIG ABORTION NOT COVERED PHYSICIAN AUDITOR REVIEW-MODIFIER 24 MEMBER NOT ELIGIBLE FOR DATES OF SERVICE PROCEDURE NOT PAYABLE VR PROCEDURE REQUIRES PRIOR AUTHORIZATION PROCEDURE IS NOT IN THE SCOPE OF THE PROGRAM PROCEDURE REQUIRES MEDICAL REVIEW PROCEDURE REQUIRES PRIOR AUTHORIZATION PROC REQUIRES REVIEW - HCBW PROCEDURE REQUIRES PRIOR AUTHORIZATION PROVIDER INELIGIBLE FOR PROCEDURES PAY TO PROVIDER NOT ELIG FOR PAY-THIS DATE OF SERV PROVIDER NUMBER IS A GROUP NUMBER NO PROVIDER MASTER RECORD DPR NUMBER IS NOT ON FILE PROVIDER IS SUSPENDED OR TERMINATED FOR PROGRAM BILLED PROVIDER INELIGIBLE ON SERVICE DATE REVIEW CLAIMS FOR THIS PROVIDER PAY TO PROVIDER IS SUSPENDED BILLING OUT OF CLIA CERTIFICATE TYPE NO PAY-TO PROVIDER RECORD REVIEW CLAIM FOR PAY-TO- PROVIDER ANESTHESIA MODIFIER IS INVALID OR MISSING SERVICING PROVIDER IS NOT A MEMBER OF PAY TO GROUP PAY-TO PROVIDER NOT ENROLLED DIAGNOSIS CODE MISSING/NOT ON FILE SURGICAL PROCEDURE CODE NOT FOUND INVALID PRINCIPAL/OTHER PROCEDURE TYPE PROCEDURE CODE/MODIFIER CONFLICT PROCEDURE REQUIRES MANUAL PRICING DENTAL PREDETERMINATION OF BENEFITS NOT ALLOWED PROCEDURE CODE IS NO LONGER VALID DATE OF SERVICE BEFORE PROCEDURE IS PAYABLE INVALID MEMBER AGE FOR THIS DIAGNOSIS INVALID MEMBER SEX FOR THIS DIAGNOSIS INVALID TOOTH NUMBER FOR THIS PROCEDURE PROCEDURE REQUIRES ADDITIONAL DOCUMENTATION PROCEDURE NOT IN SCOPE OF PROGRAM FOR THIS AGE INVALID MEMBER SEX FOR THIS PROCEDURE THIS DRUG NOT COVERED FOR THE MEMBER INVALID PROVIDER TYPE FOR THIS PROCEDURE LTC MEMBER - NONCOMP DRUG REFILLS ARE NOT ALLOWED FOR NARCOTIC DRUGS THIS DRUG REQUIRES PRIOR AUTHORIZATION LTC DRUG ONLY THIS DIAGNOSIS REQUIRES MEDICAL REVIEW THIS DIAGNOSIS REQUIRES MEDICAL REVIEW ATTENDING PROVIDER NOT FOUND REFERRING PROVIDER NUMBER NOT ON FILE

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EOB (Explanation of Benefits) Codes and Description

EOB Code

2347 2348 2350 2351 2352 2354 2356 2357 2358 2359 2360 2361 2362 2366 2369 2371 2372 2374 2375 2377 2379 2383 2385 2388 2389 2390 2391 2394 2396 2397 2399 2400 2401 2402 2406 2407 2410 2411 2412 2413 2414 2416 2417 2420 2421 2425 2430 2431 2433 2434 2435 2436 2437 2438 2439

EOB Description

THIS DIAGNOSIS REQUIRES MEDICAL REVIEW THIS DIAGNOSIS REQUIRES MEDICAL REVIEW THE NUMBER OF DETAILS IS NOT EQUAL TO THE SUBMITTED DETAIL COUNT SUBMITTED TO ALLOWED EXCEEDS PERCENT ALLOWED TO SUBMITTED EXCEEDS PERCENT THIS LAB NOT CERTIFIED TO PROVIDE THIS SERVICE NDC IS DEACTIVED AND NOT PAYABLE ON DATE FILLED THIS DRUG REQUIRES PRIOR AUTHORIZATION INACTIVE DRUG THIS DRUG REQUIRES PRIOR AUTHORIZATION THIS NATIONAL DRUG CODE IS NOT ON FILE PROCEDURE CODE IS MISSING/NOT ON FILE MEDICARE DEDUCTIBLE GREATER THAN MAXIMUM THIS DIAGNOSIS REQUIRES REVIEW MEDICARE COINSURANCE GREATER THAN MEDICARE PAID THIS DIAGNOSIS REQUIRES ADDITIONAL DOCUMENTATION ITEM NOT PAYABLE IN LONG TERM CARE FACILITY MISSING PRESCRIBER PROVIDER ON DEALER CLAIM SERVICE NOT ON EXPLANTION OF MEDICARE PAYMENTS MEMBER IS INELIGIBLE FOR THIS DRUG PROCEDURE CODE MODIFIER REQUIRES MANUAL REVIEW MULTIPLE SURGERY REQUIRES REVIEW REVENUE CODE NOT ON FILE IMPROPER MODIFIER FOR CRNA THIS MODIFIER IS ALLOWED FOR CRNA ONLY MULTIPLE EXTRACTION REQUIRES APPROPRIATE PROC CODE INVALID USE OF E DIAGNOSIS CODE VERIFY PCS TPL LOC ON CLAIM CONFLICTS WITH LOC ON FILE INVALID LTC TERMINATION CODE REFERRING PROVIDER ID IS NOT IN A VALID FORMAT INVALID LOC DAYS INVALID LEAVE DAYS INVALID TYPE OF LEAVE LTC LEAVE DATES CONFLICT THERAPEUTIC DAYS GT THAN 14 PA IS REQUIRED THERAPEUTIC DAYS USED EXCEEDS AUTHORIZATION DETAIL DENIED. ONLY ONE DATE OF SERVICE ALLOWED PER DETAIL. LTC BLOCK 13:TOTAL DAYS DO NOT EQUAL FROM/TO DAYS WAIVER SERVICES LONG TERM CARE CONFLICT AMB SERVICES ORIGIN TO DESTINATION NOT IN SCOPE REVIEW AMBULANCE NON ROUTINE DESTINATION THIS DRUG NOT PAYABLE FOR MEMBER AGE THIS DRUG NOT PAYABLE FOR MEMBER SEX THIS PROCEDURE MUST BE BILLED SEPARATELY EACH DATE LTC INVALID MEMBER ID NUMBER LTC NO PROV MASTER RECORD LTC MISSING PROVIDER NUMBER LTC INVALID PROV NUM CK-DIGIT LTC FIRST DATE OF SERVICE MISSING LTC FILING DEADLINE EXCEEDED LTC FIRST DATE GREATER LAST DATE LTC RECHECK SERVICE DATE LTC MISS MEMBER ID NUMBER

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EOB (Explanation of Benefits) Codes and Description

EOB Code

2440 2443 2444 2445 2446 2447 2448 2449 2450 2451 2452 2453 2454 2456 2458 2459 2460 2461 2462 2463 2464 2465 2466 2468 2469 2470 2471 2472 2473 2474 2475 2476 2477 2478 2479 2480 2481 2482 2483 2484 2485 2486 2487 2488 2489 2490 2491 2492 2493 2494 2495 2496 2497 2498 2499

EOB Description

TEST - NO PRICING SEGMENT ON FILE LTC MEMBER NOT ON ELIG FILE LTC MEMBER INELIGIBLE ON SERVICE DATES LTC MEMBER NOT ELIGIBLE ON SERVICE DATES LTC MEMBER SUSPEND FOR REVIEW LTC PROV IS SUSPENDED LTC PROVIDER IS INELIGIBLE ON SERVICE DATES LTC REVIEW CLAIM FOR PROV INVALID QUADRANT LTC INV PROVIDER NUMBER RENDERING PROVIDER SERVICE LOCATION IS MISSING INVALID DIAGNOSIS TREATMENT INDICATOR INVALID ASSIGNMENT CODE INVALID PROCEDURE TYPE ALIEN MEMBER ON REVIEW REVENUE CODES OP401 AND OP403 NEED HCPC CODE CANNOT DETERMINE THE INPATIENT LEVEL OF CARE OCCURENCE CODE SPAN MISSING/INVALID INVALID/MISSING SPAN DATE SPAN THRU DATE LESS THAN SPAN FROM DATE SPAN DATE CONFLICT WITH DATES OF SERVICE SHOWN SPAN DATES OVERLAP SPAN DATES DOES NOT EQUAL TOTAL LINE ITEM DAYS NAME ON CLAIM MUST MATCH DHS IDENTIFICATION LTC MEMBER NAME/ID MISMATCH NAME ON CLAIM MUST MATCH DHS IDENTIFICATION NDC IS DEACTIVED AND NOT PAYABLE ON DATE FILLED NAME ON CLAIM MUST MATCH DHS IDENTIFICATION NAME ON CLAIM MUST MATCH DHS IDENTIFICATION DATE DISPENSED AFTER BILLING DATE DATE DISPENSED AFTER ICN DATE MAXIMUM HOSPITAL DAYS FOR THIS ADULT HAS BEEN PAID THE DIAGNOSIS CODE IN SEQUENCE 10-24 IS IN AN INVALID FORMAT PCS MISSING SUBMITTED CHARGE CLIA OUT OF DATE DDSD/NFM PROVIDER-NOT DDSD/NFM MEMBER DDSD/NFM PROCEDURE - NOT DDSD/NFM MEMBER DDSD/NFM PROCEDURE - NOT DDSD/NFM PROVIDER DDSD/NFM PROVIDER - NOT DDSD/NFM PROCEDURE DDSD SERVICE REQUIRES PRIOR AUTHORIZATION DATE DISPENSED EARLIER THAN DATE PRESCRIBED INPATIENT PSYCHIATRIC NEEDS PRIOR AUTHORIZATION PRIMARY DIAG CODE DETOX/NO DETOX REVENUE CODE ADMIT DATE DOES NOT EQUAL FIRST DATE OF SERVICE NO CLIA - DOS PRIOR TO CLIA EFFECTIVE DATE INPATIENT SERVICES ARE NOT COVERED FOR THIS MEMBER DRUG NOT APPROVED NO CLIA-DOS PRIOR TO CLIA EFFECTIVE DATE NO CLIA-DOS PRIOR TO CLIA EFFECTIVE DATE NO CLIA-DOS PRIOR TO CLIA EFFECTIVE DATE NO CLIA - DOS PRIOR TO CLIA EFFECTIVE DATE NO CLIA-DOS PRIOR TO CLIA EFFECTIVE DATE NO CLIA - DOS PRIOR TO CLIA - EFFECTIVE DATE NO CLIA-DOS PRIOR TO CLIA EFFECTIVE DATE TPL PAY CHASE IMMUNO SUPPRESS DRUG

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EOB (Explanation of Benefits) Codes and Description

EOB Code

2500 2501 2502 2503 2505 2507 2508 2509 2510 2516 2517 2518 2519 2520 2521 2522 2524 2526 2527 2528 2530 2532 2534 2535 2536 2537 2538 2539 2540 2541 2542 2543 2544 2545 2546 2547 2548 2549 2550 2552 2555 2556 2557 2560 2561 2562 2563 2564 2566 2567 2569 2570 2571 2572

EOB Description

TPL - PAY AND REPORT SUSPEND FOR TPL REVIEW FILE CLAIM WITH MEDICARE THIS PATIENT HAS OTHER INSURANCE CLAIM DOCUMENTATION INDICATES OTHER INSURANCE PAYMENT WAS RECEIVED BY MEMBER OR IS NOT SUFFICIENT EPSDT-MAY HAVE TPL TPL PAY AND CHASE PHARMACY TPL PAY AND CHASE PRE-NATAL THIS PATIENT HAS TWO COVERAGE TYPES PROVIDER TYPE NOT ON TPL MATRIX TPL ON RECIPIENT FILE, NOT ON CLAIM (PAY CLAIM) PROVIDER TYPE - CLAIM INPUT CONFLICT DRUG REQUIRES PRIOR AUTHORIZATION DRUG QUANTITY PER DAY LIMIT HAS BEEN EXCEEDED TPL ON RECIPIENT FILE, NOT ON CLAIM (PAY AND LIST) MEMBER IS NOT ELIGIBLE FOR THESE SERVICES OVERNITE LABOR ROOM REQUIRES OCC CODE 51 AND DATE PCS PRIOR AUTHORIZATION NOT ON FILE PCS-NO UNITS AUTHORIZED-THESE DATES OF SERVICES PCS PRIOR AUTHORIZATION UNITS USED TIER 2 NSAID NO RECORD OF TIER ONES ON FILE DISEASE STATE MANAGEMENT PRODUR DRUG-AGE INTERACTION PDUR INGREDIENT DUPLICATION PDUR THERAPEUTIC DUPLICATION PDUR DRUG-TO-DRUG INTERACTION HMO CO-PAY/MEMBER HAS TPL PDUR EARLY REFILL ON PRESCRIPTION PDUR MINIMUM DURATION OF THERAPY PDUR DOSING PRECAUTION-HIGH DOSE PDUR DOSING PRECAUTION-LOW DOSE PDUR BREAST FEEDING/PREGNANCY PRECAUTION PDUR MAXIMUM DURATION OF THERAPY PDUR LATE REFILL ON PRESCRIPTION DRUG DISEASE MARKER HMO CO-PAY/MEMBER HAS MEDICARE PAY TO PROV FOR PROVIDER TYPE 63 MUST BE GROUP ADJUSTMENT SUSPEND FOR MANUAL REVIEW SERVICE NOT REFERRED BY PRIMARY CARE CASE MANAGER PROVIDER NOT ELIGIBLE TO PROVIDE SERVICE/MEDICAID CLAIM PAST 24 MONTH FILING - DTL MEMBER IS NOT WAIVER ELIGIBLE CLAIM PAST 24 MONTH FILING - HDR MEMBER SERVICES COVERED BY HMO PLAN PROVIDER INELIGIBLE FOR T19 SERVICES/HMO ONLY MEMBER PCPCM-CANNOT BILL OP/RHC/FQHC CLINICS RATE MEMBER NOT ENROLLED IN HMO FOR DOS SUPPLEMENTAL DELIVERY PYMT DENIAL CODE EXCEPTION CODE 566 HMO CO-PAY/NO TPL OR MEDICARE COVERAGE CC CLAIMS CAN NOT PROCESS THRU SYSTEM INVALID ELIGIBILITY FOR HMO COPAY CLAIMCHECK REBUNDLED CC INCIDENTAL TO PRIMARY PROCEDURE

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EOB (Explanation of Benefits) Codes and Description

EOB Code

2573 2574 2575 2576 2577 2578 2579 2580 2581 2582 2583 2584 2587 2588 2589 2590 2591 2592 2593 2594 2595 2597 2598 2599 2600 2601 2602 2603 2604 2605 2606 2609 2612 2614 2615 2616 2618 2619 2620 2622 2623 2625 2627 2628 2630 2631 2632 2633 2634 2635 2636 2638 2639 2642

EOB Description

CC MUTUALLY EXCLUSIVE CLAIMCHECK COSMETIC SURGERY CLAIMCHECK DUPLICATE CC UNLISTED/OBSOLETE/EXPERIMENTAL/UNSPECIFIED CLAIMCHECK POSSIBLE DUPLICATE CLAIMCHECK PRE-OP/POST-OP CC GROUPHEALTH SMARTSUSPENSE SUSPEND CLAIMCHECK MEDICAL/EVALUATION VISIT MEMBER IS LOCKED-IN TO ANOTHER PHYSICIAN MEMBER IS LOCKED-IN TO ANOTHER PHARMACY CLAIMREVIEW NEW VISIT FREQUENCY CC GROUPHLTH SMARTSUSPENSE DENY CLAIMREVIEW INTENSITY OF SERVICE STOP LOSS NOT APPROVED CC INVALID MODIFIER/PROCEDURE COMBINATION CLAIMCHECK EXCEEDS 40 LINES CLAIMREVIEW MULTIPLE/DUPLICATE COMP BILLING CLAIMCEHCK AGE REPLACEMENT CLAIMREVIEW DIAGNOSIS TO PROCEDURE CLAIMCHECK-BILL EACH DOS ON A SEPARATE LINE CLAIMCHECK AGE CONFLICT CLAIMCHECK MULTIPLE SURGERY CC-MULTIPLE SURGERY-DOUBLE MODIFIERS STOP LOSS THRESHOLD REACHED UNITS NOT EQUAL TO TEETH BILLED PART A CROSSOVER SPANS 20020501 UNITS NOT EQUAL TO TEETH BILLED PROV ID ON CLAIM DOES NOT MATCH PROV ID ON PA SERVICE AND/OR DATES DO NOT MATCH PRIOR AUTH PRIOR AUTH FUND AND CLAIM FUND DOES NOT MATCH PRIOR AUTH UNITS/AMOUNTS USED CHECK CLAIM ATTACHMENT TOOTH NUM ON CLAIM DOES NOT MATCH TOOTH NUM ON PA DIAG CODE MISSING/NOT ON FILE-INPATIENT CLAIMS NO PROVIDER RATE FOR DATE OF SERVICE (MAY HAVE BEEN BILLED UNDER INCORRECT PROVIDER NUMBER) PROCEDURE NOT COMPENSABLE FOR ASSISTANT SURGEON AUTH SERVICES-MEMBER NOT ELIG MEMBER INELIGIBLE PAY (AUTH EXAM) FROM STATE FUND MEDICARE ADJUSTED CLAIM-SUBMIT PAPER XOVER CLAIM MASS CREDIT/ADJ BEING SUSPEND THE CLAIM WAS CREATED BY A MASS ADJUSTMENT OR A MASS CREDIT FUND CODE UNDETERMINED COVERED FOR ORAL PATH ONLY DRUG REQUIRES PRIOR AUTHORIZATION/MN DIAGNOSIS NOT IN SCOPE OF DCYS PROGRAM DIAGNOSIS NOT IN SCOPE OF CCP PROGRAM DIAGNOSIS NOT IN SCOPE OF CN PROGRAM DIAGNOSIS NOT IN SCOPE OF MN PROGRAM DETAIL ATTENDING PHYSICIAN ID INVALID DETAIL FIRST OTHER PHYSICIAN ID INVALID DETAIL SECOND OTHER PHYS ID INVALID DRUG REQUIRES MEDICAL REVIEW/CN DRUG REQUIRES MEDICAL REVIEW/MN INVALID PROVIDER NUMBER

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EOB (Explanation of Benefits) Codes and Description

EOB Code

2643 2644 2646 2648 2649 2651 2652 2653 2654 2655 2657 2659 2660 2663 2664 2665 2667 2668 2669 2670 2671 2672 2673 2674 2675 2676 2677 2678 2680 2681 2682 2684 2691 2696 2697 2700 2701 2702 2703 2704 2705 2706 2707 2708 2709 2710 2711 2712 2713 2714 2715 2716 2717 2718 2719

EOB Description

ABORTION REQUIRES REVIEW PROCEDURE CODE MODIFIER NOT PAYABLE PROVIDER RATE NOT ON FILE CC SITE SPECIFIC MODIFIER-FILE ON SEPARATE LINE FILE SEPARATE CLAIMS FOR JUNE/JULY HOSPITAL DAYS INVALID TREATMENT DIAGNOSIS INDICATOR PCS-INVALID NET CLAIM CHARGE MEMBER ID IS INVALID FOR AUTH EXAM MEMBER ID IS INVALID FOR AUTH EXAM PAY STATE FD ELIG CHANGES/FILE SEPARATE CLAIMS FOR EACH MONTH POTENTIAL DISABILITY CLAIM DATE OVER 1 YR MORE THAN 90 DAYS AFTER MEDICARE PD ZERO AMOUNT TO PAY PCS-PROVIDER NUMBER IS NOT ON PROVIDER FILE PCS OVER 31 DAYS BILLED PCS MISSING PROVIDER NUMBER PCS-INVALID PROVIDER NUMBER CHECK DIGIT PCS MISSING FIRST DATE OF SERVICE PCS FILING DEADLINE EXCEEDED PCS FIRST DATE OF SERVICE GREATER THAN LAST DATE PCS SERVICE DATE IS GREATER THAN RECEIVED DATE PCS MISSING MEMBER NUMBER SUBMIT PAPER CLAIM PCS MISSING TOTAL CLAIM CHARGE PCS INVALID TOTAL CLAIM CHARGE PCS MEMBER NOT ON ELIGIBILITY FILE PCS MEMBER INELIGIBLE ON DATE OF SERVICE PCS ITEMIZED SERVICE DATE NOT IN MEMBER ELIG SPAN PCS PROVIDER IS SUSPENDED PROVIDER INELIGIBLE ON DATE OF SERVICE PCS REVIEW CLAIM FOR PROVIDER PCS INVALID PROVIDER NUMBER PCS-NO UNITS OF SERVICE CROSSOVER PART A NOT PAYABLE MEDICALLY NEEDY QMB MEMBER ELIGIBLE FOR CROSSOVER ONLY HCA FOR REVIEW PHYSICAN SIGNED CONSENT FORM BEFORE STERILIZATION DATE OF SURGERY ON CONSENT FORM IS NOT ON CLAIM MEMBER UNDER 21 WHEN SHE SIGNED CONSENT FORM REQUIRES ADDRESS FOR FACILITY FOR STERILIZATION STERILIZATION CONSENT FORM IS NOT LEGIBLE DATE ON THE CONSENT FORM IS NOT LEGIBLE STERILIZATION/HYSTERECTOMY CONSENT FORM IS MISSING PATIENT NAME ON CONSENT FORM DOES NOT MATCH CLAIM CONSENT LESS THAN 30 DAYS BEFORE STERILIZATION CONSENT MORE THAN 180 DAYS BEFORE STERILIZATION STERILIZATION CONSENT FORM NOT DATED BY PHYSICIAN CONSENT FORM IS NOT SIGNED BY THE MEMBER CONSENT FORM IS NOT SIGNED BY THE COUNSELOR CONSENT FORM DOES NOT HAVE DATE COUNSELOR SIGNED STERILIZATION CONSENT FORM IS INCOMPLETE HYSTERECTOMY CONSENT FORM REQUIRED STERILIZATION CONSENT FORM NOT SIGNED BY PHYSICIAN INVALID SURGICAL PROCEDURE CODE REFILE CLAIM WITH OPERATIVE REPORT

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EOB (Explanation of Benefits) Codes and Description

EOB Code

2720 2721 2722 2723 2724 2725 2726 2727 2728 2729 2730 2731 2732 2733 2734 2735 2736 2737 2738 2739 2740 2741 2742 2743 2744 2745 2746 2747 2748 2749 2750 2751 2752 2753 2754 2755 2756 2757 2758 2759 2760 2761 2762 2763 2764 2765 2766 2767 2768 2769 2770 2771 2772 2773 2774

EOB Description

INCORRECT MEMBER DATE OF BIRTH ON CONSENT FORM FURTHER DESCRIPTION OF SERVICE REQUIRED STRENGTH AND DOSAGE OF INJECTION MEDICATION REQ SERVICES REQ DOCUMENTATION FOR MEDICAL NECESSITY REFILE CLAIM WITH CONSULTATION/PROGRESS NOTES SERVICE NOT COVERED AS BILLED REFERRING PHYSICIAN REQUIRED ANOTHER PROVIDER HAS BEEN PAID FOR THESE SERVICES SERVICES ARE NOT AUTHORIZED DENIED AFTER SPECIAL REVIEW HYSTERECTOMY CONSENT FORM SIGNED AFTER SURGERY HEALTH CARE AUTHORITY WILL PROCESS CLAIM COUNSELOR SIGNED CONSENT FORM PRIOR TO MEMBER SERVICES/SUPPLY NOT IN SCOPE OF PROGRAM PROCEDURE/REVENUE CODE-REQUIRE PRIOR AUTHORIZATION MEMBER INELIGIBLE ON SERVICE DATES MODIFIER ADDED/DELETED DUE TO MEDICAL REVIEW INVALID MODIFIER FOR THIS PROCEDURE INVALID PROCEDURE CODE USE VALID CPT OR HCPC CODE ONE AMBULATORY SURGERY ALLOWED PER DAY INVALID CODE FOR NARRATIVE DESCRIPTION INVALID SUBMITTED CHARGE AUTHORIZED PHYSICAL REQUIRES ABCDM-16 EXCEPTION CODE 743 AUTHORIZED PHYSICAL DOES NOT MATCH ABCDM-16 REQUESTED ADDITIONAL INFORMATION NOT RECEIVED DENTAL X-RAYS ARE REQUIRED SERVICES ARE INCLUDED IN TOTAL PAID OB CARE PROCEDURE IS AN INCIDENTAL TO PAID MAJOR SURGERY OUTSIDE THE GUIDELINES OF THE MEDICAL PROGRAM EXCEEDS SUPPLY LIMIT/1 MONTH WITHIN 12 MONTHS EXCEPTION CODE 751 PER PHY MANUAL-USE 99202 ANTEPART WHEN NOT TOTAL OB PROCEDURE IS INCIDENTAL MAJOR PROCEDURE ON CLAIM REFILE USING MEMBER AREA IN SQ CM REFILE CLAIM WITH PROOF OF TIMELY FILING ATTACHED EXCEPTION CODE 756 TAKE HOME MEDICATION IS NOT PAYABLE PROVIDER NAME DOES NOT MATCH PROVIDER NUMBER NEEDS COUNTY ADMIN AND/OR PROVIDER SIGNATURE MEMBER IS DECEASED THIS DATE OF SERVICE NAME ON SUBMITTED CLAIM DOES NOT MATCH DHS FILE FILE AN ASSIGNED MEDICARE CLAIM ON THIS PATIENT PCS - HEALTH CARE AUTHORITY WILL PROCESS CLAIM DUPLICATE OF PAID CLAIM INVALID HYSTERECTOMY CONSENT FORM STERILIZATION/HYSTERECTOMY CONSENT FORM IS INVALID EXCEPTION CODE 767 REQUEST ADJUSTMENT TO PAID CLAIM-PER MANUAL PAYMENT CORRECTED/SPENDDOWN-ADM12-HIST ONLY ADJUST INSURANCE PAYMENT MORE THAN ALLOWABLE SERVICE NOT PAYABLE THIS DATE OF SERVICE TYPE OF BILL-CLAIM CONFLICT AUTHORIZED ROOM AND BOARD SERVICES ARE NOT ON CLAIM EXCEPTION CODE 774

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EOB (Explanation of Benefits) Codes and Description

EOB Code

2775 2777 2778 2779 2780 2781 2782 2783 2785 2786 2787 2788 2789 2790 2791 2792 2793 2794 2795 2796 2797 2798 2799 2800 2801 2802 2803 2804 2806 2807 2812 2813 2814 2815 2816 2820 2821 2822 2823 2824 2826 2827 2828 2829 2830 2831 2832 2833 2835 2836 2838 2839 2842 2843 2845

EOB Description

CLAIM HAS BEEN FORWARED TO HCA SHOW MEDICARE PART B PAYMENTS HEALTH CARE AUTHORITY PROCESSED ADM12 ELIGIBILITY PROBLEM PROCESSED BY DHS RESUBMIT WITH APPROPRIATE VALUE CODE AND UNITS ANOTHER DDS PAID THIS SERVICE IN PREVIOUS 12 MONTH PART OF INPATIENT HOSPITAL CHARGES PROCEDURE INCLUDED IN OFFICE CALL ANOTHER PHARMACY PAID FOR THIS PRESCRIPTION SAME NDC/DATE PAID THIS PHARM ASST SURGEON MUST FILE OWN CLM CLINIC VISIT PAID THIS DATE PROCEDURE NOT APPLICABLE FOR DIAGNOSIS SHOWN ABCDM-16/CLAIM PROV CONFLICT INVALID DIAGNOSIS FOR DESCRIPTION STERILIZATION CONSENT REQUIRED SERVICE/SUPPLY INCLUDED IN AMBULANCE TRIP CHARGE PAID CLAIM INCLUDED THIS PROCEDURE CC MUTUALLY EXCLUSIVE PATIENT HAS PRIVATE INSURANCE MEMBER TB ELIG ONLY-CLAIM REQUIRES TB DIAGNOSIS REFILE WITH MEDICARE RECHECK HIC NUMBER EXCEPTION CODE 799 PHARMACY-EXACT DUPLICATE OF ANOTHER CLAIM PHARMACY-POSSIBLE DUPLICATE OF ANOTHER CLAIM PHARMACY-POSSIBLE CONFLICT OF ANOTHER CLAIM DENTAL-EXACT DUPLICATE OF ANOTHER CLAIM DENTAL-POSSIBLE DUPLICATE OF ANOTHER CLAIM PRACTITIONER-EXACT DUPLICATE OF ANOTHER CLAIM PRACTITIONER-POSSIBLE DUPLICATE OF ANOTHER CLAIM CROSSOVER-EXACT DUPLICATE OF ANOTHER CLAIM EXCEPTION CODE 813 CROSSOVER-POSSIBLE CONFLICT OF ANOTHER CLAIM LTC-EXACT DUPLICATE OF ANOTHER CLAIM IN SYSTEM LTC-POSSIBLE DUPLICATE OF ANOTHER CLAIM PCS-EXACT DUPLICATE OF ANOTHER CLAIM PCS-POSSIBLE DUPLICATE OF ANOTHER CLAIM EXCEPTION CODE 822 OUTPATIENT-EXACT DUPLICATE OF ANOTHER CLAIM OUTPATIENT-POSSIBLE DUPLICATE OF ANOTHER CLAIM HOME HEALTH-EXACT DUPLICATE OF ANOTHER CLAIM EXCEPTION CODE 827 HOME HEALTH-POSSIBLE CONFLICT OF ANOTHER CLAIM INPATIENT-EXACT DUPLICATE OF ANOTHER CLAIM INPATIENT-POSSIBLE DUPLICATE OF ANOTHER CLAIM EXCEPTION CODE 831 TRANSPORTATION-EXACT DUPLICATE OF ANOTHER CLAIM TRANSPORTATION-POSSIBLE DUPLICATE OF ANOTHER CLAIM CHIROPRACTOR-EXACT DUPLICATE OF ANOTHER CLAIM CHIROPRACTOR-POSSIBLE DUPLICATE OF ANOTHER CLAIM LAB/XRAY-EXACT DUPLICATE OF ANOTHER CLAIM LAB/XRAY-POSSIBLE DUPLICATE OF ANOTHER CLAIM DEALER-EXACT DUPLICATE OF ANOTHER CLAIM DEALER-POSSIBLE DUPLICATE OF ANOTHER CLAIM OPTOMETRIST-EXACT DUPLICATE OF ANOTHER CLAIM

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EOB (Explanation of Benefits) Codes and Description

EOB Code

2846 2849 2850 2851 2852 2853 2854 2855 2856 2857 2858 2859 2860 2877 2880 2881 2882 2883 2884 2889 2890 2893 2894 2895 2896 2900 2901 2903 2904 2905 2906 2907 2908 2909 2910 2911 2912 2913 2914 2915 2916 2917 2918 2919 2920 2921 2922 2923 2924 2925 2926 2927 2928 2929 2930

EOB Description

OPTOMETRIST-POSSIBLE DUPLICATE OF ANOTHER CLAIM INVALID MODIFIER COMBINATION LTC/INPT POSSIBLE CONFLICT WITH INPT/LTC CLAIM LTC-HOME HEALTH CLAIM CONFLICT LTC-PCS POSSIBLE CONFLICT PCS-LTC POSSIBLE CONFLICT INPATIENT-PCS POSSIBLE CONFLICT PCS-INPATIENT POSSIBLE CONFLICT HH/INPT POSSIBLE CONFLICT WITH INPT/HH CLAIM HOSPICE TOTAL UNITS GREATER THAN TOTAL DAYS INPT/OUTPT POSSIBLE CONFLICT WITH OUTPT/INPT CLAIM EXCEPTION CODE 859 CROSS CLAIM TYPE J CODE CONFLICT REVIEW EDITS 4005/4006/4009/4084 PRIOR TO CUTBACK PRODEDURE CODE NOT VALID FOR FORM HOME HEALTH-LTC CLAIM CONFLICT LTC/XOVER POSSIBLE CONFLICT WITH XOVER/LTC CLAIM CROSSOVER-PCS POSSIBLE CONFLICT PCS-CROSSOVER POSSIBLE CONFLICT PART-A COINSURANCE GREATER MEDICARE PD AMT REVIEW CROSSOVER PART B COINSURANCE OVER $1000.00 EXCEPTION CODE 893 RURAL HEALTH REVENUE REQUIRES HCPC CODE RURAL HEALTH CLINIC REQUIRES REVENUE OP521 FILE SEPARATE CLAIMS FOR DIFFERENT YEARS PCS DAYS REDUCED-INPT/LTC CONFLICT FILE SEPARATE CLAIM FOR REMAINING UNPAID DAYS MULTIPLE CPT CODES REQUIRED DENIED FOR FLORIDA FOUNDATION FOR PEER REVIEW AUDIT REFILE SEPARATE CLAIM FOR EACH MONTH MEDICARE DEDUCTIBLE APPLIED IN PREVIOUS 60 DAYS PAY TO GROUP HAS BEEN PAID FOR THIS SERVICE ANOTHER PROVIDER WITHIN GROUP PAID FOR SERVICE FILE SEPARATE CLAIM FOR SEPTEMBER AND OCTOBER PSYCHIATRIC ADMIT AFTER 9/1/92 NEEDS PA SERVICE PREVIOUSLY PAID ON GROSS ADJUSTMENT CLAIM HAS BEEN ADJUSTED AFTER SPECIAL REVIEW CLAIM HAS BEEN ADJUSTED AFTER MEDICAL REVIEW SERVICE PREVIOUSLY PAID ON PROVIDER ALTERNATE NUM PAID TO ANOTHER PROVIDER IN GROUP ON ALTERNATE NUM EXCEPTION CODE 916 CHARGES INDICATE ERROR IN MATH INDICATE UNITS WORKED NOT DAYS FILE SEPARATE CLAIM FOR EACH DATE OF SERVICE WAIVERED SERVICE/DATES NOT ON PRIOR AUTHORIZATION LIST EACH DATE SEPARATELY PATIENT RECEIVED SETTLE/BILL PATIENT ITEMIZE CHARGES FOR SUPPLIES CLIENT RESPONSIBLE EXCEEDS ALLOWABLE MEDICAL CONDITION/DIAGNOSIS NOT COVERED DME NAME BRAND DOES NOT MATCH ORDER NUMBER INDICATE EXACT UNITS PROVIDED FOR MEMBER WHOLESALERS INVOICE REQUIRED FOR PAYMENT PROC/DIAG REQUIRE FEDERAL MANDATED STATMT-ABORTION PROCEDURE UNITS REDUCED TO ALLOWABLE

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EOB (Explanation of Benefits) Codes and Description

EOB Code

2931 2932 2933 2934 2935 2936 2937 2938 2939 2940 2941 2942 2943 2944 2945 2946 2947 2948 2949 2950 2951 2952 2953 2954 2955 2956 2957 2958 2959 2960 2961 2962 2963 2964 2965 2966 2967 2968 2969 2970 2971 2972 2973 2974 2976 2977 2978 2979 2980 2981 2982 2983 2984 2985 2986

EOB Description

EXCEPTION CODE 931 DUPLICATE OF PREVIOUSLY PAID CROSSOVER CLAIM ORIGINAL CLAIM BEING ADJUSTED-ALLOW 30 DAYS CLAIM WAS FILED WITH INVALID PROVIDER NUMBER RENTAL PREVIOUSLY PAID FOR THIS ITEM THIS MONTH CONTACT CASE MANAGER OR SUPERVISOR PROVIDER NOT ELIGIBLE THIS PROCEDURE CODE EXCEPTION CODE 938 REFILE ON PAPER CLAIM SUBMIT PAPER CLAIM WITH NARRATIVE FOR PRICING REFILE WITH MEDICARE REMITTANCE STATEMENT DUPLICATE PAID THRU FINANCE REFILE ON ADM84-TRANSPORTATION CLAIM FORM DENIED AFTER CLAIM CHECK REVIEW INVALID PROOF OF DENIAL/HMO INVALID PROOF OF INSURANCE DENIAL REFILE WITH CORRECT ADMIT DATE RESUBMIT LEGIBLE CLAIM/ATTACHMENT EXCEPTION CODE 949 THIS LEVEL TRANSPORTATION NOT REQUIRED DDSD WILL PROCESS CLAIM THROUGH FINANCE REFILE-NAME BRAND AND PRODUCT/ORDER NUMBER FOR PRICE REFILE AS CROSSOVER WITH EOMP REFILE WITH APPROPRIATE EOMP NOT ELIGIBLE FOR WAIVERED SERVICES TPL PAID COLLECT FROM PATIENT NOT VERIFIED BY OPERATIVE REPORT ITEMIZE SURGERIES PER OPERATIVE REPORT CANNOT PROCESS NEGATIVE AMOUNTS ADJUSTED PER OFPR RECOMMENDATION NON EMERGENCY SERVICES NON PAYABLE FOR ALIEN DOCUMENT OF NECESSITY/MRI REPORT REQUIRED DOCUM DOES NOT JUSTIFY THE BILLED PROCEDURE REFILE CLAIM AS LIMIT TARGETED OB ULTRASOUND PAY REMAINING DAYS ON PARAMETER FILE FILE MEDICARE PART A FOR INPATIENT SERVICES PROVIDER NOT QUALIFIED FOR TARGETED OB US INTERP REFILE AS PHARMACY WITH NATIONAL DRUG CODE NO MEDICAL JUSTIFICATION FOR TARGETED OB US SUBMIT PREVIOUSLY REQUESTED OB/US QUALIFICATION PARTIAL HOURS NON ACCEPTABLE NO MEDICAL JUSTIFICATION FOR REVERSAL/REMOVAL REFILE AS AMBULATORY SURGERY PRESCRIBING PROVIDER EXCLUDED HYSTERECTOMY REQUIRE SIGN DATE REFILE CLAIM WITH MEDICAL RECORD INPATIENT HOSPITAL CLAIM PAID THIS DATE OF SERVICE NURSING HOME CLAIMS PAID THIS DATE OF SERVICE PROCEDURE NOT PAYABLE FOR THIS AGE VERIFY PA FOR THIS PROCEDURE/DATE OF SERVICE REFILE WITH PHYSICIAN PROGRESS NOTES PROV ID ON CLAIM DOES NOT MATCH PROV ID ON PA DIAGNOSIS NOT PAYABLE FOR NURSE MIDWIFE PROVIDER IS SUSPENDED OR TERMINATED UNITS CANNOT BE GREATER THAN 999

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EOB (Explanation of Benefits) Codes and Description

EOB Code

2987 2988 2989 2990 2991 2993 2994 2995 2996 2997 2998 2999 3000 3001 3010 3023 3024 3034 3035 3036 3037 3038 3039 3041 3042 3043 3044 3045 3047 3048 3049 3050 3051 3052 3053 3054 3055 3058 3059 3322 3340 3348 3358 3360 3601 3999 4000 4003 4008 4014 4016

EOB Description

PRIOR AUTHORIZATION UNITS/AMOUNTS USED TB ONLY ELIGIBLE - NEED T IN FORCE FIELD (FF) SERVICE AND/OR DATES DO NOT MATCH PRIOR AUTH SERVICES ALLOWED AS ENCOUNTER ON ALTERNATE NUMBER UNITS REDUCED PER DOCU/AFTER SURS REVIEW EXCEPTION CODE 993 EXCEPTION CODE 994 EXCEPTION CODE 995 EXCEPTION CODE 996 EXCEPTION CODE 997 EXCEPTION CODE 998 CLAIM BILLED WITH INACTIVE RID PRIOR AUTH LINE ITEM IS USED PA NOT ON FILE OR NOT IN DATE PRIOR AUTHORIZATION NUMBER IS MISSING FIRST SURGERY PROCEDURE IS ELECTIVE AND NO PRIOR AUTH NBR ENTERED. NON-PRIOR AUTHORIZED HYSTERECTOMIES PERMISSIBLE IN DOCUMENTED EMERGENCY SITUATIONS. ELECTIVE SURGERY: NO EMERGENCY REPORT EMERGENCY TREATMENT UNDER REVIEW-DENTAL PROCEDURE PERFORMED ON DOS AFTER PRIOR AUTHORIZATION EXPIRATION DATE ELECTIVE SURGERY EMERGENCY INDICATED ELECTIVE SURGERY - NO PRIOR AUTHORIZATION NUMBER ON CLAIM ELECTIVE SURGERY: NO SCREENING ON CLAIM OUT OF STATE CLAIM NOT PAYABLE, CLAIM REVIEWED. SERVICES NOT PRIOR AUTHORIZED AND NON EMERGENCY AND ARE THEREFORE NOT COVERED. PRIOR AUTH LINE NOT APPROVED RECIPIENT NUMBER ON PA DIFF VS CLAIM PRIOR AUTHORIZATION/PROCEDURE CODE MODIFIER CONFLICT PROVIDER NUMBER DOES NOT MATCH PRIOR AUTHORIZATION DENTAL CLAIM FILED BEFORE PRIOR AUTHORIZATION BEGINNING VALID DATE SERVICE DATE 912 DAYS AFTER PA ISSUE DIAGNOSIS IS 290.0-314.9 AND PA DOES NOT BEGIN 7777 FOR ADMIT PRIOR TO 7/1/98 OR 3333 FOR ADMIT ON OR AFTER 7/1/98, OR XXXX 895 XXX (AFTER 1/1/01) MEDICAL I/P PA NOT ON FILE OR DATE ON CLAIM IS NOT IN PA DATE SPAN PROCEDURE BILLED NOT IN PRIOR AUTHORIZATION RECORD DS WAIVER REFERRING PROVIDER INVALID PRIOR AUTHORIZATION FOR PROCEDURE CODE EXHAUSTED DS WAIVER NOT APPROVED UNIT RATE NOT ALLOWED DS WAIVER ERROR, DATA REJECTED BY GATEKEEPER MATRIX SCREENING REQUIRED, NONE INDICATED FIRST SURG PROC IS ELECTIVE. PROC REQUIRES PRIOR AUTH UNLESS PERFORMED AS A RESULT OF CHCUP SCREEN. SEE MEDICAID PRO REIM HANDBK P6-27 INVALID UNITS OF SERVICE FOR REVENUE CODE 652, 652, 655-657 AND 659 PROCEDURE CODE REQUIRES MANUAL PRICING DIAGNOSIS CODE NOT COVERED FOR BIRTH CENTER PROCEDURE CODE CLAIM REQUIRES AHCA MANUAL REVIEW TAXONOMY CODE INVALID/MISSING PROCEDURE/DIAGNOSIS/DRUG NOT COVERED FOR FAMILY PLANNING CLAIM BILLED WITH INACTIVE RID MORE THAN TWO SURGICAL UNITS ON THE CLAIM DRUG IS LESS THAN EFFECTIVE - DESI INVALID RPICC SERVICE DAYS PROCEDURE BEING BILLED FOR PATHOLOGY HAS NO TECHNICAL COMPONENT SEGMENT PROCEDURE CODE INCOMPATIBLE WITH DIAG

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EOB (Explanation of Benefits) Codes and Description

EOB Code

4020 4026 4030 4033 4034 4035 4036 4037 4039 4044 4046 4068 4070 4086 4089 4095 4098 4107 4108 4114 4115 4119 4120 4121 4122 4123 4124 4127 4134 4140 4142 4149 4150 4161 4162 4181 4183 4201 4203 4206 4208 4209 4215 4216 4218 4220 4223 4227 4229 4246

EOB Description

UNITS BILLED EXCEED ALLOWABLE UNITS FOR THIS PROCEDURE CODE NDC/DAYS SUPPLY LIMITATIONS. THIS NDC BILLED MAY NOT BE GREATER THAN THE NUMBER OF DAYS ALLOWED ON THE NDC FILE. DIAG CODE INCOMPATIBLE FOR RECIPIENTS AGE (IF YOU ARE BILLING FOR MOTHER, CHECK TO SEE IF YOU USED A NEWBORN-ONLY DIAG CODE OR VICE VERSA) INVALID PROCEDURE CODE MODIFIER COMBINATION PROCEDURE CODE/AGE CONFLICT PROCEDURE CODE OR DRUG / SEX CONFLICT PROVIDER TYPE/PLACE OF SERVICE CONFLICT DIAGNOSIS IS INCORRECT FOR PROCEDURE CODE BILLED DIAGNOSIS CANNOT BE USED AS THE PRINCIPAL DIAGNOSIS PROCEDURE CODE/AGE CONFLICT PROCEDURE CODE NOT ALLOWED FOR DATE OF SERVICE NO REIMB RULE FOR ASSOCIATED CONTRACT INVALID PROCEDURE CODE MODIFIER INDEPENDENT LAB NOT CERTIFIED MISSING OR INVALID SURGERY CODE. PLEASE VERIFY TO SEE IF HCPC CODE CAN BE BILLED WITH THE SURGERY REVENUE CODE AND RESUBMIT NONSURGICAL SERVICES ARE NOT REIMBURSED INDIVIDUAL PRICING BEING REVIEWED REVENUE CODE IS NOT APPROPRIATE/NOT COVERED FOR THE (TYPE) OF SERVICE BEING PROVIDED PROVIDER CHARGE RECORD/ HMO PHP RECORD NOT FOUND PRICING BEING REVIEWED PRICING BEING REVIEWED VALUE CODE AMOUNT MISSING XYZ VALUE CODE IS MISSING MOUTH QUADRANT REQUIRED VALUE CODE IS INVALID VALUE CODE AMOUNT IS MISSING VALUE CODE AMOUNT IS INVALID CANNOT PRIORITIZE MEMBERS PROGRAMS DRG GRPR NOT ABLE TO GROUP WITH INFO PROVIDED PAY-TO PROVIDER TYPE INVALID FOR PROCEDURE CODE REVENUE CODE NOT ALLOWED FOR DIALYSIS PROVIDER PROCEDURE RESTRICTED TO CERTAIN SPECIALTY(IES). PROVIDER NOT ENROLLED FOR NECESSARY SPECIALTY. (OR TREATING PROV NOT IDENTIFIED ON CLAIM). PROCEDURE/PROVIDER CONFLICT INDEPENDENT LAB NOT CERTIFIED INVALID HOSPICE REVENUE CODE OR INVALID COMBINATION OF HOSPICE REVENUE CODES ENCOUNTER BLANKET DENIAL INVALID COMBINATION OF RPICC SERVICES. THERE IS TPL FOR THIS CLAIM NO RATE ON PROCEDURE FILE FOR DATE OF SERVICE THIS SERVICE IS A NON-COVERED FLORIDA HEALTH COVERAGE PROGRAM SERVICE AS THE RENDERING PROVIDER IS NOT RECOGNIZED BY THE FLORIDA HEALTH COVERAGE PROGRAM INVALID RPICC SERVICE DAYS NO CLIA REGISTRATION ON FILE FOR THIS PROVIDER NO MATCHING PRICING SEGMENT FOR THE PROCEDURE/MODIFIER COMBINATION BILLED REVENUE CODE NOT VALID FOR THIS BILL TYPE MODIFIERS 24, 78 AND 79 REQUIRE AHCA REVIEW INVALID PROCEDURE FOR CLAIM FORM EPOGEN REQUIRES VALUE CODE 68 PROCEDURE REQUIRES MEDICAL REVIEW THIS REVENUE CODE IS NOT COVERED FOR THIS MEMBER DIAGNOSIS REQUIRES MEDICAL REVIEW ADJUSTMENT NET PAID AMOUNT EXCEEDS THE CASH RECEIPT BALANCE

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EOB (Explanation of Benefits) Codes and Description

EOB Code

4251 4252 4253 4254 4257 4282 4311 4312 4315 4316 4350 4351 4352 4353 4371 4384 4388 4389 4390 4391 4393 4415 4486 4711 4714 4715 4742 4760 4768 4776 4798 4801 4802 4804 4806 4812 4813 4821 4822 4871 4874 4888 4889 5000 5001 5002 5003

EOB Description

DECIMAL UNITS NOT BILLABLE FOR PROCEDURE DIAGNOSIS CODE 10-24 NOT ON FILE REVENUE CODE REQUIRES MEDICAL REVIEW REVENUE CODE VS AGE RESTRICTION INVALID PROCEDURE CODE MODIFIER CLAIM HAS BEEN REVIEWED. REFER TO EOB CODES 1901 - 1940 FOR DENIAL REASON. DIAG CODE MISSING OR INCOMPLETE. OUTPATIENT HOSP - REV CODES 273 AND 279 NOT PAYABLE UNLESS DIAGNOSIS IS INCLUDED IN RANGE 940.0-949.5. PROCEDURE CODE INCOMPATIBLE WITH DIAGNOSIS CODE PROCEDURE CODE INCOMPATIBLE WITH DIAGNOSIS CODE PROCEDURE CODE INCOMPATIBLE WITH DIAGNOSIS CODE DIAGNOSIS REQUIRES MEDICAL REVIEW ICD9 PROCEDURE REQUIRES MEDICAL REVIEW DIAGNOSIS REQUIRES AHCA MEDICAL REVIEW ICD9 PROCEDURE REQUIRES AHCA MEDICAL REVIEW PROCEDURE CODE NOT COVERED FOR CLAIM TYPE GROUPER ERROR - PRIMARY DIAGNOSIS INVALID DRG GROUPER INVALID AGE DRG GROUPER INVALID GENDER DRG GROUPER INVALID DISCHARGE STATUS DRG GROUPER INVALID LENGTH OF STAY INVALID REVENUE CODE/PROCEDURE CODE COMBINATION PROCEDURE NOT ALLOWED WITH NOT ALLOWED WITH S5102 RECIPIENT ID NOT ON FILE. DENIED AFTER PENDING 14 DAYS AWAITING AHCA UPDATE IF NUMBER IS INCORRECT, RESUB. IF CORRECT, CONTACT YOUR AHCA DISTRICT OFFICE. DIAGNOSIS CODE INCOMPATIBLE FOR RECIPIENTS AGE. IF YOU ARE BILLING FOR MOTHER, CHECK TO SEE IF YOU USED A NEWBORN-ONLY DIAG CODE OR VICE VERSA. PROCEDURE CODE/AGE CONFLICT PROCEDURE CODE/AGE CONFLICT DIAG CODE MISSING OR INCOMPLETE. OUTPATIENT HOSP - REV CODES 273 AND 279 NOT PAYABLE UNLESS DIAGNOSIS IS INCLUDED IN RANGE 940.0-949.5. ICD9 PROCEDURE REQUIRES MEDICAL REVIEW ICD9 PROCEDURE REQUIRES MEDICAL REVIEW DIAGNOSIS NOT COVERED SUBMITTED CHARGE IS NOT EVENLY DIVISIBLE BY UNITS OF SERVICE THESE SERVICES CANNOT BE BILLED ON THIS CLAIM FORM OR THE PROVIDER TYPE LISTED FOR THIS PROVIDER NUMBER CANNOT FILE THIS TYPE OF CLAIM NO CONTRACT FOR BILLED DIAGNOSIS PROVIDER INELIGIBLE FOR CATEGORY OF SERVICE FOR THIS DATE OF SERVICE PROVIDER INELIGIBLE FOR CATEGORY OF SERVICE FOR THIS DATE OF SERVICE DIAGNOSIS REQUIRES MEDICAL REVIEW PROCEDURE REQUIRES MEDICAL REVIEW PROV TYPE/PLACE OF SERVICE CONFLICT PROC CANNOT BE PERFORMED AT PLACE OF SERVICE INDICATED ON CLAIM OR IF 99160 OR 99162 BILLED. SERV PAYABLE ONLY IF EMERGENCY BLOCK CHECKED. PROCEDURE CODE NOT COVERED FOR CLAIM TYPE OUTPATIENT REV CODE NOT ON FILE OR NOT COVERED - IF REV CODE IS IN THE RANGE 960-981 (PROFESSIONAL SERVICES), IT MUST BE BILLED ON THE CMS-1500 NDC MISSING/INVALID INVALID NDC/J-CODE COMBINATION THIS IS A DUPLICATE OF ANOTHER CLAIM THIS IS A DUPLICATE OF ANOTHER CLAIM THIS ADJUSTMENT IS A DUPLICATE OF A PREVIOUS ADJUSTMENT THIS IS A DUPLICATE OF ANOTHER CLAIM REVERSAL

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EOB (Explanation of Benefits) Codes and Description

EOB Code

5004 5005 5006 5007 5010 5017 5030 5031 5032 5033 5034 5035 5036 5038 5042 5043 5045 5046 5048 5049 5051 5052 5053 5056 5057 5058 5059 5060 5061 5062 5063 5065 5066 5067 5068 5069 5070 5071 5072 5073 5074 5075 5076 5077 5078 5079 5080 5081 5082 5083 5084 5085

EOB Description

REVERSAL NOT PROCESSED, NO MATCH FOUND ON RX NUMBER AND PROVIDER NUMBER. PLEASE REFER TO YOUR POS MANUAL. REVERSAL NOT PROCESSED - MULTIPLE MATCHES FOUND WITH SAME RX NUMBER, PROVIDER NUMBER AND DISPENSING DATE. PLEASE REFER TO YOUR POS MANUAL. REVERSAL NOT PROCESSED, CLAIM OVER 60 DAYS - SUBMIT MANUAL ADJUSTMENT THIS IS A DUPLICATE OF ANOTHER CLAIM. IF THIS CLAIM WAS INTENDED TO BE AN ADJUSTMENT, PLEASE SUBMIT THE APPROPRIATE ADJUSTMENT REQUEST FORM. EXACT DUPLICATE - TOOTH SURFACE MOUTH QUADRANT/ TOOTH SURFACE DUPLICATE NOT ALLOWED SAME DATE OF SERVICE PROCEDURE NOT ALLOWED SAME DATE OF SERVICE NOT ALLOWED WITH COMPONENT NOT ALLOWED SAME DAY WITH CMH SERVICES NOT ALLOWED ON SAME DATE OF SERVICE FOR CMH. PAID RELATED CLAIM NOT ALLOWED WITH C-SECTION INVALID PROCEDURE/MODIFIER COMBINATION NOT ALLOWED WITH OBSTETRIC PANEL NOT ALLOWED WITH OBSTETRIC PANEL-LABORATORY NOT ALLOWED WITH HEPATIC FUNCTION NOT ALLOWED WITH HEPATITIS FUNCTION NOT ALLOWED WITH LIPID PANEL NOT ALLOWED WITH LIPID PANEL - LABORATORY NOT ALLOWED WITH ARTHRITIS PANEL - LABORATORY NOT ALLOWED WITH ARTHRITIS PANEL ? TORCH ANTIBODY PANEL NOT ALLOWED WITH ARTHRITIS PANEL ? TORCH ANTIBODY PANEL LAB SERVICES NOT ALLOWED ON THE SAME DAY SERVICE NOT ALLOWED WITH ANESTHESIA PROCEDURE CODE COMBINATION NOT ALLOWED MULTIPLE VISITS SAME DAY PROCEDURE CODE COMBINATION NOT ALLOWED PROCEDURE CODE COMBINATION NOT ALLOWED PROCEDURE CODE COMBINATION NOT ALLOWED PROCEDURE CODE COMBINATION NOT ALLOWED PROCEDURE CODE COMBINATION NOT ALLOWED PROCEDURE CODE COMBINATION NOT ALLOWED PROCEDURE CODE COMBINATION NOT ALLOWED PROCEDURE CODE COMBINATION NOT ALLOWED PROCEDURE CODE COMBINATION NOT ALLOWED PROCEDURE CODE COMBINATION NOT ALLOWED PROCEDURE CODE COMBINATION NOT ALLOWED PROCEDURE CODE COMBINATION NOT ALLOWED PROCEDURE CODE COMBINATION NOT ALLOWED PROCEDURE CODE COMBINATION NOT ALLOWED PROCEDURE CODE COMBINATION NOT ALLOWED PROCEDURE CODE COMBINATION NOT ALLOWED PROCEDURE CODE COMBINATION NOT ALLOWED PROCEDURE CODE COMBINATION NOT ALLOWED PROCEDURE CODE COMBINATION NOT ALLOWED PROCEDURE CODE COMBINATION NOT ALLOWED PROCEDURE CODE COMBINATION NOT ALLOWED PROCEDURE CODE COMBINATION NOT ALLOWED PROCEDURE CODE COMBINATION NOT ALLOWED PROCEDURE CODE COMBINATION NOT ALLOWED PROCEDURE CODE COMBINATION NOT ALLOWED

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EOB (Explanation of Benefits) Codes and Description

EOB Code

5086 5087 5088 5089 5090 5091 5092 5093 5094 5095 5096 5097 5098 5099 5100 5101 5102 5104 5111 5112 5113 5114 5115 5116 5117 5118 5119 5120 5121 5122 5123 5124 5125 5126 5127 5128 5129 5130 5132 5133 5134 5135 5136 5137 5138 5139 5140 5142 5143 5144 5145 5146 5147 5148 5149

EOB Description

PROCEDURE CODE COMBINATION NOT ALLOWED PROCEDURE CODE COMBINATION NOT ALLOWED PROCEDURE CODE COMBINATION NOT ALLOWED PROCEDURE CODE COMBINATION NOT ALLOWED PROCEDURE CODE COMBINATION NOT ALLOWED PROCEDURE CODE COMBINATION NOT ALLOWED PROCEDURE CODE COMBINATION NOT ALLOWED PROCEDURE CODE COMBINATION NOT ALLOWED PROCEDURE CODE COMBINATION NOT ALLOWED PROCEDURE CODE COMBINATION NOT ALLOWED PROCEDURE CODE COMBINATION NOT ALLOWED PROCEDURE CODE COMBINATION NOT ALLOWED PROCEDURE CODE COMBINATION NOT ALLOWED PROCEDURE CODE COMBINATION NOT ALLOWED PROCEDURE CODE COMBINATION NOT ALLOWED PROCEDURE CODE COMBINATION NOT ALLOWED PROCEDURE CODE COMBINATION NOT ALLOWED SERVICES NOT ALLOWED ON THE SAME DAY SERVICES NOT ALLOWED ON THE SAME DAY (STANDBY) SERVICES NOT ALLOWED ON THE SAME DAY (NEWBORN) SERVICES NOT ALLOWED ON THE SAME DAY (EPSDT) BED RAILS PURCHASED WITH BED NOT ALLOWED SAME DAY, SAME RECIPIENT, SAME PROVIDER NOT ALLOWED WITH EP STUDIES SERVICE NOT ALLOWED WITH NICU (VARIED) NOT ALLOWED WITH COMPONENT NOT ALLOWED WITH COMPONENT SPEECH THERAPIES NOT ALLOWED SAME DAY CMH SERVICES NOT ALLOWED SAME DAY NOT ALLOWED SAME DAY WITH CMH SERVICES NOT ALLOWED SAME DAY WITH CMH SERVICES NOT ALLOWED WITH C-SECTION NOT ALLOWED WITH 85018 NOT ALLOWED WITH 87220 NOT ALLOWED WITH PINWORM EXAM SERVICE NOT ALLOWED WITH CRITICAL CARE SERVICE NOT ALLOWED SAME DATE OF SERVICE/PROVIDER (VARIED SERVICE NOT ALLOWED WITH NICU SERVICE NOT ALLOWED SAME DATE OF SERVICE/PROVIDER (MEDICINE, PSYCH) SERVICE NOT ALLOWED SAME DATE OF SERVICE/PROVIDER (EMERGENCY SCREENING) SERVICE NOT ALLOWED SAME DATE OF SERVICE/PROVIDER (CPAP) SERVICE NOT ALLOWED SAME DATE OF SERVICE/PROVIDER (HOSPITAL CARE/FOLLOW-UP) SERVICE NOT ALLOWED SAME DATE OF SERVICE/PROVIDER (CIRCUMCISION) NOT ALLOWED SAME DATE OF SERVICE - OB NOT ALLOWED SAME DATE OF SERVICE ? HOME HEALTH NOT ALLOWED WITH ER SCREENING NOT ALLOWED WITH STFC CRISIS (S5145 HK) NOT ALLOWED WITH ROOT CANALS NOT ALLOWED WITH PULP DEBRIDE NOT ALLOWED WITH OFFICE REPAIR (W3056) NOT ALLOWED WITH DISPENSING (V0235) NOT ALLOWED SAME DAY SAME RECIPIENT SAME PROVIDER (LABOR MANAGEMENT) NOT ALLOWED SAME DAY SAME RECIPIENT SAME PROVIDER (LABOR MANAGEMENT) NOT ALLOWED SAME DAY SAME RECIPIENT SAME PROVIDER (LABOR MANAGEMENT) PPEC SERVICES NOT ALLOWED SAME DAY

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EOB (Explanation of Benefits) Codes and Description

EOB Code

5150 5151 5152 5415 5473 5474 5475 5476 5477 5500 5501 5512 5514 5578 5626 5627 5831 5924 5925 5926 5935 6030 6031 6032 6033 6034 6035 6037 6038 6039 6040 6041 6042 6043 6044 6046 6047 6052 6054 6055 6059 6060 6061 6062

EOB Description

SERVICES NOT ALLOWED ON THE SAME DAY SERVICES NOT ALLOWED ON THE SAME DAY (90749) PROCEDURE NOT ALLOWED SAME DATE OF SERVICE - PHARMACOLOGICAL MANAGEMENT PROCEDURE NOT ALLOWED WITH NOT ALLOWED WITH S5101 PROCEDURE CODE COMBINATION NOT ALLOWED PROCEDURE NOT ALLOWED WITH HEPATITIS PANEL BILLING 80059 OR 80074 PROCEDURE NOT ALLOWED WITH HEPATITIS PANEL BILLING 80059 OR 80074 PROCEDURE NOT ALLOWED WITH HEPATITIS PANEL BILLING 80059 OR 80074 PROCEDURE NOT ALLOWED WITH HEPATITIS PANEL BILLING 80059 OR 80074 STEP THERAPY REQUIREMENTS NOT MET FOR THIS DRUG INPATIENT CLAIM DUPLICATE OF OUTPATIENT CLAIM OR VICE VERSA. OUTPATIENT SERV NOT PAYABLE FOR DAY BEFORE OR SAME DAY OF AN INPATIENT ADMISSION. RURAL HEALTH ENCOUNTER LIMIT. CANNOT BILL MULTIPLE RURAL HEALTH ENCOUNTERS FOR THE SAME SERVICE DATE. FQHC ENCOUNTER LIMIT - CANNOT BILL MULTIPLE FQHC ENCOUNTERS FOR THE SAME SERVICE DATE. FIRST DATE OF SERVICE IS BEFORE THE RECIPIENTS DATE OF BIRTH. TAPE OR ASAP BILLING - DENY INVALID COMBINATION OF RPICC SERVICES. THERE IS TPL FOR THIS CLAIM INVALID COMBINATION OF RPICC SERVICES. THERE IS TPL FOR THIS CLAIM. PROCEDURE CANNOT BE BILLED INDEPENDENTLY THIS PROC IS CONSIDERED CONTENT OF SERVICE OF ANOTHER PROC BILLED ON THE SAME CLAIM THIS PROC IS CONTENT OF SERV OF A LESSER PROC BILLED ON A SEPARATE CLAIM OR PAID IN HISTORY THIS PROC IS CONTENT OF SERV OF A GREATER PROC BILLED ON A CLAIM OR PAID IN HISTORY COMPONENT LAB PROCEDURES SHOULD BE BILLED USING THE LAB PANEL CODE PROCEDURE IS LIMITED TO ONE TIME IN A ONE YEAR PERIOD. IF YOU BILLED FOR MORE THAN ONE UNIT ON THIS CLAIM, REBILL FOR ONE UNIT ONLY. PROCEDURE IS LIMITED TO ONE TIME IN A ONE YEAR PERIOD. IF YOU BILLED FOR MORE THAN ONE UNIT ON THIS CLAIM, REBILL FOR ONE UNIT ONLY. PROCEDURE IS LIMITED TO THREE TIMES IN ONE YEAR PERIOD PER RECIPIENT PROCEDURE LIMITED TO TWO TIMES IN A ONE YEAR PERIOD PROCEDURE LIMITED TO TWO TIMES IN A ONE YEAR PERIOD THIS PROCEDURE IS LIMITED TO FOUR TIMES IN A LIFETIME. RESUBMIT CLAIM AND ATTACH DOCUMENTATION WHICH JUSTIFIES EXCEEDING THE LIMIT. LIMIT FIVE TIMES PER LIFETIME DENTURE RELININGS ARE LIMITED TO ONE PER DENTURE IN ONE YEAR. THIS LIMIT HAS BEEN PREVIOUSLY MET. PROCEDURES APPLICABLE TO THIS EXCEPTION ARE LIMITED TO THREE IN A LIFETIME. THIS LIMIT HAS BEEN PREVIOUSLY MET. SERVICE LIMITED TO ONE IN 280 DAYS. THIS LIMIT HAS BEEN EXCEEDED PAID RELATED CLAIM MALOCCLUSION ADJUSTMENT LIMIT 24 PER LIFETIME INITIAL CONSULTATIONS ARE LIMITED TO ONE PER RECIPIENT PER PROVIDER CRUTCHES ARE LIMITED TO ONE PER YEAR THIS PROCEDURE CODE IS LIMITED TO TWO UNITS PER CLIENT PER MONTH PROCEDURE LIMITED TO 4 TIMES PER MONTH PER RECIPIENT WHEN PERFORMED IN A NURSING HOME. SERVICE LIMIT EXCEEDED. VISIT LIMITATION EXCEEDED TREATMENT PLAN CANNOT NOT EXCEED ONE PER STATE FISCAL YEAR HEARING AID DISPENSING FEES ARE LIMITED TO ONE IN THREE YEARS UNITS OF SERVICE EXCEED ALLOWED FOR THIS REVENUE CODE UNITS OF SERVICE EXCEED ALLOWED FOR THIS REVENUE CODE W1074 LIMITED TO 26 PER FISCAL YEAR FOR CMH MORE THAN TWO SURGEONS BILLED MODIFIER 62 FOR SAME RECIPIENT, DOS, PROCEDURE

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EOB (Explanation of Benefits) Codes and Description

EOB Code

6063 6064 6065 6066 6067 6068 6069 6071 6072 6073 6074 6075 6076 6079 6080 6081 6082 6083 6084 6085 6086 6087 6089 6090 6091 6092 6093 6095 6096 6097 6098 6099 6100 6101 6102 6103 6104 6105 6106 6107 6108 6109 6110 6111

EOB Description

CMH LIMIT TO ONE PER FISCAL YEAR BILLABLE LIMIT ONCE MONTHLY COMPREHENSIVE ASSESSMENT LIMITED TO ONE PER FISCAL YEAR PROCEDURE LIMITED TO ONE TIME IN SIX MONTHS NEBULIZER RENTAL LIMIT EXCEEDED. TREATMENT PLAN REVIEW LIMITED TO SIX TIMES PER FISCAL YEARS PROCEDURE IS LIMITED TO TWO TIMES IN THREE YEARS. IF YOU BILLED FOR MORE THAN TWO UNITS ON THIS CLAIM, REBILL FOR TWO UNITS ONLY. PROCEDURE LIMITED TO FOUR TIMES IN A LIFETIME ONE NEW HOME VISIT PER LIFE TIME PER PROVIDER PER RECIPIENT. THIS LIMIT HAS BEEN PREVIOUSLY MET. NEW PATIENT NURSING HOME VISITS ARE LIMITED TO ONE PER LIFETIME PER RECIPIENT PROCEDURE IS LIMITED TO TWO TIMES IN THREE YEARS. IF YOU BILLED FOR MORE THAN TWO UNITS ON THIS CLAIM, REBILL FOR TWO UNITS ONLY. SERVICE LIMITED TO ONE/THREE YEARS C-SECTIONS OR TOTAL OB CARE IS LIMITED TO ONE IN 300 DAYS PROCEDURE LIMITED TO FOUR TIMES IN A LIFETIME PROCEDURE CODE EXCEEDS UNITS OF SERVICE LIMIT. THIS PROCEDURE IS LIMITED TO TWO IN 280 DAYS NEPHRECTOMY IS LIMITED TO TWO IN A LIFETIME. THIS LIMIT HAS BEEN PREVIOUSLY MET. ORCHIECTOMY IS LIMITED TO TWO IN A LIFETIME. THIS LIMIT HAS BEEN PREVIOUSLY MET. SALPINGECTOMY/OOPHORECTOMY IS LIMITED TO TWO IN A LIFETIME. THIS LIMIT HAS BEEN PREVIOUSLY MET. APPENDECTOMY IS LIMITED TO ONE IN A LIFETIME. THIS LIMIT HAS BEEN PREVIOUSLY MET. NEW PATIENT VISIT HAS BEEN PREVIOUSLY PAID VISIT LIMITATION EXCEEDED THIS PROCEDURE LIMITED TO 6 UNITS PER YEAR PER CLIENT MASTOIDECTOMY IS LIMITED TO TWO IN A LIFETIME. THIS LIMIT HAS BEEN PREVIOUSLY MET. PROCEDURE CODE EXCEEDS UNITS OF SERVICE LIMIT LARYNGECTOMY IS LIMITED TO ONE PER LIFETIME PATIENT DUCTUS ARTERIOSUS IS LIMITED TO ONE TIME PER LIFETIME. THIS LIMIT HAS BEEN PREVIOUSLY MET. SPLENECTOMY IS LIMITED TO ONE TIME IN A LIFETIME. THIS LIMIT HAS BEEN PREVIOUSLY MET. LIMIT OF ONE PRENATAL PAYMENT A YEAR COMPLETE GASTRECTOMY IS LIMITED TO ONE IN A LIFETIME. THIS LIMIT HAS BEEN PREVIOUSLY MET. ONE PER MONTH ASSISTIVE CARE PROVIDERS CANNOT BILL FOR MORE THAN 31 UNITS PER MONTH. PLEASE CHECK THE SUBMITTED CLAIM FOR THE CORRECT UNITS. HEPATECTOMY IS LIMITED TO ONE TIME IN A LIFETIME. THIS LIMIT HAS BEEN PREVIOUSLY MET. CHOLECYSTECTOMY IS LIMITED TO ONE IN A LIFETIME. THIS LIMIT HAS BEEN PREVIOUSLY MET. CYSTECTOMY IS LIMITED TO ONE IN A LIFETIME. THIS LIMIT HAS BEEN PREVIOUSLY MET. NORMAL NEWBORN CARE. LIMIT 1 IN LIFETIME. TOTAL HYSTERECTOMY IS LIMITED TO ONE IN A LIFETIME. THIS LIMIT HAS BEEN PREVIOUSLY MET. C SECTION WITH HYSTERECTOMY IS LIMITED TO ONE IN A LIFETIME. THIS LIMIT HAS BEEN PREVIOUSLY MET. VAGINAL DELIVERIES OR TOTAL OB CARE IS LIMITED TO ONE PER RECIPIENT IN 280 DAYS. THIS LIMIT HAS BEEN PREVIOUSLY MET. SERVICES APPLICABLE TO THIS EDIT ARE LIMITED TO ONE IN 280 DAYS. THIS LIMIT HAS BEEN PREVIOUSLY MET. WHEEL CHAIR RENTAL LIMITED TO 10 PAYMENTS IN TEN MONTHS, ONCE PER LIFETIME PROCEDURES APPLICABLE TO THIS EDIT ARE LIMITED TO ONE IN THREE YEARS WALKERS ARE LIMITED TO ONE PER YEAR PROCEDURE APPLICABLE TO THIS EDIT ARE LIMITED TO 10 IN A LIFETIME

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EOB (Explanation of Benefits) Codes and Description

EOB Code

6112 6113 6114 6115 6116 6118 6119 6122 6123 6125 6126 6127 6128 6131 6132 6133 6134 6135 6136 6137 6138 6139 6140 6141 6142 6143 6144 6145 6146 6147 6148 6149 6150 6151 6152 6153 6154 6155 6156 6157 6158 6159 6160 6161 6162 6163 6164 6166 6167 6168 6169 6170 6171

EOB Description

RENTAL OF HOSPITAL BED SIDE RAILS IS LIMITED TO 10 IN A RECIPIENT?S LIFETIME THIS PROCEDURE IS LIMITED TO FOUR IN ONE WEEK. LIMIT HAS BEEN MET DESCRIPTION FOR THIS EOB IS NOT IN THE EOB DESCRIPTIONS ADJ RSN CD REMRK CD TEXT FILE. FOLLOW UP REQUIRED. THIS PROCEDURE IS LIMITED TO TWO TIMES IN A LIFETIME LIMITED TO 52 PER FISCAL YEAR CMH 2PROCEDURE LIMITED TO ONE TIME IN A ONE YEAR PERIOD 99203/99214 LIMITED TO ONE PER FISCAL YEAR FOR CMH THIS PROCEDURE IS LIMITED TO ONE TIME IN A LIFETIME THIS PROCEDURE IS LIMITED TO TWO TIMES IN A LIFETIME SERVICE LIMIT 224 UNITS IN 7 DAYS PER RECIPIENT THIS PROCEDURE IS LIMITED TO 10 IN 280 DAYS THIS PROCEDURE IS LIMITED TO 14 IN 280 DAYS ONE VISIT PER RECIPIENT PER PROVIDER PER MONTH CHIROPRACTIC SERVICES ARE LIMITED TO TWENTY-FOUR PER CALENDAR YEAR PROCEDURE IS LIMITED TO TWO TIMES IN THREE YEARS. IF YOU BILLED FOR MORE THAN TWO UNITS ON THIS CLAIM, REBILL FOR TWO UNITS ONLY. PROCEDURE CODE EXCEEDS UNITS OF SERVICE LIMIT PROCEDURE CODE EXCEEDS UNITS OF SERVICE LIMIT PROCEDURE CODE EXCEEDS UNITS OF SERVICE LIMIT PROCEDURE CODE EXCEEDS UNITS OF SERVICE LIMIT PROCEDURE CODE EXCEEDS UNITS OF SERVICE LIMIT PROCEDURE CODE EXCEEDS UNITS OF SERVICE LIMIT PROCEDURE CODE EXCEEDS UNITS OF SERVICE LIMIT PROCEDURE CODE EXCEEDS UNITS OF SERVICE LIMIT PROCEDURE CODE EXCEEDS UNITS OF SERVICE LIMIT PROCEDURE CODE EXCEEDS UNITS OF SERVICE LIMIT PROCEDURE CODE EXCEEDS UNITS OF SERVICE LIMIT PROCEDURE CODE EXCEEDS UNITS OF SERVICE LIMIT PROCEDURE CODE EXCEEDS UNITS OF SERVICE LIMIT PROCEDURE CODE EXCEEDS UNITS OF SERVICE LIMIT PROCEDURE CODE EXCEEDS UNITS OF SERVICE LIMIT PROCEDURE CODE EXCEEDS UNITS OF SERVICE LIMIT PROCEDURE CODE EXCEEDS UNITS OF SERVICE LIMIT PROCEDURE CODE EXCEEDS UNITS OF SERVICE LIMIT PROCEDURE CODE EXCEEDS UNITS OF SERVICE LIMIT PROCEDURE CODE EXCEEDS UNITS OF SERVICE LIMIT PROCEDURE CODE EXCEEDS UNITS OF SERVICE LIMIT PROCEDURE CODE EXCEEDS UNITS OF SERVICE LIMIT PROCEDURE CODE EXCEEDS UNITS OF SERVICE LIMIT PROCEDURE CODE EXCEEDS UNITS OF SERVICE LIMIT PROCEDURE CODE EXCEEDS UNITS OF SERVICE LIMIT PROCEDURE CODE EXCEEDS UNITS OF SERVICE LIMIT PROCEDURE CODE EXCEEDS UNITS OF SERVICE LIMIT PROCEDURE CODE EXCEEDS UNITS OF SERVICE LIMIT PROCEDURE CODE EXCEEDS UNITS OF SERVICE LIMIT PROCEDURE CODE EXCEEDS UNITS OF SERVICE LIMIT PROCEDURE CODE EXCEEDS UNITS OF SERVICE LIMIT PROCEDURE CODE EXCEEDS UNITS OF SERVICE LIMIT PROCEDURE CODE EXCEEDS UNITS OF SERVICE LIMIT PROCEDURE CODE EXCEEDS UNITS OF SERVICE LIMIT PROCEDURE CODE EXCEEDS UNITS OF SERVICE LIMIT PROCEDURE CODE EXCEEDS UNITS OF SERVICE LIMIT PROCEDURE CODE EXCEEDS UNITS OF SERVICE LIMIT PROCEDURE CODE EXCEEDS UNITS OF SERVICE LIMIT

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EOB (Explanation of Benefits) Codes and Description

EOB Code

6172 6173 6174 6175 6176 6177 6178 6179 6180 6181 6182 6183 6184 6185 6186 6187 6188 6189 6190 6191 6192 6193 6194 6195 6196 6197 6198 6199 6200 6201 6202 6203 6204 6205 6206 6207 6208 6209 6210 6211 6212 6213 6214 6215 6216 6217 6218 6219 6220 6221 6222 6223 6224 6225 6226 PROCEDURE PROCEDURE PROCEDURE PROCEDURE PROCEDURE PROCEDURE PROCEDURE PROCEDURE PROCEDURE PROCEDURE PROCEDURE PROCEDURE PROCEDURE PROCEDURE PROCEDURE PROCEDURE PROCEDURE PROCEDURE PROCEDURE PROCEDURE PROCEDURE PROCEDURE PROCEDURE PROCEDURE PROCEDURE PROCEDURE PROCEDURE PROCEDURE PROCEDURE PROCEDURE PROCEDURE PROCEDURE PROCEDURE PROCEDURE PROCEDURE PROCEDURE PROCEDURE PROCEDURE PROCEDURE PROCEDURE PROCEDURE PROCEDURE PROCEDURE PROCEDURE PROCEDURE PROCEDURE PROCEDURE PROCEDURE PROCEDURE PROCEDURE PROCEDURE PROCEDURE PROCEDURE PROCEDURE PROCEDURE CODE CODE CODE CODE CODE CODE CODE CODE CODE CODE CODE CODE CODE CODE CODE CODE CODE CODE CODE CODE CODE CODE CODE CODE CODE CODE CODE CODE CODE CODE CODE CODE CODE CODE CODE CODE CODE CODE CODE CODE CODE CODE CODE CODE CODE CODE CODE CODE CODE CODE CODE CODE CODE CODE CODE EXCEEDS EXCEEDS EXCEEDS EXCEEDS EXCEEDS EXCEEDS EXCEEDS EXCEEDS EXCEEDS EXCEEDS EXCEEDS EXCEEDS EXCEEDS EXCEEDS EXCEEDS EXCEEDS EXCEEDS EXCEEDS EXCEEDS EXCEEDS EXCEEDS EXCEEDS EXCEEDS EXCEEDS EXCEEDS EXCEEDS EXCEEDS EXCEEDS EXCEEDS EXCEEDS EXCEEDS EXCEEDS EXCEEDS EXCEEDS EXCEEDS EXCEEDS EXCEEDS EXCEEDS EXCEEDS EXCEEDS EXCEEDS EXCEEDS EXCEEDS EXCEEDS EXCEEDS EXCEEDS EXCEEDS EXCEEDS EXCEEDS EXCEEDS EXCEEDS EXCEEDS EXCEEDS EXCEEDS EXCEEDS UNITS UNITS UNITS UNITS UNITS UNITS UNITS UNITS UNITS UNITS UNITS UNITS UNITS UNITS UNITS UNITS UNITS UNITS UNITS UNITS UNITS UNITS UNITS UNITS UNITS UNITS UNITS UNITS UNITS UNITS UNITS UNITS UNITS UNITS UNITS UNITS UNITS UNITS UNITS UNITS UNITS UNITS UNITS UNITS UNITS UNITS UNITS UNITS UNITS UNITS UNITS UNITS UNITS UNITS UNITS OF OF OF OF OF OF OF OF OF OF OF OF OF OF OF OF OF OF OF OF OF OF OF OF OF OF OF OF OF OF OF OF OF OF OF OF OF OF OF OF OF OF OF OF OF OF OF OF OF OF OF OF OF OF OF

EOB Description

SERVICE SERVICE SERVICE SERVICE SERVICE SERVICE SERVICE SERVICE SERVICE SERVICE SERVICE SERVICE SERVICE SERVICE SERVICE SERVICE SERVICE SERVICE SERVICE SERVICE SERVICE SERVICE SERVICE SERVICE SERVICE SERVICE SERVICE SERVICE SERVICE SERVICE SERVICE SERVICE SERVICE SERVICE SERVICE SERVICE SERVICE SERVICE SERVICE SERVICE SERVICE SERVICE SERVICE SERVICE SERVICE SERVICE SERVICE SERVICE SERVICE SERVICE SERVICE SERVICE SERVICE SERVICE SERVICE LIMIT LIMIT LIMIT LIMIT LIMIT LIMIT LIMIT LIMIT LIMIT LIMIT LIMIT LIMIT LIMIT LIMIT LIMIT LIMIT LIMIT LIMIT LIMIT LIMIT LIMIT LIMIT LIMIT LIMIT LIMIT LIMIT LIMIT LIMIT LIMIT LIMIT LIMIT LIMIT LIMIT LIMIT LIMIT LIMIT LIMIT LIMIT LIMIT LIMIT LIMIT LIMIT LIMIT LIMIT LIMIT LIMIT LIMIT LIMIT LIMIT LIMIT LIMIT LIMIT LIMIT LIMIT LIMIT

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EOB (Explanation of Benefits) Codes and Description

EOB Code

6227 6228 6229 6230 6231 6232 6233 6234 6235 6236 6237 6238 6239 6240 6241 6242 6243 6244 6245 6246 6247 6248 6249 6250 6251 6252 6253 6254 6255 6256 6257 6258 6259 6260 6261 6262 6263 6264 6265 6266 6267 6268 6269 6270 6271 6272 6273 6274 6275 6276 6277 6278 6279 6280 6281 PROCEDURE PROCEDURE PROCEDURE PROCEDURE PROCEDURE PROCEDURE PROCEDURE PROCEDURE PROCEDURE PROCEDURE PROCEDURE PROCEDURE PROCEDURE PROCEDURE PROCEDURE PROCEDURE PROCEDURE PROCEDURE PROCEDURE PROCEDURE PROCEDURE PROCEDURE PROCEDURE PROCEDURE PROCEDURE PROCEDURE PROCEDURE PROCEDURE PROCEDURE PROCEDURE PROCEDURE PROCEDURE PROCEDURE PROCEDURE PROCEDURE PROCEDURE PROCEDURE PROCEDURE PROCEDURE PROCEDURE PROCEDURE PROCEDURE PROCEDURE PROCEDURE PROCEDURE PROCEDURE PROCEDURE PROCEDURE PROCEDURE PROCEDURE PROCEDURE PROCEDURE PROCEDURE PROCEDURE PROCEDURE CODE CODE CODE CODE CODE CODE CODE CODE CODE CODE CODE CODE CODE CODE CODE CODE CODE CODE CODE CODE CODE CODE CODE CODE CODE CODE CODE CODE CODE CODE CODE CODE CODE CODE CODE CODE CODE CODE CODE CODE CODE CODE CODE CODE CODE CODE CODE CODE CODE CODE CODE CODE CODE CODE CODE EXCEEDS EXCEEDS EXCEEDS EXCEEDS EXCEEDS EXCEEDS EXCEEDS EXCEEDS EXCEEDS EXCEEDS EXCEEDS EXCEEDS EXCEEDS EXCEEDS EXCEEDS EXCEEDS EXCEEDS EXCEEDS EXCEEDS EXCEEDS EXCEEDS EXCEEDS EXCEEDS EXCEEDS EXCEEDS EXCEEDS EXCEEDS EXCEEDS EXCEEDS EXCEEDS EXCEEDS EXCEEDS EXCEEDS EXCEEDS EXCEEDS EXCEEDS EXCEEDS EXCEEDS EXCEEDS EXCEEDS EXCEEDS EXCEEDS EXCEEDS EXCEEDS EXCEEDS EXCEEDS EXCEEDS EXCEEDS EXCEEDS EXCEEDS EXCEEDS EXCEEDS EXCEEDS EXCEEDS EXCEEDS UNITS UNITS UNITS UNITS UNITS UNITS UNITS UNITS UNITS UNITS UNITS UNITS UNITS UNITS UNITS UNITS UNITS UNITS UNITS UNITS UNITS UNITS UNITS UNITS UNITS UNITS UNITS UNITS UNITS UNITS UNITS UNITS UNITS UNITS UNITS UNITS UNITS UNITS UNITS UNITS UNITS UNITS UNITS UNITS UNITS UNITS UNITS UNITS UNITS UNITS UNITS UNITS UNITS UNITS UNITS OF OF OF OF OF OF OF OF OF OF OF OF OF OF OF OF OF OF OF OF OF OF OF OF OF OF OF OF OF OF OF OF OF OF OF OF OF OF OF OF OF OF OF OF OF OF OF OF OF OF OF OF OF OF OF

EOB Description

SERVICE SERVICE SERVICE SERVICE SERVICE SERVICE SERVICE SERVICE SERVICE SERVICE SERVICE SERVICE SERVICE SERVICE SERVICE SERVICE SERVICE SERVICE SERVICE SERVICE SERVICE SERVICE SERVICE SERVICE SERVICE SERVICE SERVICE SERVICE SERVICE SERVICE SERVICE SERVICE SERVICE SERVICE SERVICE SERVICE SERVICE SERVICE SERVICE SERVICE SERVICE SERVICE SERVICE SERVICE SERVICE SERVICE SERVICE SERVICE SERVICE SERVICE SERVICE SERVICE SERVICE SERVICE SERVICE LIMIT LIMIT LIMIT LIMIT LIMIT LIMIT LIMIT LIMIT LIMIT LIMIT LIMIT LIMIT LIMIT LIMIT LIMIT LIMIT LIMIT LIMIT LIMIT LIMIT LIMIT LIMIT LIMIT LIMIT LIMIT LIMIT LIMIT LIMIT LIMIT LIMIT LIMIT LIMIT LIMIT LIMIT LIMIT LIMIT LIMIT LIMIT LIMIT LIMIT LIMIT LIMIT LIMIT LIMIT LIMIT LIMIT LIMIT LIMIT LIMIT LIMIT LIMIT LIMIT LIMIT LIMIT LIMIT

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EOB (Explanation of Benefits) Codes and Description

EOB Code

6282 6283 6284 6285 6286 6287 6288 6289 6290 6291 6292 6293 6294 6295 6296 6297 6298 6299 6300 6301 6302 6303 6304 6305 6306 6307 6308 6309 6310 6311 6312 6313 6314 6315 6316 6317 6318 6319 6320 6321 6322 6323 6324 6325 6326 6328 6329 6330 6331 6332 6333

EOB Description

PROCEDURE CODE EXCEEDS UNITS OF SERVICE LIMIT UNIT/VISIT LIMIT EXCEEDED UNIT/VISIT LIMIT EXCEEDED UNIT/VISIT LIMIT EXCEEDED UNIT/VISIT LIMIT EXCEEDED PROCEDURE CODE EXCEEDS UNITS OF SERVICE LIMIT PROCEDURE CODE EXCEEDS UNITS OF SERVICE LIMIT PROCEDURE CODE EXCEEDS UNITS OF SERVICE LIMIT PROCEDURE CODE EXCEEDS UNITS OF SERVICE LIMIT PROCEDURE CODE EXCEEDS UNITS OF SERVICE LIMIT PROCEDURE CODE EXCEEDS UNITS OF SERVICE LIMIT PROCEDURE CODE EXCEEDS UNITS OF SERVICE LIMIT PROCEDURE CODE EXCEEDS UNITS OF SERVICE LIMIT PROCEDURE CODE EXCEEDS UNITS OF SERVICE LIMIT PROCEDURE CODE EXCEEDS UNITS OF SERVICE LIMIT PROCEDURE CODE EXCEEDS UNITS OF SERVICE LIMIT PROCEDURE CODE EXCEEDS UNITS OF SERVICE LIMIT PROCEDURE CODE EXCEEDS UNITS OF SERVICE LIMIT PROCEDURE CODE EXCEEDS UNITS OF SERVICE LIMIT PROCEDURE CODE EXCEEDS UNITS OF SERVICE LIMIT PROCEDURE CODE EXCEEDS UNITS OF SERVICE LIMIT PROCEDURE CODE EXCEEDS UNITS OF SERVICE LIMIT PROCEDURE CODE EXCEEDS UNITS OF SERVICE LIMIT PROCEDURE CODE EXCEEDS UNITS OF SERVICE LIMIT PROCEDURE CODE EXCEEDS UNITS OF SERVICE LIMIT PROCEDURE CODE EXCEEDS UNITS OF SERVICE LIMIT PROCEDURE CODE EXCEEDS UNITS OF SERVICE LIMIT PROCEDURE CODE EXCEEDS UNITS OF SERVICE LIMIT PROCEDURE CODE EXCEEDS UNITS OF SERVICE LIMIT PROCEDURE CODE EXCEEDS UNITS OF SERVICE LIMIT PROCEDURE CODE EXCEEDS UNITS OF SERVICE LIMIT PROCEDURE CODE EXCEEDS UNITS OF SERVICE LIMIT PROCEDURE CODE EXCEEDS UNITS OF SERVICE LIMIT PROCEDURE CODE EXCEEDS UNITS OF SERVICE LIMIT PROCEDURE CODE EXCEEDS UNITS OF SERVICE LIMIT PROCEDURE CODE EXCEEDS UNITS OF SERVICE LIMIT PROCEDURE CODE EXCEEDS UNITS OF SERVICE LIMIT PROCEDURE CODE EXCEEDS UNITS OF SERVICE LIMIT PROCEDURE CODE EXCEEDS UNITS OF SERVICE LIMIT PROCEDURE CODE EXCEEDS UNITS OF SERVICE LIMIT THIS PROCEDURE LIMITED TO ONCE IN A LIFETIME. THIS LIMIT HAS BEEN PREVIOUSLY MET. CHIROPRACTIC SERVICES ARE LIMITED TO TWELVE IN TWELVE MONTHS THIS PROCEDURE LIMITED TO $500.00 PER MONTH PER CLIENT THIS PROCEDURE LIMITED TO $500.00 PER MONTH PER CLIENT SERVICE NOT AUTHORIZED BY MEDIPASS PRIMARY CARE PHYSICIAN. REFERRING PHYSICIAN NOT MEDIPASS PRIMARY CARE PHYSICIAN. CONSENT FORM INCOMPLETE. YOU MAY COMPLETE ANY ITEM ON THE FORM EXCEPT SIGNATURE AND DATE OF: PATIENT, PERSON OBTAINING CONSENT AND INTERPRETER. CONSENT FORM INCOMPLETE. YOU MAY COMPLETE ANY ITEM ON THE FORM EXCEPT SIGNATURE AND DATE OF: PATIENT, PERSON OBTAINING CONSENT AND INTERPRETER. TREATMENT PLAN CANNOT NOT EXCEED ONE PER STATE FISCAL YEAR SERVICE LIMITED TO ONE IN 280 DAYS. THIS LIMIT HAS BEEN EXCEEDED ASSISTIVE CARE PROVIDERS CANNOT BILL FOR MORE THAN 31 UNITS PER MONTH. PLEASE CHECK THE SUBMITTED CLAIM FOR THE CORRECT UNITS. THIS PROCEDURE IS LIMITED TO ONE IN SEVEN DAYS

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EOB (Explanation of Benefits) Codes and Description

EOB Code

6334 6335 6336 6337 6338 6339 6340 6341 6342 6343 6344 6345 6346 6347 6348 6349 6350 6351 6352 6353 6354 6355 6356 6357 6358 6359 6360 6361 6362 6363 6364 6365 6368 6369 6370 6371 6372 6373 6374 6375 6376 6377 6378 6379 6380 6514 6554 6658 6660 6661 6700 6701 6702

EOB Description

PROCEDURE CODE EXCEEDS UNITS OF SERVICE LIMIT PROCEDURE CODE EXCEEDS UNITS OF SERVICE LIMIT PROCEDURE CODE EXCEEDS UNITS OF SERVICE LIMIT PROCEDURE CODE EXCEEDS UNITS OF SERVICE LIMIT PROCEDURE CODE EXCEEDS UNITS OF SERVICE LIMIT PROCEDURE CODE EXCEEDS UNITS OF SERVICE LIMIT PROCEDURE CODE EXCEEDS UNITS OF SERVICE LIMIT PROCEDURE CODE EXCEEDS UNITS OF SERVICE LIMIT PROCEDURE CODE EXCEEDS UNITS OF SERVICE LIMIT PROCEDURE CODE EXCEEDS UNITS OF SERVICE LIMIT PROCEDURE CODE EXCEEDS UNITS OF SERVICE LIMIT PROCEDURE CODE EXCEEDS UNITS OF SERVICE LIMIT PROCEDURE CODE EXCEEDS UNITS OF SERVICE LIMIT PROCEDURE CODE EXCEEDS UNITS OF SERVICE LIMIT HMO REFORM SERVICE LIMIT OF 280 DAYS FOR OB SERVICES HOSPITAL BEDS LIMITED TO 10 RENTAL PAYMENTS IN A RECIPIENTS LIFETIME TREATMENT PLAN CANNOT NOT EXCEED ONE PER STATE FISCAL YEAR TREATMENT PLAN REVIEW LIMITED TO SIX TIMES PER FISCAL YEARS LENS TINTS ARE LIMITED TO TWO IN TWO YEARS CANES ARE LIMITED TO ONE PER YEAR BENEFIT CAP LIMIT HAS BEEN EXCEEDED PROCEDURE MODIFIER BILLED REQUIRES MANUAL PRICING. PLEASE RESUBMIT WITH MEDICAL REPORT ATTACHED. BENEFIT CAP LIMIT HAS BEEN EXCEEDED BENEFIT CAP LIMIT HAS BEEN EXCEEDED BENEFIT CAP LIMIT HAS BEEN EXCEEDED BENEFIT CAP LIMIT HAS BEEN EXCEEDED SNU MAX DAYS EXCEEDED BENEFIT CAP LIMIT HAS BEEN EXCEEDED BENEFIT CAP LIMIT HAS BEEN EXCEEDED BENEFIT CAP LIMIT HAS BEEN EXCEEDED HOSPICE CAP LIMIT REACHED PROCEDURE LIMITED TO TWO TIMES IN A ONE YEAR PERIOD PROCEDURE CODE EXCEEDS UNITS OF SERVICE LIMIT CLAIM/DETAIL DENIED. T1028 UA LIMITED TO 2 UNITS PER 366 DAYS. CLAIM/DETAIL DENIED. PROCEDURE LIMITED TO 1 UNIT PER MONTH. CLAIM/DETAIL DENIED. PROCEDURE LIMITED TO $7500 PER 366 DAYS. CLAIM/DETAIL DENIED. PROCEDURE LIMITED TO $10,000 PER 366 DAYS. CLAIM/DETAIL DENIED. PROCEDURE LIMITED TO $300 PER 366 DAYS. CLAIM/DETAIL DENIED. PROCEDURE LIMITED TO $5000 PER 366 DAYS. CLAIM/DETAIL DENIED. THIS PROCEDURE CODE LIMITED TO 14 UNITS PER MONTH. CLAIM/DETAIL DENIED. THIS PROCEDURE CODE LIMITED TO 1 UNIT PER 8 YEARS. CLAIM/DETAIL DENIED. PROCEDURE LIMITED TO 1 PER MONTH. CLAIM/DETAIL DENIED. PROCEDURE LIMITED TO 1 UNIT PER 8 YEARS. CLAIM/DETAIL DENIED. PROCEDURE LIMITED TO 52 PER 365 DAYS. CLAIM/DETAIL DENIED. PROCEDURE LIMITED TO 1 PER MONTH. HOME HEALTH LIMITS EXCEEDED FOR 1 MONTH WAIVER LIMIT FOR PHARMACY HAS BEEN REACHED DUPLICATE DENTAL RESIN WITHIN THREE YEARS THERAPEUTIC LEAVE DAYS GREATER THAN 14 CANNOT BE BILLED PROFESSIONAL AND TECHNICAL COMPONENTS OF SERVICES ARE NOT PAYABLE WHEN THE COMPREHENSIVE SERVICE HAS BEEN PAID FOLLOW-UP VISITS NOT PAYABLE WITHIN 10 DAYS OF SURGICAL PROCEDURE FOLLOW-UP VISITS NOT PAYABLE WITHIN 30 DAYS OF SURGICAL PROCEDURE FOLLOW-UP VISITS NOT PAYABLE WITHIN 45 DAYS OF SURGICAL PROCEDURE

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EOB (Explanation of Benefits) Codes and Description

EOB Code

6703 6704 6734 6735 6861 6863 7000 7001 7010 7200 7201 7202 7203 7204 7205 7206 7207 7208 7209 7210 7211 7212 7213 7214 7215 7216 7217 7218 7219 7220 7221 7222 7223 7233 7234 7235 7236 7237 7238 7239 7240 7241 7242 7243 7244 7245 7246 7247 7248 7249 7250 7251 7252

EOB Description

FOLLOW-UP VISITS NOT PAYABLE WITHIN 60 DAYS OF SURGICAL PROCEDURE FOLLOW-UP VISITS NOT PAYABLE WITHIN 90 DAYS OF SURGICAL PROCEDURE SERVICE NOT AUTHORIZED BY MEDIPASS PRIMARY CARE PHYSICIAN. REFERRING PHYSICIAN NOT MEDIPASS PRIMARY CARE PHYSICIAN. SERVICE NOT AUTHORIZED BY MEDIPASS PRIMARY CARE PHYSICIAN. REFERRING PHYSICIAN NOT MEDIPASS PRIMARY CARE PHYSICIAN. PROCEDURE INVALID IN NURSING HOME POSSIBLE DUPLICATE CONFLICT. MAY BE A CONFLICT WITH ANOTHER PROVIDERS CLAIM CLAIM FAILED A PRODUR ALERT CLAIM GENERATED AN INFORMATIONAL PRODUR ALERT TOTAL UNITS GREATER THAN TOT DAYS MISCELLANEOUS CLAIMCHECK ERROR PROCEDURE IS A NEWBORN PROCEDURE; AGE SHOULD BE LESS THAN 1 YEAR PROCEDURE IS A PEDIATRIC PROCEDURE; AGE SHOULD BE 1-17 YEARS PROCEDURE IS A MATERNITY PROCEDURE; AGE SHOULD BE 12-55 YEARS PROCEDURE IS AN ADULT PROCEDURE; AGE SHOULD BE OVER 14 YEARS PROCEDURE IS NOT INDICATED FOR A MALE PROCEDURE IS NOT INDICATED FOR A FEMALE PROCEDURE IS CLASSIFIED AS A COSMETIC PROCEDURE PROCEDURE IS AN UNLISTED PROCEDURE PROCEDURE IS CLASSIFIED AS EXPERIMENTAL PROCEDURE IS CLASSIFIED AS OBSOLETE PROCEDURE IS INVALID FOR PATIENTS AGE PROCEDURE ADDED DUE TO ALTERNATE CODE REPLACEMENT (AGE) PROCEDURE IS INVALID FOR PATIENTS SEX PROCEDURE ADDED DUE TO ALTERNATE CODE REPLACEMENT (SEX) PROCEDURE CODE IS INCIDENTAL VISIT PROCEDURE CODE IS NOT INDICATED FOR SEPARATE REIMBURSEMENT PROCEDURE CODE HAS BEEN REBUNDLED PROCEDURE ADDED DUE TO REBUNDLING PROCEDURE IS MUTUALLY EXCLUSIVE PROCEDURE IS WITHIN THE NUMBER OF DAYS PRE-OP RANGE PROCEDURE IS WITHIN THE NUMBER OF DAYS POST-OP RANGE PROCEDURE DOES NOT REQUIRE AN ASSISTANT SURGEON PROCEDURE MAY NOT REQUIRE AN ASSISTANT SURGEON DUPLICATE DENIED - INCLUDES UNILATERAL OR BILATERAL DENIED DUPLICATE - IS BILATERAL DENIED DUPLICATE - CAN ONLY BE DONE XX TIMES IN LIFETIME DENIED DUPLICATE - CAN ONLY BE DONE XX TIMES IN A DAY DENIED DUPLICATE (REBUNDLED) PROCEDURE ADDED DUE TO DUPLICATE REBUNDLING PROCEDURE IS A POSSIBLE DUPLICATE SMARTSUSPENSE SUSPEND SMARTSUSPENSE DENIAL DIAGNOSIS TO PROCEDURE COMPARISON PROCEDURE DENIED DIAGNOSIS TO PROCEDURE COMPARISON PROCEDURE SUSPENDED MEDICAL VISIT DENIED PROCEDURE ADDED DUE TO NEW VISIT FREQUENCY CODE REPLACEMENT PROCEDURE REPLACED DUE TO INTENSITY OF SERVICE REPLACEMENT PROCEDURE ADDED DUE TO INTENSITY OF SERVICE REPLACEMENT INTENSITY OF PROCEDURE WAS FOUND TO BE HIGHER THAN EXPECTED BASED ON DIAGNOSIS PROCEDURE SHOULD BE REVIEWED AS POSSIBLE MULTIPLE COMPONENT PROCEDURE SHOULD BE REVIEWED AS POSSIBLE DUPLICATE COMPONENT PROCEDURE IS ELIGIBLE FOR WORKERS COMPENSATION/AUTO PAYOR DIAGNOSIS 1 HAS BEEN DETECTED AS BEING ELIGIBLE FOR 3RD PARTY PAYOR BY CLAIMC

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EOB (Explanation of Benefits) Codes and Description

EOB Code

7253 7254 7255 7256 7257 7258 7259 7260 7261 7262 7263 7264 7265 7266 7267 7268 7269 7270 7271 7272 7273 7274 7275 7276 7277 7278 7279 7280 7281 7282 7283 7284 7285 7286 7287 7288 7289 7291 7499 7500 7501 7502 7503 7504 7505 7506 7507 7508 7509 7834 8000 8001 8002

EOB Description

DIAGNOSIS 2 HAS BEEN DETECTED AS BEING ELIGIBLE FOR 3RD PARTY PAYOR BY CLAIMC DIAGNOSIS 3 HAS BEEN DETECTED AS BEING ELIGIBLE FOR 3RD PARTY PAYOR BY CLAIMC DIAGNOSIS 4 HAS BEEN DETECTED AS BEING ELIGIBLE FOR 3RD PARTY PAYOR BY CLAIMC MODIFIER 51 INVALID FOR PRIMARY PROCEDURE MODIFIER 51 MISSING FOR NON-PRIMARY PROCEDURE REVIEW MODIFIER 51 SPLIT DECISION WAS RENDERED ON EXPANSION OF UNITS MORE THAN 40 LINES WERE ELIGIBLE FOR CLAIMCHECK PROCESSING INVALID CHCUP REFERRAL CODE DOB CANNOT BE GREATER THAN DATE OF SERVICE DOS REQUIRED FOR PROCEDURE DOS CANNOT BE A FUTURE DATE BIRTHDATE CANNOT BE A FUTURE DATE AGE CANNOT BE GREATER THAN 124 YEARS ONLY ONE PROVIDER ALLOWED FOR CURRENT PROCEDURES PROVIDER IS REQUIRED FOR HISTORY PROCEDURES MODIFIER NOT VALID FOR THIS PROCEDURE INVALID MODIFIER/PROCEDURE CODE COMBINATION CURRENT PROCEDURE LINES MUST HAVE SAME PROVIDER ID DIAGNOSIS 1 MUST BE A VALID CODE DIAGNOSIS 2 MUST BE A VALID CODE DIAGNOSIS 3 MUST BE A VALID CODE DIAGNOSIS 4 MUST BE A VALID CODE DIAGNOSIS MUST BE A VALID CODE PROCEDURE LINE DIAGNOSIS MUST BE A VALID CODE INVALID DATE (DATE OF BIRTH) INVALID AMOUNT CHARGED CLAIM LEVEL PROVIDER OR PROCEDURE LINE PROVIDER IS REQUIRED DIAGNOSIS TO PROCEDURE COMPARISON PROCEDURE INTENSITY OF PROCEDURE WAS FOUND TO BE HIGHER THAN EXPECTED BASED ON DIAGNOSIS PROCEDURE SHOULD BE REVIEWED AS POSSIBLE MULTIPLE COMPONENT PROCEDURE SHOULD BE REVIEWED AS POSSIBLE DUPLICATE COMPONENT PROCEDURE IS ELIGIBLE FOR WORKERS COMPENSATION/AUTO PAYOR DIAGNOSIS IS ELIGIBLE FOR WORKERS COMPENSATION/AUTO PAYOR DIAGNOSIS IS ELIGIBLE FOR WORKERS COMPENSATION/AUTO PAYOR SMARTSUSPENSE FLAG SMARTSUSPENSE MONITOR MODIFIER 51 ADDED FOR NON-PRIMARY PROCEDURE INVALID R.A.P. REFERRING PROVIDER NUMBER YOUR CLAIM IS BEING REVIEWED YOUR CLAIM IS BEING REVIEWED MEMBER LOCKED IN TO A SPECIFIC PROVIDER MISSING/INVALID PRODUR CONFLICT CODE. ALERT ON RESPONSE DOES NOT MATCH AN ALERT SET ON THE CLAIM. PLEASE USE APPROPRIATE DD, LD, HD, ER, LR, PA, PG, MC, TD MISSING/INVALID PRODUR INTERVENTION CODE. PLEASE USE M0, P0 OR R0 AND RESUBMIT. MISSING/INVALID PRODUR OUTCOME CODE. PLEASE USE 1A-1G, 2A OR 2B RESPONSE CLAIM. ORIGINAL CLAIM FAILED A NON-OVERRIDEABLE ALERT CONTACT, COLLEGE OF PHARMACY TO RECEIVE PRIOR AUTHORIZATION. VALID OUTCOME CODE OF (NOT FILLED) RECEIVED. RESPONSE ACCEPTED, CLAIM REJECTED. QUANTITY DISPENSED ON RESPONSE CLAIM SAME AS ORIGINAL CLAIM RENDERING PROVIDER ON PREPAYMENT REVIEW RECIPIENT SERVICES COVERED BY PMHP PLAN PROVIDER REQUESTED ADDITIONAL PAYMENT DUE TO BILLING ERROR. PROVIDER REQUESTED ADDITIONAL PAYMENT DUE TO CHANGE IN OTHER PROVIDER REQUESTED ADDITIONAL PAYMENT DUE TO CHANGE IN MEDICARE

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EOB (Explanation of Benefits) Codes and Description

EOB Code

8003 8004 8005 8006 8007 8008 8019 8020 8021 8022 8023 8024 8025 8026 8027 8028 8030 8031 8032 8033 8034 8035 8036 8037 8038 8059 8060 8061 8062 8063 8064 8065 8066 8067 8068 8069 8070 8071 8072 8073 8074 8075 8082 8083 8084 8085 8090 8091 8092 8093 8094 8095 8096 8097 8098

EOB Description

PROVIDER REQUESTED ADDITIONAL PAYMENT DUE TO KEYING ERROR PROVIDER REQUESTED ADDITIONAL PAYMENT DUE TO PATIENT LIABILITY PROVIDER REQUESTED ADDITIONAL PAYMENT DUE TO SPENDDOWN PROVIDER REQUESTED ADDITIONAL PAYMENT DUE TO MISCELLANEOUS ERROR PROVIDER REQUESTED CLAIM ADJUSTMENT DUE TO BILLING ERROR PROVIDER REQUESTED CLAIM ADJUSTMENT DUE TO MISC OR UNSPECIFIED ERROR PROVIDER REQUESTED A FULL OFFSET DUE TO A MISCELLANEOUS OR UNSPECIFIED ERROR SURS INITIATED A FULL OFFSET DUE TO A DUPLICATE PAYMENT SURS INITIATED A FULL OFFSET DUE TO WRONG PROVIDER SURS INITIATED A FULL OFFSET DUE TO WRONG MEMBER NUMBER SURS INITIATED A FULL OFFSET DUE TO WRONG NDC/PROCEDURE CODE/MODIFIER CODE SURS INITIATED A FULL OFFSET DUE TO WRONG UNITS OF SERVICE SURS INITIATED A FULL OFFSET DUE TO WRONG PATIENT LIABILITY AMOUNT SURS INITIATED A FULL OFFSET DUE TO PAYMENT IN FULL FROM ANOTHER INSURANCE SURS INITIATED A FULL OFFSET DUE TO PAYMENT IN FULL FROM MEDICARE SURS INITIATED A FULL OFFSET DUE TO WRONG DATE(S) OF SERVICE PROVIDER REQUESTED OFFSET DUE TO BILLING ERROR PROVIDER REQUESTED OFFSET DUE TO OTHER INSURANCE PROVIDER REQUESTED OFFSET DUE MEDICARE PROVIDER REQUESTED OFFSET DUE TO PATIENT LIABILITY PROVIDER REQUESTED OFFSET DUE TO SPENDDOWN PROVIDER REQUESTED OFFSET DUE TO AUTO LIABILITY PROVIDER REQUESTED OFFSET DUE TO WORKERS COMP PROVIDER REQUESTED CLAIM VOID DUE TO BILLING ERROR PROVIDER REQUESTED OFFSET DUE TO MISCELLANEOUS OR UNSPECIFIED ERROR PROVIDER SENT A FULL REFUND DUE TO MISCELLANEOUS OR UNSPECIFIED ERROR PROVIDER SENT REFUND DUE TO BILLING ERROR. PROVIDER SENT REFUND DUE TO CLAIMS PROCESSING ERROR PROVIDER SENT REFUND DUE TO DUPLICATE PAYMENT PROVIDER SENT REFUND DUE TO EFT DEPOSIT ERROR. PROVIDER SENT REFUND DUE TO MEDICARE. PROVIDER SENT REFUND DUE TO OFMQ REVIEW. PROVIDER SENT REFUND DUE TO OTHER INSURANCE PROVIDER SENT REFUND DUE TO SURS REVIEW PROVIDER SENT REFUND PAYMENT DUE TO SURS REVIEW PROVIDER SENT REFUND DUE TO LEGAL SETTLEMENT PROVIDER SENT REFUND DUE TO MEDICAID FRAUD PROVIDER SENT REFUND PAYMENT DUE TO MEDICAID FRAUD PROVIDER SENT REFUND DUE TO AUTO LIABILITY PROVIDER SENT REFUND DUE TO WORKERS COMP. PROVIDER SENT REFUND FOR CLAIM NOT IN HISTORY PROVIDER SENT REFUND DUE TO MISCELLANEOUS OR UNSPECIFIED ERROR NON-CLAIM SPECIFIC REFUND DUE TO BILLING ERROR NON-CLAIM SPECIFIC REFUND DUE TO OTHER INSURANCE NON-CLAIM SPECIFIC REFUND DUE TO SURS NON-CLAIM SPECIFIC REFUND DUE TO MISC OR UNSPECIFIED ERROR AHCA REQUESTED REFUND DUE TO ACCOUNTS RECEIVABLE AHCA REQUESTED REFUND DUE TO AUDIT DIVISION REVIEW AHCA REQUESTED REFUND DUE TO BILLING ERROR AHCA REQUESTED REFUND DUE TO CLAIMS PROCESSING ERROR AHCA REQUESTED REFUND DUE TO WRONG PROVIDER PAID/EFT ERROR AHCA REQUESTED REFUND DUE TO MEDICARE AHCA REQUESTED REFUND DUE TO OFMQ AHCA REQUESTED REFUND DUE TO OTHER INSURANCE AHCA REQUESTED REFUND DUE TO SURS REVIEW

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EOB (Explanation of Benefits) Codes and Description

EOB Code

8099 8100 8110 8111 8112 8113 8114 8115 8116 8117 8118 8119 8120 8121 8122 8123 8124 8125 8126 8127 8128 8129 8130 8131 8132 8133 8134 8135 8136 8137 8138 8139 8140 8150 8151 8152 8153 8154 8155 8156 8157 8158 8159 8160 8161 8162 8163 8164 8165 8166 8167 8179 8180 8181 8182

EOB Description

AHCA REQUESTED REFUND DUE TO LEGAL SETTLEMENT AHCA REQUESTED REFUND DUE TO MEDICAID FRAUD AHCA INITIATED OFFSET DUE AUDIT DIVISION REVIEW AHCA INITIATED OFFSET DUE TO CALL CENTER AHCA INITIATED OFFSET DUE TO CLAIMS RESOLUTION AHCA INITIATED OFFSET DUE TO COST SETTLEMENT ADJUSTMENT AHCA INITIATED OFFSET DUE TO CUSTOMER SERVICE AHCA INITIATED OFFSET DUE TO SERVICES AFTER DEATH OF MEMBER AHCA INITIATED OFFSET DUE TO DHS/CHILD WELFARE AHCA INITIATED OFFSET DUE TO DHS/DCYS AHCA INITIATED OFFSET DUE TO DHS/DDSD AHCA INITIATED OFFSET DUE TO DISPROPORTIONATE SHARE ADJUS AHCA INITIATED OFFSET DUE TO DRUG REBATE AHCA INITIATED OFFSET DUE TO FINANCIAL MANAGEMENT DIVISION REVIEW AHCA INITIATED OFFSET DUE TO FQHC AHCA INITIATED OFFSET DUE TO JUVENILE JUSTICE AHCA INITIATED OFFSET DUE TO KEYING ERROR AHCA INITIATED OFFSET DUE TO LEGAL SETTLEMENT AHCA INITIATED OFFSET DUE TO MEDICAID FRAUD AHCA INITIATED OFFSET DUE TO MEDICAL REVIEW AHCA INITIATED OFFSET DUE TO MEDICARE AHCA INITIATED OFFSET DUE TO OFMQ REVIEW AHCA INITIATED OFFSET DUE TO PHARMACY REVIEW AHCA INITIATED OFFSET DUE TO PROCESSING ERROR AHCA INITIATED OFFSET DUE TO SURS REVIEW AHCA INITIATED OFFSET DUE TO WRONG PROVIDER PAID AHCA INITIATED OFFSET DUE TO MISCELLANEOUS OR UNSPECIFIED ERROR EDS INITIATED OFFSET DUE TO PROCESSING ERROR EDS INITIATED ADJUSTMENTS DUE TO PROCESSING ERROR AHCA INITIATED PARTIAL CLAIM OFFSET DUE TO OFMQ REVIEW AHCA INITIATED OFFSET DUE TO PRESCRIBING PROVIDER EXCLUDED AHCA INITIATED OFFSET OF FFS CLAIM FOR MEMBER ENROLLED IN MANAGED CARE AHCA INITIATED OFFSET OF OUT-PATIENT CLAIM DUE TO PAID IN-PATIENT CLAIM AHCA INITIATED ADDITIONAL PAYMENT DUE TO CALL CENTER AHCA INITIATED ADDITIONAL PAYMENT DUE TO CLAIMS RESOLUTION AHCA INITIATED ADDITIONAL PAYMENT DUE TO DHS/CHILD WELFARE AHCA INITIATED ADDITIONAL PAYMENT DUE TO DHS/DDSD AHCA INITIATED ADDITIONAL PAYMENT DUE TO DISPROPORTIONATE SHARE AHCA INITIATED ADDITIONAL PAYMENT DUE TO FINANCIAL MANAGEMENT REVIEW AHCA INITIATED ADDITIONAL PAYMENT DUE TO FQHC AHCA INITIATED ADDITIONAL PAYMENT DUE TO KEYING ERROR AHCA INITIATED ADDITIONAL PAYMENT DUE TO MEDICAL REVIEW AHCA INITIATED ADDITIONAL PAYMENT DUE TO MEDICAL AUTHORIZATION AHCA INITIATED ADDITIONAL PAYMENT DUE TO MEDICARE AHCA INITIATED ADDITIONAL PAYMENT DUE TO OTHER INSURANCE AHCA INITIATED ADDITIONAL PAYMENT DUE TO PATIENT LIABILITY AHCA INITIATED ADDITIONAL PAYMENT DUE TO PROCESSING ERROR AHCA INITIATED ADDITIONAL PAYMENT DUE TO RATE CHANGE AHCA INITIATED ADDTNL PYMNT DUE TO MISC OR UNSPEC ERROR EDS INITIATED ADDITIONAL PAYMENT DUE TO PROCESSING ERROR EDS INITIATED ADJUSTMENTS DUE TO PROCESSING ERROR. VOID OUTPATIENT CLAIM OF INPATIENT DUPLICATE MASS ADJUSTMENT - INPATIENT HOSPITAL RATE CHANGE MASS ADJUSTMENT - OUTPATIENT HOSPITAL RATE CHANGE MASS ADJUSTMENT- INDIAN HOSPITAL RATE CHANGE

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EOB (Explanation of Benefits) Codes and Description

EOB Code

8183 8184 8185 8186 8187 8188 8189 8190 8191 8200 8201 8202 8203 8204 8205 8206 8207 8208 8209 8210 8212 8213 8214 8217 8220 8224 8225 8226 8227 8228 8229 8230 8231 8232 8234 8240 8241 8242 8244 8245 8246 8286 8287 8288 8289 8290 8291 8292 8293 8294 8295 8296 8297 8298 8299

EOB Description

MASS ADJUSTMENT - RURAL HEALTH CLINIC RATE CHANGE MASS ADJUSTMENT - PROCEDURE CODE RATE CHANGE MASS ADJUSTMENT - RETROACTIVE RATE CHANGE MASS ADJUSTMENT PROVIDER BILLING ERROR (RATE CHANGE). OTHER REQUEST FOR MASS ADJUSTMENT VOID TRANSACTIONS - MASS ADJUSTMENT MASS ADJUSTMENT - VOID TRANSACTIONS - REFUND RECEIVED MASS ADJUSTMENT - VOID TRANSACTIONS - WARRANT CANCELLED MASS ADJUSTMENT - VOID TRANSACTIONS OTHER REQUEST TPL PRIVATE HEALTH INSURANCE - CARRIER TPL PRIVATE HEALTH INSURANCE - PROVIDER TPL PRIVATE HEALTH INSURANCE - MEMBER AUTO LIABILITY - CARRIER AUTO LIABILITY - PROVIDER AUTO LIABILITY - MEMBER NON-AUTO LIABILITY - CARRIE NON-AUTO LIABILITY - PROVIDER NON-AUTO LIABILITY - MEMBER WORKERS COMP - CARRIER WORKERS COMP - PROVIDER PROBATES ESTATE INCOME PENSION TRUST RECOVERIES VICTIMS RESTITUTION DUE TO MISCELLANEOUS OR UNSPECIFIED REASON SAVE FOR FUTURE USE * TEMPORARILY USE FOR VOIDS * SAVE FOR FUTURE USE. CAPITATION - DEATH OF MEMBER CAPITATION - MEMBER INCARCERATED CAPITATION - EPSDT CLAIM CAPITATION - MEMBER ENROLLED IN ERROR CAPITATION - FAMILY PLANNING CAPITATION - INCORRECT RATE CATEGO CAPITATION - DEMOGRAPHIC CHANGE CAPITATION - OTHER TPL VENDOR VOID ADJUSTMENT GENERATED DUE TO SURS REVIEW ADJUSTMENT GENERATED DUE TO CHANGE IN PATIENT LIABILITY ADJUSTMENT GENERATED DUE TO RATE CHANGE PAYOUT PROCESSED DUE TO DISPROPORTIONATE SHARE POINT OF SALE POINT OF SALE REVERSAL RECIPIENT HAS VERIFIED INSURANCE COMPANY CHECK HISTORY MASS VOID AUTO RECOUPMENT, SYSTEM CHARGE AUTO RECOUPMENT, SYSTEM ERROR AHCA ORDERED REPROCESSED CLAIMS COURT ORDERED SETTLEMENT DISPROPORTIONATE SHARE PAYMENT CLAIM ADJUSTMENT VIA TPL BILLING FILE CREDIT BALANCE FROM EDS CHANGE IN PATIENT RESOURCES INSTITUTIONAL CARE PROVIDER CHANGE OF OWNERSHIP OUTPATIENT CLAIM CONFLICT WITH INPATIENT STAY LTCF OV TRANSACTION CODE CREDIT LTCF OV PROVIDER DECREASE BY STATE

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EOB (Explanation of Benefits) Codes and Description

EOB Code

8300 8301 8302 8303 8304 8305 8306 8307 8308 8309 8310 8311 8312 8313 8314 8315 8316 8317 8318 8319 8320 8321 8322 8323 8324 8325 8326 8327 8328 8329 8330 8331 8332 8336 8399 8400 8401 8402 8403 8404 8405 8406 8407

EOB Description

A PAYOUT HAS BEEN ESTABLISHED FOR THE PROVIDER. THE REIMBURSEMENT IS INCLUDED IN THE CHECKWRITE. A PAYOUT HAS BEEN ESTABLISHED FOR THE PROVIDER. THE REIMBURSEMENT HAS BEEN EXCLUDED FROM THE CHECKWRITE A PAYOUT IS DUE TO THE PROVIDER AS A RESULT OF OVER REFUND. THE REIMBURSEMENT IS INCLUDED IN THE CHECKWRITE A PAYOUT IS DUE TO THE PROVIDER AS A RESULT OF OVER PAYMENT. THE REIMBURSEMENT HAS BEEN EXCLUDED FROM THE CHECKWRITE. PAYOUT DUE TO ADVANCE. PAYMENT INCLUDED IN CHECKWRITE. PAYOUT DUE TO ADVANCE. PAYMENT EXCLUDED FROM CHECKWRITE. CHECK RECEIVED BY EDS FOR CLAIM ADJUSTMENT ON A PREVIOUSLY ADJUSTED CLAIM. AMOUNT OF REFUND BEING RETURNED TO PROVIDER PAYOUT EXCLUDED FROM CHECKWRITE PAYOUT DUE TO HOSPITAL SUPPLEMENTAL GME ADJUSTMENT PAYOUT DUE TO MANAGED CARE - RESIDENT PCP PAYMENT PAYOUT DUE TO MANAGED CARE - RESIDENT DELIVERY PAYMENT PAYOUT DUE TO MANAGED CARE - ABD RISK BASED PAYM PAYOUT DUE TO MANAGED CARE - SP/ABD QUARTERLY PAYMENT PAYOUT DUE TO MANAGED CARE - EPSDT BONUS PAYMENT PAYOUT DUE TO MANAGED CARE - CUSTODY INDICATOR ERROR PAYOUT DUE TO MANAGED CARE - ENROLLMENT ERROR PAYOUT DUE TO MANAGED CARE - OTHER PAYOUT DUE TO MEDICAL AUTHORIZATION UNIT REVIEW-CCU PAYOUT DUE TO LONG TERM CARE FACILITY CERTIFICATION DATE ERROR PAYOUT DUE TO LONG TERM CARE FACILITY CLAIM PROCESSING ERROR PAYOUT DUE TO PATIENT LIABILITY ERROR PAYOUT DUE TO PATIENT SPENDDOWN ERROR PAYOUT DUE TO ENHANCED RATE-OUT OF STATE RTC SERVICES PAYOUT DUE TO NON-EMERGENCY TRANSPORTATION PAYOUT DUE TO PROGRAM RULES PAYOUT DUE TO GAS SURCHARGE PAYOUT DUE TO CORRECTION TO ACCOUNTS RECEIVABLE PROCESSED PAYOUT DUE TO DHS/DDSD SUPPORTED LIVING PROGRAM AUDIT PAYOUT DUE TO DHS/DDSD AUDIT PAYOUT PROCESSED FROM STATE ONLY FUNDS PAYOUT DUE TO ELIGIBILITY NOT ON FILE PAYOUT DUE TO CLAIM TOO OLD TO PROCESS PAYOUT DUE TO MISCELLANEOUS OR UNSPECIFIED REASON RETROACTIVE INTEREST PAYMENT THIS ACTION IS THE RESULT OF A STOP PAYMENT. A MANUAL CHECK HAS BEEN ISSUED. ACCOUNTS RECEIVABLE HAS BEEN ESTABLISHED. THE AMOUNT WILL BE DEDUCTED FROM YOUR FUTURE PAYMENTS DUE TO A CHECK ADVANCE, AN ACCOUNTS RECEIVABLE HAS BEEN ESTABLISHED. THE AMOUNT WILL BE DEDUCTED FROM YOUR FUTURE PAYMENTS. DUE TO AN IRS LIEN, AN ACCOUNTS RECEIVABLE HAS BEEN ESTABLISHED. THE AMOUNT WILL BE DEDUCTED FROM YOUR PAYMENTS. DUE TO A GARNISHMENT, AN ACCOUNTS RECEIVABLE HAS BEEN ESTABLISHED. THE AMOUNT WILL BE DEDUCTED FROM YOUR PAYMENTS. DUE TO A LIABILITY AND CASUALTY LIEN, AN ACCOUNTS RECEIVABLE HAS BEEN ESTABLISHED. THE AMOUNT WILL BE DEDUCTED FROM YOUR PAYMENTS. DUE TO A LIEN, AN ACCOUNTS RECEIVABLE HAS BEEN ESTABLISHED. THE AMOUNT WILL BE DEDUCTED FROM YOUR PAYMENTS. DUE TO TAX ASSESSMENT (31%), AN ACCOUNTS RECEIVABLE HAS BEEN ESTABLISHED. THE AMOUNT WILL BE DEDUCTED FROM YOUR PAYMENTS. RELEASE OF LIEN RECEIVED BY LIEN HOLDER

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EOB (Explanation of Benefits) Codes and Description

EOB Code

8408 8409 8420 8421 8422 8423 8424 8425 8426 8427 8428 8429 8430 8431 8432 8433 8434 8435 8436 8437 8438 8439 8450 8451 8452 8453 8454 8455 8456 8457 8458 8459 8460 8461 8462 8463 8464 8465 8466 8467

EOB Description

DECREASE TO ORIGINAL LIEN AMOUNT INCREASE TO ORIGINAL LIEN AMOUNT AS THE RESULT OF AN AUDIT DIVISION REVIEW, AN ACCOUNTS RECEIVABLE HAS BEEN ESTABLISHED. THE AMOUNT WILL BE DEDUCTED FROM YOUR PAYMENTS. AS THE RESULT OF CLAIMS PROCESSING ERROR, AN ACCOUNTS RECEIVABLE HAS BEEN ESTABLISHED. THE AMOUNT WILL BE DEDUCTED FROM YOUR PAYMENTS. AS THE RESULT OF A COST SETTLEMENT REVIEW, AN ACCOUNTS RECEIVABLE HAS BEEN ESTABLISHED. THE AMOUNT WILL BE DEDUCTED FROM YOUR PAYMENTS. AN ACCOUNTS RECEIVABLE HAS BEEN ESTABLISHED DUE TO DHS/DDSD AUDIT AN ACCOUNTS RECEIVABLE HAS BEEN ESTABLISHED DUE TO DHS/CHILD WELFARE. AN ACCOUNTS RECEIVABLE HAS BEEN ESTABLISHED DUE TO JUVENILE JUSTICE AN ACCOUNTS RECEIVABLE HAS BEEN ESTABLISHED DUE TO DISPROPORTIONATE SHARE ADJUSTMENT AN ACCOUNTS RECEIVABLE HAS BEEN ESTABLISHED DUE TO DRUG REBATE AS THE RESULT OF A FINANCIAL MANAGEMENT REVIEW, AN ACCOUNTS RECEIVABLE HAS BEEN ESTABLISHED. THE AMOUNT WILL BE DEDUCTED FROM YOUR PAYMENTS. AS THE RESULT OF A LEGAL SETTLEMENT, AN ACCOUNTS RECEIVABLE HAS BEEN ESTABLISHED. THE AMOUNT WILL BE DEDUCTED FROM YOUR PAYMENTS. AN ACCOUNTS RECEIVABLE HAS BEEN ESTABLISHED DUE TO LONG TERM CARE FACILITY CLAIM PROCESSING ERROR AN ACCOUNTS RECEIVABLE HAS BEEN ESTABLISHED DUE TO MANAGED CARE ADJUSTMENTS AN ACCOUNTS RECEIVABLE HAS BEEN ESTABLISHED DUE TO MEDICAID FRAUD AN ACCOUNTS RECEIVABLE HAS BEEN ESTABLISHED DUE TO MEDICAL DIVISION REVIEW AS THE RESULT OF AN OFMQ REVIEW, AN ACCOUNTS RECEIVABLE HAS BEEN ESTABLISHED. THE AMOUNT WILL BE DEDUCTED FROM YOUR PAYMENTS. AN ACCOUNTS RECEIVABLE HAS BEEN ESTABLISHED DUE TO PATIENT LIABILITY ERROR AN ACCOUNTS RECEIVABLE HAS BEEN ESTABLISHED DUE TO PATIENT SPENDDOWN ERROR AN ACCOUNTS RECEIVABLE HAS BEEN ESTABLISHED DUE TO PHARMACY DIVISION REVIEW AS THE RESULT OF A SURS AUDIT, AN ACCOUNTS RECEIVABLE HAS BEEN ESTABLISHED. AMOUNT WILL BE DEDUCTED FROM YOUR PAYMENTS. AN ACCOUNTS RECEIVABLE HAS BEEN ESTABLISHED DUE TO THIRD PARTY LIABILITY DUE TO A TRANSFER OF ACCOUNT, AN ACCOUNTS RECEIVABLE HAS BEEN ESTABLISHED. THE AMOUNT WILL BE DEDUCTED FROM YOUR PAYMENTS. ADJUSTMENT REQUEST FOR A CLAIM TOO OLD TO PROCESS, AN ACCOUNT RECEIVABLE HAS BEEN ESTABLISHED. THE AMOUNT WILL BE DEDUCTED FROM YOUR PAYMENTS. AN ACCOUNTS RECEIVABLE HAS BEEN ESTABLISHED DUE TO MISCELLANEOUS OR UNSPECIFIED ERROR THIS ACCOUNTS RECEIVABLE WAS ESTABLISHED FOR THE WRONG AMOUNT. WE HAVE MADE CORRECTION AND INCREASED THIS ACCOUNTS RECEIVABLE. THIS ACCOUNTS RECEIVABLE WAS ESTABLISHED FOR THE WRONG AMOUNT. WE HAVE MADE CORRECTION AND DECREASED THIS ACCOUNTS RECEIVABLE. THIS ACCOUNTS RECEIVABLE WAS ESTABLISHED FOR THE WRONG PROVIDER. WE HAVE CORRECTED THE ACTION AND DECREASED THIS ACCOUNTS RECEIVABLE. A CASH RECEIPT WAS APPLIED TO AND DECREASED THIS ACCOUNTS RECEIVABLE AN OVER REFUND HAS BEEN APPLIED AND DECREASED THIS ACCOUNTS RECEIVABLE A STOP PAYMENT CHECK WAS APPLIED AND DECREASED THIS ACCOUNTS RECEIVABLE THIS ACCOUNTS RECEIVABLE HAS BEEN INCREASED DUE TO FINANCIAL DIVISION REVIEW THIS ACCOUNTS RECEIVABLE HAS BEEN DECREASED DUE TO FINANCIAL DIVISION REVIEW THIS ACCOUNTS RECEIVABLE HAS BEEN INCREASED DUE TO AUDIT DIVISION REVIEW THIS ACCOUNTS RECEIVABLE HAS BEEN DECREASED DUE TO AUDIT DIVISION REVIEW THIS ACCOUNTS RECEIVABLE HAS BEEN INCREASED DUE TO SURS REVIEW THIS ACCOUNTS RECEIVABLE HAS BEEN DECREASED DUE TO SURS REVIEW THIS ACCOUNTS RECEIVABLE HAS BEEN INCREASED DUE TO INTEREST BEING APPLIED THIS ACCOUNTS RECEIVABLE HAS BEEN DECREASED BY A MISCELLANEOUS ACTION THIS ACCOUNTS RECEIVABLE HAS BEEN INCREASED BY A MISCELLANEOUS ACTION

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EOB (Explanation of Benefits) Codes and Description

EOB Code

8468 8469 8480 8481 8482 8483 8484 8500 8501 8502 8510 8511 8512 8513 8514 8515 8600 8601 8602 8603 8604 8605 8606 8607 8608 8609 8610 8611 8612 8613 8614 8615 8616 8617 8618 8619 8620 8621 8622 8623 8624 8625 8626 8627 8628 8629 8630 8631 8632 8633 8634 8635 8636 8637 8638

EOB Description

THIS ACCOUNTS RECEIVABLE HAS BEEN WRITTEN OFF THIS ACCOUNTS RECEIVABLE WAS DECREASED BY A CLAIM OFFSET AHCA INITIATED OFFSET DUE TO CLAIMCHECK INCIDENTAL TO PRIMARY PROCEDURE AHCA INITIATED OFFSET DUE TO CLAIMCHECK MUTUALLY EXCLUSIVE AHCA INITIATED OFFSET DUE TO CLAIMCHECK PRE-OP/POST-OP AHCA INITIATED OFFSET DUE TO CLAIMCHECK MEDICAL/EVALUATION VISIT AHCA INITIATED OFFSET DUE TO CLAIMCHECK NEW VISIT FREQUENCY PAYMENT WITHHELD DUE TO A LIEN THAT WAS ESTABLISHED FROM A COURT ORDER PAYMENT WITHHELD DUE TO AN IRS LEVY ESTABLISHED PAYMENT WITHHELD DUE TO A LIEN THAT WAS ESTABLISHED FROM OTHER LEGAL ENTITY CYCLE ACTIVITY DECREASE TO ORIGINAL LIEN AMOUNT RECEIVED BY LIEN HOLDER DECREASE TO ORIGINAL LIEN AMOUNT DUE TO PAYMENT RECEIVED INCREASE TO ORIGINAL LIEN AMOUNT RECEIVED BY LIEN HOLDER RELEASE OF LIEN RECEIVED BY LIEN HOLDER THIS CLAIM HAS BEEN DENIED DUE TO A POS REVERSAL TRANSACTION 01-M/I BIN 02-M/I VERSION NUMBER 03-M/I TRANSACTION CODE 04-M/I PROCESSOR CONTROL NUMBER 05-M/I PHARMACY NUMBER 06-M/I GROUP NUMBER 07-M/I CARDHOLDER ID NUMBER 08-M/I PERSON CODE 09-M/I BIRTH DATE 1C-M/I SMOKER/NON-SMOKER CODE 1E-M/I PRESCRIBER LOCATION CODE 10-M/I PATIENT GENDER CODE 11-M/I PATIENT RELATIONSHIP CODE 12-M/I PATIENT LOCATION 13-M/I OTHER COVERAGE CODE 14-M/I ELIGIBILITY CLARIFICATION CODE 15-M/I DATE OF SERVICE 16-M/I PRESCRIPTION/SERVICE REFERENCE NUMBER 17-M/I FILL NUMBER 19-M/I DAYS SUPPLY 2C-M/I PREGNANCY INDICATOR 2E-M/I PRIMARY CARE PROVIDER ID QUALIFIER 20-M/I COMPOUND CODE 21-M/I PRODUCT/SERVICE ID 22-M/I DISPENSE AS WRITTEN (DAW)/PRODUCT SELECTION CODE 23-M/I INGREDIENT COST SUBMITTED 25-M/I PRESCRIBER ID 26-M/I UNIT OF MEASURE 28-M/I DATE PRESCRIPTION WRITTEN 29-M/I NUMBER REFILLS AUTHORIZED 3A-M/I REQUEST TYPE 3B-M/I REQUEST PERIOD DATE-BEGIN 3C-M/I REQUEST PERIOD DATE-END 3D-M/I BASIS OF REQUEST 3E-M/I AUTHORIZED REPRESENTATIVE FIRST NAME 3F-M/I AUTHORIZED REPRESENTATIVE LAST NAME 3G-M/I AUTHORIZED REPRESENTATIVE STREET ADDRESS 3H-M/I AUTHORIZED REPRESENTATIVE CITY ADDRESS 3J-M/I AUTHORIZED REPRESENTATIVE STATE/PROVINCE ADDRESS

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EOB (Explanation of Benefits) Codes and Description

EOB Code

8639 8640 8641 8642 8643 8644 8645 8646 8647 8648 8649 8650 8651 8652 8653 8654 8655 8656 8657 8658 8659 8660 8661 8662 8663 8664 8665 8666 8667 8668 8669 8670 8671 8672 8673 8674 8675 8676 8677 8678 8679 8680 8681 8682 8683 8684 8685 8686 8687 8688 8689 8690 8691 8692 8693

EOB Description

3K-M/I AUTHORIZED REPRESENTATIVE ZIP/POSTAL ZONE 3M-M/I PRESCRIBER PHONE NUMBER 3N-M/I PRIOR AUTHORIZED NUMBER ASSIGNED 3P-M/I AUTHORIZATION NUMBER 3R-PRIOR AUTHORIZATION NOT REQUIRED 3S-M/I PRIOR AUTHORIZATION SUPPORTING DOCUMENTATION 3T-ACTIVE PRIOR AUTHORIZATION EXISTS RESUBMIT AT EXPIRATION OF PRIOR AUTH 3W-PRIOR AUTHORIZATION IN PROCESS 3X-AUTHORIZATION NUMBER NOT FOUND 3Y-PRIOR AUTHORIZATION DENIED 32-M/I LEVEL OF SERVICE 33-M/I PRESCRIPTION ORIGIN CODE 34-M/I SUBMISSION CLARIFICATION CODE 35-M/I PRIMARY CARE PROVIDER ID 38-M/I BASIS OF COST 39-M/I DIAGNOSIS CODE 4C-M/I COORDINATION OF BENEFITS/OTHER PAYMENTS COUNT 4E-M/I PRIMARY CARE PROVIDER LAST NAME 40-PHARMACY NOT CONTRACTED WITH PLAN ON DATE OF SERVICE 41-SUBMIT BILL TO OTHER PROCESSOR OR PRIMARY PAYER 5C-M/I OTHER PAYER COVERAGE TYPE 5E-M/I OTHER PAYER REJECT COUNT 50-NON-MATCHED PHARMACY NUMBER 51-NON-MATCHED GROUP ID 52-NON-MATCHED CARDHOLDER ID 53-NON-MATCHED PERSON CODE 54-NON-MATCHED PRODUCT/SERVICE ID NUMBER 55-NON-MATCHED PRODUCT PACKAGE SIZE 56-NON-MATCHED PRESCRIBER ID 58-NON-MATCHED PRIMARY PRESCRIBER 6C-M/I OTHER PAYER ID QUALIFIER 6E-M/I OTHER PAYER REJECT CODE 60-PRODUCT/SERVICE NOT COVERED FOR PATIENT AGE 61-PRODUCT/SERVICE NOT COVERED FOR PATIENT GENDER 62-PATIENT/CARD HOLDER ID NAME MISMATCH 63-INSTITUTIONALIZED PATIENT PRODUCT/SERVICE ID NOT COVERED 64-CLAIM SUBMITTED DOES NOT MATCH PRIOR AUTHORIZATION 65-PATIENT IS NOT COVERED 66-PATIENT AGE EXCEEDS MAXIMUM AGE 67-FILLED BEFORE COVERAGE EFFECTIVE 68-FILLED AFTER COVERAGE EXPIRED 69-FILLED AFTER COVERAGE TERMINATED 7C-M/I OTHER PAYER ID 7E-M/I DUR/PPS CODE COUNTER 70-PRODUCT/SERVICE NOT COVERED 71-PRESCRIBER IS NOT COVERED 72-PRIMARY PRESCRIBER IS NOT COVERED 73-REFILLS ARE NOT COVERED 74-OTHER CARRIER PAYMENT MEETS OR EXCEEDS PAYABLE 75-PRIOR AUTHORIZATION REQUIRED 76-PLAN LIMITATIONS EXCEEDED 77-DISCONTINUED PRODUCT/SERVICE ID NUMBER 78-COST EXCEEDS MAXIMUM 79-REFILL TOO SOON 8C-M/I FACILITY ID

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EOB (Explanation of Benefits) Codes and Description

EOB Code

8694 8695 8696 8697 8698 8699 8700 8701 8702 8703 8704 8705 8706 8707 8708 8709 8710 8711 8712 8713 8714 8715 8716 8717 8718 8719 8720 8721 8722 8723 8724 8725 8726 8727 8728 8729 8730 8731 8732 8733 8734 8735 8736 8737 8738 8739 8740 8741 8742 8743 8744 8745 8746 8747 8748

EOB Description

8E-M/I DUR/PPS LEVEL OF EFFORT 80-DRUG-DIAGNOSIS MISMATCH 81-CLAIM TOO OLD 82-CLAIM IS POST-DATED 83-DUPLICATE PAID/CAPTURED CLAIM 84-CLAIM HAS NOT BEEN PAID/CAPTURED 85-CLAIM NOT PROCESSED 86-SUBMIT MANUAL REVERSAL 87-REVERSAL NOT PROCESSED 88-DUR REJECT ERROR 89-REJECTED CLAIM FEES PAID 90-HOST HUNG UP 91-HOST RESPONSE ERROR 92-SYSTEM UNAVAILABLE/HOST UNAVAILABLE 95-TIME OUT 96-SCHEDULED DOWNTIME 97-PAYER UNAVAILABLE 98-CONNECTION TO PAYER IS DOWN 99-HOST PROCESSING ERROR AA-PATIENT SPENDDOWN NOT MET AB-DATE WRITTEN IS AFTER DATE FILLED AC-PRODUCT NOT COVERED NON-PARTICIPATING MANUFACTURER AD-BILLING PROVIDER NOT ELIGIBLE TO BILL THIS CLAIM TYPE AE-QMB (QUALIFIED MEDICARE BENEFICIARY)-BILL AF-PATIENT ENROLLED UNDER MANAGED CARE AG-DAYS SUPPLY LIMITATION FOR PRODUCT/SERVICE AH-UNIT DOSE PACKAGING ONLY PAYABLE FOR NURSING HOME RECIPIENTS AJ-GENERIC DRUG REQUIRED AK-M/I SOFTWARE VENDOR/CERTIFICATION ID AM-M/I SEGMENT IDENTIFICATION A9-M/I TRANSACTION COUNT BE-M/I PROFESSIONAL SERVICE FEE SUBMITTED B2-M/I SERVICE PROVIDER ID QUALIFIER CA-M/I PATIENT FIRST NAME CB-M/I PATIENT LAST NAME CC-M/I CARDHOLDER FIRST NAME CD-M/I CARDHOLDER LAST NAME CE-M/I HOME PLAN CF-M/I EMPLOYER NAME CG-M/I EMPLOYER STREET ADDRESS CH-M/I EMPLOYER CITY ADDRESS CI-M/I EMPLOYER STATE/PROVINCE ADDRESS CJ-M/I EMPLOYER ZIP POSTAL ZONE CK-M/I EMPLOYER PHONE NUMBER CL-M/I EMPLOYER CONTACT NAME CM-M/I PATIENT STREET ADDRESS CN-M/I PATIENT CITY ADDRESS CO-M/I PATIENT STATE/PROVINCE ADDRESS CP-M/I PATIENT ZIP/POSTAL ZONE CQ-M/I PATIENT PHONE NUMBER CR-M/I CARRIER ID CW-M/I ALTERNATE ID CX-M/I PATIENT ID QUALIFIER CY-M/I PATIENT ID CZ-M/I EMPLOYER ID

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EOB (Explanation of Benefits) Codes and Description

EOB Code

8749 8750 8751 8752 8753 8754 8755 8756 8757 8758 8759 8760 8761 8762 8763 8764 8765 8766 8767 8768 8769 8770 8771 8772 8773 8774 8775 8776 8777 8778 8779 8780 8781 8782 8783 8784 8785 8786 8787 8788 8789 8790 8791 8792 8793 8794 8795 8796 8797 8798 8799 8800 8801 8802 8803

EOB Description

DC-M/I DISPENSING FEE SUBMITTED DN-M/I BASIS OF COST DETERMINATION DQ-M/I USUAL AND CUSTOMARY CHARGE DR-M/I PRESCRIBER LAST NAME DT-M/I UNIT DOSE INDICATOR DU-M/I GROSS AMOUNT DUE DV-M/I OTHER PAYER AMOUNT PAID DX-M/I PATIENT PAID AMOUNT SUBMITTED DY-M/I DATE OF INJURY DZ-M/I CLAIM/REFERENCE ID EA-M/I ORIGINALLY PRESCRIBED PRODUCT/SERVICE CODE EB-M/I ORIGINALLY PRESCRIBED QUANTITY EC-M/I COMPOUND INGREDIENT COMPONENT COUNT ED-M/I COMPOUND INGREDIENT QUANTITY EE-M/I COMPOUND INGREDIENT DRUG COST EF-M/I COMPOUND DOSAGE FORM DESCRIPTIN CODE EG-M/I COMPOUND DISPENSING UNIT FORM INDICATOR EH-M/I COMPOUND ROUTE OF ADMINISTRATION EJ-M/I ORIGINALLY PRESCRIBED PRODUCT/SERVICE ID QUALIFIER EK-M/I SCHEDULED PRESCRIPTION ID NUMBER EM-M/I PRESCRIPTION/SERVICE REFERENCE NUMBER QUALIFIER EN-M/I ASSOCIATED PRESCRIPTION/SERVICE REFERENCE NUMBER EP-M/I ASSOCIATED PRESCRIPTION/SERVICE DATE ER-M/I PROCEDURE MODIFIER CODE ET-M/I QUANTITY PRESCRIBED EU-M/I PRIOR AUTHORIZATION TYPE CODE EV-M/I PRIOR AUTHORIZATION NUMBER SUBMITTED EW-M/I INTERMEDIARY AUTHORIZATION TYPE ID EX-M/I INTERMEDIARY AUTHORIZATION ID EY-M/I PROVIDER ID QUALIFIER EZ-M/I PRESCRIBER ID QUALIFIER E1-M/I PRODUCT/SERVICE ID QUALIFIER E3-M/I INCENTIVE AMOUNT SUBMITTED E4-M/I REASON FOR SERVICE CODE E5-M/I PROFESSIONAL SERVICE CODE E6-M/I RESULT OF SERVICE CODE E7-M/I QUANTITY DISPENSED E8-M/I OTHER PAYER DATE E9-M/I PROVIDER ID FO-M/I PLAN ID GE-M/I PERCENTAGE SALES TAX AMOUNT SUBMITTED HA-M/I FLAT SALES TAX AMOUNT SUBMITTED HB-M/I OTHER PAYER AMOUNT PAID COUNT HC-M/I OTHER PAYER AMOUNT PAID QUALIFIER HD-M/I DISPENSING STATUS HE-M/I PERCENTAGE SALES TAX RATE SUBMITTED HF-M/I QUANTITY INTENDED TO BE DISPENSED HG-M/I DAYS SUPPLY INTENDED TO BE DISPENSED H1-M/I MEASUREMENT TIME H2-M/I MEASUREMENT DIMENSION H3-M/I MEASUREMENT UNIT H4-M/I MEASUREMENT VALUE H5-M/I PRIMARY CARE PROVIDER LOCATION CODE H6-M/I DUR CO-AGENT ID H7-M/I OTHER AMOUNT CLAIMED SUBMITTED COUNT

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EOB (Explanation of Benefits) Codes and Description

EOB Code

8804 8805 8806 8807 8808 8809 8810 8811 8812 8813 8814 8815 8816 8817 8818 8819 8820 8821 8822 8823 8824 8825 8826 8827 8828 8829 8830 8831 8832 8833 8834 8835 8836 8837 8838 8839 8840 8841 8842 8843 8844 8845 8846 8847 8848 8849 8850 8851 8852 8853 8854 8855 8856 8857 8858

EOB Description

H8-M/I OTHER AMOUNT CLAIMED SUBMITTED QUALIFIER H9-M/I OTHER AMOUNT CLAIMED SUBMITTED JE-M/I PERCENTAGE SALES TAX BASIS SUBMITTED J9-M/I DUR CO-AGENT ID QUALIFIER KE-M/I COUPON TYPE M1-PATIENT NOT COVERED IN THIS AID CATEGORY M2-RECIPIENT LOCKED IN M3-HOST PA/MC ERROR M4-PRESCRIPTION/SERVICE REFERENCE NUMBER/TIME LIMIT EXCEEDED M5-REQUIRES MANUAL CLAIM M6-HOST ELIGIBILITY ERROR M7-HOST DRUG FILE ERROR M8-HOST PROVIDER FILE ERROR ME-M/I COUPON NUMBER MZ-ERROR OVERFLOW NE-M/I COUPON VALUE AMOUNT NN-TRANSACTION REJECTED AT SWITCH OR INTERMEDIARY PA-PA EXHAUSTED/NOT RENEWABLE PB-INVALID TRANSACTION COUNT FOR THIS TRANSACTION CODE PC-M/I CLAIM SEGMENT PD-M/I CLINICAL SEGMENT PE-M/I COB/OTHER PAYMENTS SEGMENT PF-M/I COMPOUND SEGMENT PG-M/I COUPON SEGMENT PH-M/I DUR/PPS SEGMENT PJ-M/I INSURANCE SEGMENT PK-M/I PATIENT SEGMENT PM-M/I PHARMACY PROVIDER SEGMENT PN-M/I PRESCRIBER SEGMENT PP-M/I PRICING SEGMENT PR-M/I PRIOR AUTHORIZATION SEGMENT PS-M/I TRANSACTION HEADER SEGMENT PT-M/I WORKERS COMPENSATION SEGMENT PV-NON-MATCHED ASSOCIATED PRESCRIPTION/SERVICE DATE PW-NON-MATCHED EMPLOYER ID PX-NON-MATCHED OTHER PAYER ID PY-NON-MATCHED UNIT FORM/ROUTE OF ADMINISTRATION PZ-NON-MATCHED UNIT OF MEASURE TO PRODUCT/SERVICE ID P1-ASSOCIATED PRESCRIPTION/SERVICE REFERENCE NUMBER NOT FOUND P2-CLINICAL INFORMATION COUNTER OUT OF SEQUENCE P3-COMPOUND INGREDIENT COMPONENT COUNT DOES NOT MATCH NUMBER OF REPETITIONS P4-COORDINATION OF BENEFITS/OTHER PAYMENT COUNT DOES NOT MATCH # OF REPETITIONS P5-COUPON EXPIRED P6-DATE OF SERVICE PRIOR TO DATE OF BIRTH P7-DIAGNOSIS CODE COUNT DOES NOT MATCH NUMBER OF REPETITIONS P8-DUR/PPS CODE COUNTER OUT OF SEQUENCE P9-FIELD IS NON-REPEATABLE RA-PA REVERSAL OUT OF ORDER RB-MULTIPLE PARTIALS NOT ALLOWED RC-DIFFERENT DRUG ENTITY BETWEEN PARTIAL AND COMPLETION RD-MISMATCHED CARDHOLDER/GROUP ID-PARTIAL TO COMPLETION RE-M/I COMPOUND PRODUCT ID QUALIFIER RF-IMPROPER ORDER OF DISPENSING STATUS, CODE ON PARTIAL FILL TRANSACTION RG-M/I ASSOCIATED PRESCRIPTION/SERVICE REFERENCE # ON COMPLETION TRANSACTION RH-M/I ASSOCIATED PRESCRIPTION/SERVICE DATE ON COMPLETION TRANSACTION

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EOB (Explanation of Benefits) Codes and Description

EOB Code

8859 8860 8861 8862 8863 8864 8865 8866 8867 8868 8869 8870 8871 8872 8873 8874 8875 8876 8877 8878 8879 8880 8881 8882 8883 8998 8999 9000 9001 9002 9003 9004 9005 9006 9007 9008 9009 9010 9011 9012 9016 9017 9030

EOB Description

RJ-ASSOCIATED PARTIAL FILL TRANSACTION NOT ON FILE RK-PARTIAL FILL TRANSACTION NOT SUPPORTED RM-COMPLETION TRANSACTION NOT PERMITTED WITH SAME SERVICE DATE AS PARTIAL TXN RN-PLAN LIMITS EXCEEDED ON INTENDED PARTIAL FILL VALUES RP-OUT OF SEQUENCE (P) REVERSAL ON PARTIAL FILL TRANSACTION RS-M/I ASSOCIATED PRESCRIPTION/SERVICE DATE ON PARTIAL TRANSACTION RT-M/I ASSOCIATED PRESCRIPTION/SERVICE REFERENCE NUMBER ON PARTIAL TRANSACTION RU-MANDATORY DATA ELEMENTS MUST OCCUR BEFORE OPTIONAL ELEMENTS IN A SEGMENT R1-OTHER AMOUNT CLAIMED SUBMITTED COUNT DOES NOT MATCH NUMBER OF REPETITIONS R2-OTHER PAYER REJECT COUNT DOES NOT MATCH NUMBER OF REPETITIONS R3-PROCEDURE MODIFIER CODE COUNT DOES NOT MATCH NUMBER OF REPETITIONS R4-PROCEDURE MODIFIER CODE INVALID FOR PRODUCT/SERVICE ID R5-PRODUCT/SERVICE ID MUST BE ZERO WHEN PRODUCT/SERVICE ID QUALIFIER EQUALS 06 R6-PRODUCT/SERVICE NOT APPROPRIATE FOR THIS LOCATION R7-REPEATING SEGMENT NOT ALLOWED IN SAME TRANSACTION R8-SYNTAX ERROR R9-VALUE IN GROSS AMOUNT DUE DOES NOT FOLLOW PRICING FORMULAE SE-M/I PROCEDURE MODIFIER CODE COUNT TE-M/I COMPOUND PRODUCT ID UE-M/I COMPOUND INGREDIENT BASIS OF COST DETERMINATION VE-M/I DIAGNOSIS CODE COUNT WE-M/I DIAGNOSIS CODE QUALIFIER XE-M/I CLINICAL INFORMATION COUNTER ZE-M/I MEASUREMENT DATE PHARMACY INCENTIVE AMOUNT APPLIED CLAIM BEING REVIEWED ADJUSTMENT TO CROSSOVER PAID PRIOR TO 1/1/95. THIS CLAIM HAS BEEN MANUALLY PRICED USING THE MEDICARE COINSURANCE, DEDUCTIBLE AND PSYCHE REDUCTION AMOUNTS. THE SUBMITTED CHARGE EXCEEDS THE ALLOWED CHARGE. CLAIM PAID AT THE FLORIDA HEALTH PROGRAM ALLOWED AMOUNT. REIMBURSEMENT REDUCED BY THE MEMBERS CO-PAYMENT AMOUNT ACTUAL ITEMIZED COST INVOICE MUST BE SUBMITTED WHEN BILLING THIS PROCEDURE CODE. PLEASE RESUBMIT WITH AN INVOICE. NO PAYMENT MADE-TPL/SPENDDOWN IS MORE THAN THE ALLOWED AMOUNT PERSONAL RESOURCE AMOUNT DEDUCTED FROM THE ALLOWED AMOUNT COMPLETE PROCEDURE NOT PAYABLE WHEN THE TECHNICAL AND PROFESSIONAL COMPONENTS HAVE BEEN PAID FOR THE SAME PROCEDURES ON THE SAME DATE OF SERVICE THIS ITEM SHOULD NOT BE BILLED WITH THIS PROCEDURE CODE A PROCEDURE CODE IS REQUIRED WHEN BILLING THIS REVENUE CODE. PLEASE RESUBMIT WITH A PROCEDURE CODE. LINE ITEM SUBMITTED WITH UNCLEAR ITEMIZATION. RESUBMIT W/APPROPRIATE AND/OR ADDITIONAL INFORMATION. SERVICE DENIED. REIMBURSEMENT FOR INPATIENT HOSP CARE LIMITED TO ONCE PER DAY. SERVICE IS NON-COVERED UNDER THE FLORIDA HEALTH COVERAGE PROGRAM SUPPORTING DOCUMENTATION IS NEEDED FOR THE MODIFIER(S) SUBMITTED ON THIS CLAIM WRONG CLAIM FORM SUBMITTED. PLEASE RESUBMIT ON A UB92 CLAIM FORM. THE OVERHEAD OCCURRENCE DATES BILLED ON THE CLAIM DO NOT AGREE WITH THE DOS BILLED ON THE CLAIM DETAILS. THE FEE WAS APPLIED TO ALL DETAILS. SEPARATE REIMBURSEMENT IS NOT AVAILABLE FOR COMPONENT PROCEDURES WHEN GLOBAL PROCEDURE HAS BEEN PAID CRITICAL CARE/NEONATAL INTENSIVE CARE VISIT NOT PAYABLE. THE AMOUNT PREVIOUSLY PAID FOR PROCEDURES INCLUDED IN THE VISIT CODE EQUAL THE MAXIMUM ALLOWED. GLOBAL IMMUNIZATION PROCEDURE CODES NOT PAYABLE WHEN THE AMOUNT PREVIOUSLY REIMBURSED FOR THE RELATED COMPONENT IMMUNIZATION PROCEDURE(S) EQUALS THE REIMBURSE

9031

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EOB (Explanation of Benefits) Codes and Description

EOB Code

9036 9040 9075 9090 9091 9095 9097 9098 9100 9101 9107 9111 9175 9256 9257 9260 9300 9301 9302 9303 9304 9305 9306 9307 9308 9309 9310 9311 9312 9313 9314 9315 9316 9317 9318 9319 9320 9321 9322 9323 9324 9325 9326 9327 9328 9329

EOB Description

ORAL SURGERY NOT PAYABLE WHEN AMOUNT PAID FOR APICOECTOMY ON SAME DATE OF SERVICE EXCEEDS FLORIDA HEALTH COVERAGE PROGRAM ALLOWABLE FOR THE PROCEDURE BILLED. REIMBURSEMENT IS FOR THE VFC (VACCINE FOR CHILDRENS PROGRAM) VACCINE ADMINISTRATION FEE ONLY CLAIM DENIED. STERILIZATION CONSENT FORM INCOMPLETE/IMPROPERLY COMPLETED. A STERILIZATION CHECKLIST AND YOUR CLAIM ARE BEING SENT TO YOU WITH THE ERRORS. DUMMY TEST CODE TEST - DUMMY CODE NUMBER TWO DUMMY CONFLICT EOB FOR TEST CASE 22445. INPT HOSPTIAL IN CONFLICT WITH OUTPT HOSPITAL CLAIM. STEP THERAPY DUMMY CODE TEST CASE 22455 TEST CASE 26549 (AUDIT CRITERIA WINDOW) THIS IS A TEST TO DEMONSTRATE SETTING UP A BUNDLING AUDIT THIS IS A TEST TO SET UP AN UNBUNDLING AUDIT FULL SERIES SPINAL X-RAY NOT PAYABLE WHEN AMOUNT PAID FOR COMPONENTS OF THE SERIES WITHIN THE SAME CALENDAR YEAR EQUAL THE ALLOWED AMOUNT. INTERNAL PROCESSING ERROR - CONTACT SE MANAGER CLAIM DENIED. MEMBERS SIGNATURE AND DATE OF SIGNATURE IN THE MEMBERS SECTION OF THE CONSENT FORM ARE IN ERROR AND ARE NON CORRECTABLE FIELDS. TREND EVENT MONITOR IS REIMBURSABLE TO A MAXIMUM OF $850.00 PER MONTH, BUT IS NOT PAYABLE WHEN RELATED COMPONENTS HAVE BEEN REIMBURSED FOR THE MAXIMUM AMOUNT MAXIMUM REIMBURSEMENT FOR OXIMETRY IS $280.00 PER 30 DAYS. MAXIMUM REIMBURSEMENT HAS BEEN PAID. PARENTERAL/ENTERAL FEEDING KIT PAYABLE AT A REDUCED AMOUNT WHEN RELATED SUPPLIES HAVE BEEN PAID WITHIN THE SAME THIRTY DAY PERIOD. ARCHIVE ADJUSTMENTS TPL MPI RELATED REGULAR DISPROPORTIONATE SHARE RPICC DISPRORTIONATE PRIMARY CARE DISPROPORTIONATE TEACHING (GME) DISPROPORTIONATE SPECIALTY CARE (TB) DISPROPORTIONATE MENTAL HEALTH DISPROPORTIONATE RURAL DISPROPORTIONATE SHARE CHILDREN DISPROPORTIONATE SHARE SUPPLEMENTAL PAYMENT DOS AFTER DATE OF DEATH NEWBORN SYSTEM DISCREPANCY PROVIDER SUBMITTED REFUND RISK RETENTION TPL RECOVERY MEDICARE PART A TPL RECOVERY MEDICARE PART B TPL RECOVERY HEALTH INSURANCE TPL RECOVERY CARRIER BILLING TPL RECOVERY TRICARE/CHAMPVA TPL RECOVERY MPI PROJECT TPL RECOVERY OTHER TPL VENDOR/SUBCONTRACTOR RECOVERY 08 TPL VENDOR/SUBCONTRACTOR RECOVERY 09 TPL VENDOR/SUBCONTRACTOR RECOVERY 10 TPL VENDOR/SUBCONTRACTOR RECOVERY 11 TPL RECOVERY CASUALTY TPL RECOVERY ESTATE TPL RECOVERY TRUST TPL VENDOR/SUBCONTRACTOR RECOVERY 15

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EOB (Explanation of Benefits) Codes and Description

EOB Code

9330 9331 9332 9333 9334 9335 9336 9337 9338 9339 9340 9341 9342 9343 9344 9345 9346 9347 9348 9349 9350 9351 9352 9353 9354 9355 9356 9357 9358 9359 9360 9361 9362 9363 9364 9365 9366 9367 9368 9369 9370 9371 9372 9373 9374 9375 9376 9377 9378 9379 9380 9381 9382 9383 9384

EOB Description

TPL VENDOR/SUBCONTRACTOR RECOVERY 16 TPL VENDOR/SUBCONTRACTOR RECOVERY 17 TPL VENDOR/SUBCONTRACTOR RECOVERY 18 TPL VENDOR/SUBCONTRACTOR RECOVERY 19 TPL VENDOR/SUBCONTRACTOR RECOVERY 20 EDS NEWBORN PAYMENT EDS HEART TRANSPLANT EDS RECOVERY CASUALTY INSURANCE EDS RECOVERY RELATIVE EDS RECOVERY ESTATE EDS RECOVERY FRAUD AND ABUSE EDS RECOVERY OTHER RECOVERIES EDS RECOVERY PART OVERPAYMENT EDS RECOVERY WRONG PROVIDER EDSRECOVERY WRONG RECIPIENT EDS RECOVERY DUPLICATE PAYMENT FULL EDS RECOVERY OTHER OVERPAYMENT DUPLICATE PAYMENT RECOVERY TPL RECOVERY ESTATE FRAUD AND ABUSE OVERPAYMENT FRAUD AND ABUSE ADMINISTRATION FINES FRAUD AND ABUSE RESTITUTION FRAUD AND ABUSE PRO DENIALS FRAUD AND ABUSE OVERPAY, ADMINISTRATION FRAUD AND ABUSE OVERPAY, RESTITUTION FRAUD AND ABUSE OVERPAY, PRO CASH CALL FOR N/H RECOUP BAL TPL BILLING CFS PSN ADMINISTRATIVE ALLOCATION EMERGENCY PAYMENT RECOUPMENT RESIDENT PROTECT T/F RECOUPMENT TPL RECOVERY OTHER RECOVERIES HMO PROCESSING FEE HMO CLAIMS AMOUNT RETRO RATE ADJUST COLLECTION BEGINNING CREDIT BALANCE ENDING CREDIT BALANCE BEGINNING DUMMY CREDIT BALANCE ENDING DUMMY CREDIT BALANCE BEGINNING RECOUPMENT BALANCE ENDING RECOUPMENT BALANCE BEGINNING DUMMY RECOUPMENT BALANCE ENDING DUMMY RECOUPMENT BALANCE DRUG UNIT DOSE ADJUSTMENT PROVIDER NUMBER WRONG FISCAL AGENT RECIPIENT NUMBER WRONG FISCAL AGENT DRUG/PROCEDURE CODE WRONG FISCAL AGENT PROCEDURE MODIFIER WRONG FISCAL AGENT UNITS OF SERVICE WRONG FISCAL AGENT SUBMITTED CHARGE WRONG FISCAL AGENT TPL PAYMENT WRONG FISCAL AGENT DUPLICATE PAYMENT FISCAL AGENT PAYMENT TO WRONG PROVIDER FISCAL AGENT MISCELLANEOUS OR UNSPECIFIED ERROR FISCAL AGENT PROVIDER NUMBER WRONG PROVIDER PROCESSING

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EOB (Explanation of Benefits) Codes and Description

EOB Code

9385 9386 9387 9388 9389 9390 9391 9392 9393 9394 9395 9396 9397 9398 9399 9400 9600 9601 9603 9604 9605 9634 9651 9661 9663 9664 9665 9666 9700 9701 9702 9703 9704 9705 9706 9707 9708 9709 9710 9800 9900 9901 9905 9906

EOB Description

RECIPIENT NUMBER WRONG ? PROVIDER DRUG/PROCEDURE WRONG ? PROVIDER PROCEDURE MODIFIER WRONG ? PROVIDER UNITS OF SERVICE WRONG ? PROVIDER SUBMITTED CHARGE WRONG ? PROVIDER TPL PAYMENT WRONG ? PROVIDER DUPLICATE PAYMENT ? PROVIDER PAYMENT TO WRONG PROVIDER ? PROVIDER MISCELLANEOUS OR UNSPECIFIED ERROR PROVIDER-REQUESTED REPROCESS RECIPIENT DID NOT RECEIVE SERVICE EXTERNAL NEGATIVE BALANCE COLLECTION LIEN AMOUNT PAID TO IRS CHANGE IN RECIPIENT ELIGIBILITY RECIPIENT HAS MEDICARE COVERAGE RECIPIENT HAS VERIFIED INSURANCE COMPANY REIMBURSMENT IS LIMITED TO A MAXIMUM OF ONE (1) PAIR OF LENSES PER YEAR FOR MEMBERS 18 YEARS OF AGE AND UNDER. PROVIDERS MUST SUBMIT XP-MODIFIER WHEN MEMBERS REIMBURSEMENT IS LIMITED TO A MAXIMUM OF ONE (1) PAIR OF FRAMES PER YEAR FOR MEMBERS 18 YEARS OF AGE AND UNDER. PROVIDERS MUST SUBMIT XP-MODIFIER WHEN MEMBERS THE DATE OF SERVICE ON THIS CLAIM MATCHES THE MEMBERS SPENDOWN MET DATE FOR THE MONTH. AN 8A FORM REQUIRED. POS PROVIDERS MUST SUBMIT THIS CLM ON PAPER. REIMBURSMENT IS LIMITED TO A MAXIMUM OF ONE (1) PAIR OF LENSES EVERY (2) TWO YEARS FOR MEMBERS 19 YRS OF AGE OR OLDER. HOSPITAL LEAVE DAYS ARE LIMITED TO 15 PER HOSPITALIZATION. THE PATIENT SHOULD BE DISCHARGED AND READMITTED FOLLOWING THE HOSPITAL STAY. COMPLETE PROCEDURE NOT PAYABLE WHEN THE TECHNICAL AND PROFESSIONAL COMPONENTS HAVE BEEN PAID FOR THE SAME PROCEDURE ON THE SAME DATE OF SERVICE SURGERIES ON THE SAME DATE OF SERVICE, IN THE EXCESS OF TWO, ARE PAID AT 25 PERCENT OF THE FLORIDA HEALTH COVERAGE PROGRAMS ALLOWED POS REVERSAL PROCESSING DEFERRED DURING FINANCIAL CYCLE ATTACHMENT BEING SENT BY PROVIDER FOR AN ELECTRONIC CLAIM THE NUMBER OF QUADRANTS BILLED ON THE CLAIM IS NOT EQUAL TO THE NUMBER OF UNITS BILLED. TOOTH NUMBERS CANNOT BE BILLED WITH A PROCEDURE THAT REQUIRES QUADRANTS THE ATTACHMENT TYPE IS NOT VALID. THE DISPENSING FEE HAS BEEN REDUCED TO THE ALLOWABLE THE QUANTITY DISPENSED HAS BEEN REDUCED TO THE ALLOWABLE QUANTITY DOLLARS ADJUSTED TO PARAMETER LIMIT QTY ADJUSTED TO PARAMETER LIMIT COVERED DAYS REDUCED TO ALLOWABLE VISITS REDUCED TO AUTHORIZED PA CHARGE REDUCED TO AUTHORIZED PA UNITS REDUCED TO AUTHORIZED THER DAYS REDUCED TO AUTHORIZED MAX 14 CONSECUTIVE THER DAYS ALLOWED HOSP LEAVE DAYS REDUCED TO AUTHORIZED CUTBACK DUE TO HMO PAYMENT/COVERAGE REIMBURSEMENT LIMITED TO ONE SET OF LENSES PER YEAR FOR MEMBERS 18 YEARS OF AGE AND YOUNGER UNLESS REPAIRS OR REPLACEMENTS ARE DUE TO EXTENUATING CIRCUMSTANCE REIMBURSEMENT LIMITED TO ONE SET OF FRAMES, PER YEAR FOR MEMBERS 18 YEARS OF AGE AND YOUNGER UNLESS REPAIRS OR REPLACEMENT IS DUE TO EXTENUATING CIRCUMSTANCES SERVICE DENIED-MEDICAL NECESSITY DOCUMENTATION MUST BE PROVIDED WITH CLAIM STATING REASON FOR MEDICAL NECESSITY PRICING ADJUSTMENT - MEDICARE PART B PRICING APPLIED

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EOB (Explanation of Benefits) Codes and Description

EOB Code

9907 9908 9909 9910 9911 9912 9913 9914 9915 9916 9917 9918 9919 9920 9921 9922 9923 9924 9925 9926 9927 9929 9930 9931 9932 9933 9937 9938 9941 9942 9943 9965 9991 9992 9995 9996 9997 9998 9999

EOB Description

TPL AMOUNT APPLIED PRICING ADJUSTMENT - PHARMACY PRICING APPLIED PRICING ADJUSTMENT - 50% OF AMOUNT BILLED APPLIED PHARMACY DISPENSING FEE APPLIED PRICING ADJUSTMENT - LONG TERM CARE PRICING APPLIED PRICING ADJUSTMENT - AMBULATORY SURGERY PRICING APPLIED PRICING ADJUSTMENT - OUTPATIENT EPOGEN PRICING APPLIED PRICING ADJUSTMENT - REVENUE CODE RATE PRICING APPLIED PRICING ADJUSTMENT - MEDICARE PART A PRICING APPLIED PRICING ADJUSTMENT - UCC RATE PRICING APPLIED PRICING ADJUSTMENT - PREVAILING FEE PRICING APPLIED PRICING ADJUSTMENT - MAX FEE PRICING APPLIED PRICING ADJUSTMENT - PROVIDER LOC PRICING APPLIED PRICING ADJUSTMENT - RBRVS PRICING APPLIED PRICING ADJUSTMENT - PA PRICING APPLIED PATIENT LIABILITY DEDUCTED SPENDDOWN PATIENT LIABILITY APPLIED CLAIM HAS FICA AMOUNT CLAIM HAS RECOUPMENT AMOUNT CLAIM HAS CUTBACK AMOUNT SYSTEM FUND CODE REASSIGNMENT PRICING ADJUSTMENT: PROVIDER SPECIFIC ASC PRICING APPLIED MULTIPLE SURGERY REDUCTION APPLIED PRICING ADJUSTMENT - RPICC PRICING APPLIED PER DIEM PLUS PRICING APPLIED PATIENT RESPONSIBILITY ADJUSTMENT-LTC PRICING APPLIED PRICING ADJUSTMENT - UCC FLAT FEE PRICING APPLIED PRICING ADJUSTMENT - PRICING APPLIED SERVICE PAID ACCORDING TO ANESTHESIA REIMBURSEMENT RULES FOR THE DOS PER DIEM PRICING APPLIED OUT OF STATE PRICING APPLIED TOOTH NUMBERS CANNOT BE BILLED WITH A PROCEDURE THAT REQUIRES A QUADRANT. REFUND AMOUNT LESS THAN ADJUSTED AMOUNT REFUND AMOUNT GREATER THAN ADJUSTED AMOUNT ADJUSTMENT DETAIL MANUALLY DENIED PAYMENT REDUCED DUE TO PATIENT LIABILITY DEDUCTION PERSONAL RESOURCES DEDUCTED FROM THE CLAIM ARE A RESULT OF PREVIOUS RESOURCES COLLECTED FOR THE MEMBER IN THE SAME MONTH CLAIM IS PENDING. CLAIM WILL APPEAR AS PAID OR DENIED ON A FUTURE REMITTANCE VOUCHER. PROCESSED PER MEDICAID POLICY

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