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Good Faith Claim Correctly Denied. This service is payable at a frequency of once per month period, per provider, per hearing aid. Claims Cannot Exceed 28 Details. Combine Like Details And Resubmit.
Services Denied. Please Resubmit Corr. This Claim Is Being Returned. The relationship between the Billed and Allowed Amounts exceeds a variance threshold. Verify billed amount and quantity billed.
If correct, special billing instructions apply. Resubmission of the claim is required due to new claim submission guidelines. Submitclaim to the appropriate Medicare Part D plan. Assessment limit per calendar year has been exceeded. Submit Claim To Insurance Carrier. Requires A Unique Modifier. Speech Therapy Is Not Warranted. Contact The Nursing Home.
Continuous home care must be billed in an hourly quantity equal to or greater than eight hours, up to and including 24 hours.
Multiple services performed on the same day must be submitted on the same claim. The member is locked-in to a pharmacy provider or enrolled in hospice. Rebill Using Correct Procedure Code. Concurrent Services Are Not Appropriate. Only Medicare Crossover claims are reimbursed for coinsurance, copayment, and deductible. Submit Claim To For Reimbursement. This dental service limited to once per five years. Prior Authorization is needed to exceed this limit. Diagnosis V Healthcheck screenings or outreach is limited to six per year for members up to one year of age.
Healthcheck screenings or outreach limited to three per year for members between the age of one and two years. Healthcheck screenings or outreach limited to two per year for members betweenthe ages of two and three years. A Procedure Code without a modifier billed on the same day as a Procedure Codewith modifier 11 are viewed as the same trip.
Dental service is limited to once every six months. This limitation may only exceeded for x-rays when an emergency is indicated. Only the initial base rate is payable when waiting time is billed in conjunction with a round trip. This Adjustment Was Initiated By. Only one initial visit of each discipline Nursing is allowedper day per member.
Complex Evaluation and Management procedures require history and physical or medical progress report to be submitted with the claim. This claim must contain at least one specified Surgical Procedure Code.
A covered DRG cannot be assigned to the claim. The information on the claim isinvalid or not specific enough to assign a DRG. Claim reimbursement has been cutback to reimbursement limits for denture repairs performed within 6 months.
If laboratory costs exceed reimbursement, submit a claim adjustment request with lab bills for reconsideration. Home Health visits Nursing and therapy in excess of 30 visits per calendar year per member require Prior Authorization.
Therapy visits in excess of one per day per discipline per member are not reimbursable. Refer To Provider Handbook. Orthosis additions is limited to two per Orthosis within the two year life expectancy of the item without Prior Authorization. Critical care performed in air ambulance requires medical necessity documentation with the claim.
Critical care in non-air ambulance is not covered. Individual Test Paid. Ongoing assessment is not reimbursable when skilled nursing visits have been performed within the past sixty days. Home care ongoing assessments are allowed once every sixty days per member. A valid Level of Effort is also required for pharmacuetical care reimbursement. The revenue accomodation billing code on the claim does not match the revenue accomodation billing code on the member file or does not match for these dates of service.
Child Care Coordination services are reimbursable only if both the member and provider are located in Milwaukee County. Two different providers cannot be reimbursed for the same procedure for the same member on the same Date Of Service DOS. Payment Recouped. No Action Required. Medicare Disclaimer Code invalid. Request Denied. A six week healing period is required after last extraction, prior to obtaining impressions for denture. Service is covered only during the first month of enrollment in the Home and Community Based Waiver.
Additional Reimbursement Is Denied. Pharmaceutical Care Code must be billed with a payable drug detail or if a prescription was not filled, the quantity dispensed must be zero. Rqst For An Exempt Denied. DRG cannotbe determined. Reimbursement determination has been made under DRG , , or Wis Adm Code Prior Authorization is required to exceed this limit. Compound drugs require a minimum of two components with at least one payable FowardHealth covered drug.
Pharmacuetical care limitation exceeded. Pharmaceutical care indicates the prescription was not filled. A quantity dispensed is required. The sum of the Medicare paid, deductible s , coinsurance, copayment and psychiatric reduction amounts does not equal the Medicare allowed amount.
PA required for payment of this service. Procedure Code and modifiers billed must match approved PA. Type of Bill indicates services not reimbursable or frequency indicated is notvalid for the claim type. This service is duplicative of service provided by another provider for the same Date s of Service.
Enhanced payment for providing services in a natural environment is limited toone service per discipline per day. Dosings for Narcotic Treatment Service program are limited to six per Sunday thru Saturday calendar week. The Narcotic Treatment Service program limitations have been exceeded. Refer to the Onine Handbook. LTC hospital bedhold quantity must be equal to or less than occurrence code 75span date range s. Member is assigned to a Hospice provider.
All services should be coordinated with the Hospice provider. Member is assigned to a Lock-in primary provider. All services should be coordinated with the primary provider. Member is assigned to an Inpatient Hospital provider. All services should be coordinated with the Inpatient Hospital provider. Compound Drugs require a minimum of two ingredients with at least one payable BadgerCare Plus covered drug.
This claim was processed using a program assigned provider ID number, e. Prior Authorization PA is required for payment of this service. Claim count of Present on Admission POA indicators does not match count of non-admitting and non-emergency diagnosis codes.
Please submit claim to BadgerRX Gold. This claim is a duplicate of a claim currently in process. There is no action required. Please watch future remittance advice. Do not resubmit. BMN prior authorization may be submitted for Mental Health drugs for which a Core Plan transitioned member has been previously grandfathered.
This drug is not covered for Core Plan members. Prior authorization requests for this drug are not accepted. Prior Authorization is needed for additional services. When diagnoses Policy override must be granted by the Drug Authorization and Policy Override Center to dispense less than a day supply. Healthcare providers working in our network are subject to limits that they can charge for care, as determined by CareFirst. Out-of-network providers may charge more for their services.
If you see an out-of-network provider, you may be responsible to pay the difference between their price and the CareFirst allowed amount. Your benefits are the services covered by your plan. Depending on the plan you have, your benefits may cover the entire amount charged for the service s or a partial amount.
A claim is an official document that details what kind of care you received so that CareFirst can pay your medical provider. A claim will include details about your care including relevant procedures, exams, prescriptions, etc. CareFirst processes claims based on your benefits.
The EOB shows how your benefits were applied and what you may owe your provider. Depending on when claims are submitted, your EOBs may include details for multiple claims. Usually, there is more than one kind of service covered by a copay. Your deductible is a fixed dollar amount that you must pay out-of-pocket every plan year before CareFirst pays its portion of your care. For most plans, any money you pay toward the allowed charge for care will count toward your overall deductible. Your deductible depends on the health plan you choose.
Many CareFirst health plans cover preventive services before you meet your deductible. For most plans, the allowed amount that you pay for deductibles, copays, coinsurance and prescription drugs counts toward your overall out-of-pocket maximum.
Your premium is the amount you pay regularly for your insurance plan. It does not include what you may owe for copays, coinsurance or your deductible. Have a question for us? Please contact us at Start Tour Again.
See FAQs. Log In To My Account. Frequently Asked Questions. Click communication preferences. Opt in to electronic communication and update your email address. Why doesn't my graph have three colors? Here are some examples of when that might happen: You saw an in-network provider and CareFirst is covering your total cost.
Your claim was denied, but the provider is liable. Here, you owe nothing, but neither does CareFirst. The provider is covering the cost. About Claims How is a claim processed? Plan holders can view pharmacy claims details for dependents under Dependents 12 and over can view their claims by creating their own My Account. Benefits Your benefits are the services covered by your plan.
Claim A claim is an official document that details what kind of care you received so that CareFirst can pay your medical provider.
You saw an in-network provider and CareFirst is covering your total cost. Your claim was processed as out-of-network and you are liable for the entire bill. Depending on your health plan, CareFirst may reimburse you for part or all of the charge. Whenever you receive care from an in-network healthcare provider, they fill out an insurance claim form and submit it to CareFirst.
Providers have up to one year to submit a claim after the date of service. Claims are entered into our system and processed according to your benefits. It takes CareFirst about 30 days to process new claims. How long will it take to process this claim? Any time you receive care outside this area, your claim will take additional time to process. My claim was denied by CareFirst. What are the next steps to investigate a claim?
If an insurance claim is denied for any reason, you may ask CareFirst to review it. For a step-by-step guide to the appeal process, visit our Appeal a Claim page. Various state and federal laws dictate who can see what information, regardless of relation.
In most cases:. The allowed amount or allowed charge is the maximum amount your insurance plan will pay for a single covered healthcare service. Healthcare providers working in our network are subject to limits that they can charge for care, as determined by CareFirst. Out-of-network providers may charge more for their services. If you see an out-of-network provider, you may be responsible to pay the difference between their price and the CareFirst allowed amount.
Your benefits are the services covered by your plan. Depending on the plan you have, your benefits may cover the entire amount charged for the service s or a partial amount. A claim is an official document that details what kind of care you received so that CareFirst can pay your medical provider.
A claim will include details about your care including relevant procedures, exams, prescriptions, etc. CareFirst processes claims based on your benefits. The EOB shows how your benefits were applied and what you may owe your provider. Depending on when claims are submitted, your EOBs may include details for multiple claims.
Usually, there is more than one kind of service covered by a copay. Your deductible is a fixed dollar amount that you must pay out-of-pocket every plan year before CareFirst pays its portion of your care. For most plans, any money you pay toward the allowed charge for care will count toward your overall deductible. Your deductible depends on the health plan you choose. Many CareFirst health plans cover preventive services before you meet your deductible.
For most plans, the allowed amount that you pay for deductibles, copays, coinsurance and prescription drugs counts toward your overall out-of-pocket maximum. Your premium is the amount you pay regularly for your insurance plan. It does not include what you may owe for copays, coinsurance or your deductible.
Have a question for us? Please contact us at Not paid separately when the patient is an inpatient. Equipment is the same or similar to equipment already being used. Alert: This is the last monthly installment payment for this durable medical equipment. Monthly rental payments can continue until the earlier of the 15th month from the first rental month, or the month when the equipment is no longer needed.
Alert: You must furnish and service this item for any period of medical need for the remainder of the reasonable useful lifetime of the equipment.
No rental payments after the item is purchased, returned or after the total of issued rental payments equals the purchase price. We do not accept blood gas tests results when the test was conducted by a medical supplier or taken while the patient is on oxygen. Alert: This is the tenth rental month. Equipment purchases are limited to the first or the tenth month of medical necessity.
DME, orthotics and prosthetics must be billed to the DME carrier who services the patient's zip code. Diagnostic tests performed by a physician must indicate whether purchased services are included on the claim. Only one initial visit is covered per specialty per medical group. No separate payment for an injection administered during an office visit, and no payment for a full office visit if the patient only received an injection. Alert: Payment approved as you did not know, and could not reasonably have been expected to know, that this would not normally have been covered for this patient.
Certain services may be approved for home use. Missing invoice. The information furnished does not substantiate the need for this level of service. Also refer to N Alert: The patient has been relieved of liability of payment of these items and services under the limitation of liability provision of the law. This does not qualify for payment under Part B when Part A coverage is exhausted or not otherwise available. Missing pathology report.
Missing radiology report. Alert: This is a conditional payment made pending a decision on this service by the patient's primary payer. Claim lacks the CLIA certification number. This is the 11th rental month. Not covered when the patient is under age Alert: The patient is liable for the charges for this service as they were informed in writing before the service was furnished that we would not pay for it and the patient agreed to be responsible for the charges.
Alert: The patient is not liable for payment of this service as the advance notice of non-coverage you provided the patient did not comply with program requirements. Claim must be assigned and must be filed by the practitioner's employer.
We do not pay for this as the patient has no legal obligation to pay for this. The medical necessity form must be personally signed by the attending physician. Payment for services furnished to hospital inpatients other than professional services of physicians can only be made to the hospital. We do not pay for self-administered anti-emetic drugs that are not administered with a covered oral anti-cancer drug. Missing Certificate of Medical Necessity.
We cannot pay for this as the approval period for the FDA clinical trial has expired. We do not pay for more than one of these on the same day. One interpreting physician charge can be submitted per claim when a purchased diagnostic test is indicated. Our records indicate that you billed diagnostic tests subject to price limitations and the procedure code submitted includes a professional component. Paid at the regular rate as you did not submit documentation to justify the modified procedure code.
Total payment reduced due to overlap of tests billed. Multiple automated multichannel tests performed on the same day combined for payment. You are required to code to the highest level of specificity. Service is not covered when patient is under age Service is not covered unless the patient is classified as at high risk.
Medical code sets used must be the codes in effect at the time of service. Subjected to review of physician evaluation and management services. We cannot pay for laboratory tests unless billed by the laboratory that did the work.
Not covered more than once under age Not covered more than once in a 12 month period. Lab procedures with different CLIA certification numbers must be billed on separate claims. Information supplied supports a break in therapy. Information supplied does not support a break in therapy.
The technical component of a service furnished to an inpatient may only be billed by that inpatient facility. Not paid to practitioner when provided to patient in this place of service.
Begin to report the Universal Product Number on claims for items of this type. We do not pay for an oral anti-emetic drug that is not administered for use immediately before, at, or within 48 hours of administration of a covered chemotherapy drug.
Service not performed on equipment approved by the FDA for this purpose. Payment reduced as day rolling average hematocrit for ESRD patient exceeded We have provided you with a bundled payment for a teleconsultation.
We do not pay for chiropractic manipulative treatment when the patient refuses to have an x-ray taken. This item is denied when provided to this patient by a non-contract or non-demonstration supplier. Processed under a demonstration project or program. Not covered unless submitted via electronic claim. Letter to follow containing further information. We pay for this service only when performed with a covered cryosurgical ablation.
Missing indication of whether the patient owns the equipment that requires the part or supply. Missing patient medical record for this service. Missing physician financial relationship form. Missing pacemaker registration form. Claim did not identify who performed the purchased diagnostic test or the amount you were charged for the test. Part B coinsurance under a demonstration project or pilot program.
Patient identified as a demonstration participant but the patient was not enrolled in the demonstration at the time services were rendered. Denied services exceed the coverage limit for the demonstration. Service not covered until after the patient's 50th birthday, i. Missing physician certified plan of care. The provider must update license information with the payer. Alert: If you do not agree with what we approved for these services, you may appeal our decision.
Alert: If you do not agree with this determination, you have the right to appeal. Secondary payment cannot be considered without the identity of or payment information from the primary payer. Incorrect admission date patient status or type of bill entry on claim. Alert: The claim information has also been forwarded to Medicaid for review. Alert: Claim information was not forwarded because the supplemental coverage is not with a Medigap plan, or you do not participate in Medicare.
Alert: The patient's payment was in excess of the amount owed. Payment is being issued on a conditional basis. You have not established that you have the right under the law to bill for services furnished by the person s that furnished this these service s. Alert: You may be subject to penalties if you bill the patient for amounts not reported with the PR patient responsibility group code. Alert: The patient is a member of an employer-sponsored prepaid health plan.
Alert: Your claim has been separated to expedite handling. The patient is covered by the Black Lung Program. We are the primary payer and have paid at the primary rate. Alert: The claim information is also being forwarded to the patient's supplemental insurer. Skilled Nursing Facility SNF stay not covered when care is primarily related to the use of an urethral catheter for convenience or the control of incontinence.
SSA records indicate mismatch with name and sex. Demand bill approved as result of medical review. A patient may not elect to change a hospice provider more than once in a benefit period. Alert: Our records indicate that you were previously informed of this rule. Alert: Receipt of this notice by a physician or supplier who did not accept assignment is for information only and does not make the physician or supplier a party to the determination.
Alert: No appeal rights. Alert: As previously advised, a portion or all of your payment is being held in a special account. Alert: The new information was considered but additional payment will not be issued. Physician certification or election consent for hospice care not received timely. Alert: The patient overpaid you for these services. Alert: This is a telephone review decision.
Our records indicate that we should be the third payer for this claim. Alert: Correction to a prior claim. Alert: We did not crossover this claim because the secondary insurance information on the claim was incomplete. Alert: The patient overpaid you for these assigned services. Informational remittance associated with a Medicare demonstration. Alert: This payment replaces an earlier payment for this claim that was either lost, damaged or returned. Alert: The patient overpaid you.
The patient overpaid you. Billed in excess of interim rate. Informational notice. Did not indicate whether we are the primary or secondary payer. Patient identified as participating in the National Emphysema Treatment Trial but our records indicate that this patient is either not a participant, or has not yet been approved for this phase of the study. Alert: This determination is the result of the appeal you filed.
Missing plan information for other insurance. Did not enter the statement 'Attending physician not hospice employee' on the claim form to certify that the rendering physician is not an employee of the hospice. A not otherwise classified or unlisted procedure code s was billed but a narrative description of the procedure was not entered on the claim. Claim rejected. Claim Rejected. Paper claim contains more than three separate data items in field Paper claim contains more than one data item in field Claim processed in accordance with ambulatory surgical guidelines.
Did not complete the statement 'Homebound' on the claim to validate whether laboratory services were performed at home or in an institution. Alert: No Medicare payment issued for this claim for services or supplies furnished to a Medicare-eligible veteran through a facility of the Department of Veterans Affairs. Provider level adjustment for late claim filing applies to this claim. Your center was not selected to participate in this study, therefore, we cannot pay for these services.
Processed for IME only. Per legislation governing this program, payment constitutes payment in full. Pancreas transplant not covered unless kidney transplant performed. Reserved for future use. This provider was not certified for this procedure on this date of service.
Physician already paid for services in conjunction with this demonstration claim. Adjustment to the pre-demonstration rate. Claim overlaps inpatient stay. Alert: You may appeal this decision in writing within the required time limits following receipt of this notice by following the instructions included in your contract, plan benefit documents or jurisdiction statutes.
This allowance has been made in accordance with the most appropriate course of treatment provision of the plan. Missing consent form. EOB received from previous payer. Crossover claim denied by previous payer and complete claim data not forwarded. Adjustment represents the estimated amount a previous payer may pay. Denial reversed because of medical review. Policy provides coverage supplemental to Medicare. Payment based on a contractual amount or agreement, fee schedule, or maximum allowable amount.
Services for a newborn must be billed separately. Per admission deductible. Payment based on the Medicare allowed amount. Procedure code incidental to primary procedure. Service not payable with other service rendered on the same date. Alert: Your line item has been separated into multiple lines to expedite handling. This company has been contracted by your benefit plan to provide administrative claims payment services only.
Consent form requirements not fulfilled. Patient ineligible for this service. Claim must be submitted by the provider who rendered the service. No record of health check prior to initiation of treatment.
Claim must meet primary payer's processing requirements before we can consider payment. Authorization request denied. Missing mental health assessment. Bed hold or leave days exceeded. Payer's share of regulatory surcharges, assessments, allowances or health care-related taxes paid directly to the regulatory authority. Payment based on authorized amount. Claim conflicts with another inpatient stay.
Claim information does not agree with information received from other insurance carrier. Court ordered coverage information needs validation. Patient not enrolled in the billing provider's managed care plan on the date of service. Alert: Please refer to your provider manual for additional program and provider information. A valid NDC is required for payment of drug claims effective October Rebill services on separate claims.
Dates of service span multiple rate periods. Rebill services on separate claim lines. The 'from' and 'to' dates must be different. Professional provider services not paid separately. Prior payment being cancelled as we were subsequently notified this patient was covered by a demonstration project in this site of service.
Consolidated billing and payment applies. Your unassigned claim for a drug or biological, clinical diagnostic laboratory services or ambulance service was processed as an assigned claim. Resubmit with multiple claims, each claim covering services provided in only one calendar month. Service billed is not compatible with patient location information.
Procedure billed is not compatible with tooth surface code. Provider must accept insurance payment as payment in full when a third party payer contract specifies full reimbursement. No appeal rights. Alert: Further installment payments are forthcoming. Alert: This is the final installment payment. A failed trial of pelvic muscle exercise training is required in order for biofeedback training for the treatment of urinary incontinence to be covered.
Home use of biofeedback therapy is not covered. Alert: This payment is being made conditionally. Alert: Payment information for this claim has been forwarded to more than one other payer, but format limitations permit only one of the secondary payers to be identified in this remittance advice.
Covered only when performed by the attending physician. Services not included in the appeal review. This facility is not certified for digital mammography.
A separate claim must be submitted for each place of service. Patients with stress incontinence, urinary obstruction, and specific neurologic diseases e. Patient must have had a successful test stimulation in order to support subsequent implantation. Patient must be able to demonstrate adequate ability to record voiding diary data such that clinical results of the implant procedure can be properly evaluated.
Additional information is needed in order to process this claim. Records indicate this patient was a prisoner or in custody of a Federal, State, or local authority when the service was rendered.
This facility is not certified for film mammography. This claim is excluded from your electronic remittance advice. Only one initial visit is covered per physician, group practice or provider.
Alert: This payment is being made conditionally because the service was provided in the home, and it is possible that the patient is under a home health episode of care. This service is paid only once in a patient's lifetime. This service is not paid if billed more than once every 28 days.
Payment is subject to home health prospective payment system partial episode payment adjustment. Add-on code cannot be billed by itself. Alert: This is a split service and represents a portion of the units from the originally submitted service. Social Security Records indicate that this individual has been deported. This amount represents the prior to coverage portion of the allowance. Not eligible due to the patient's age.
Total payments under multiple contracts cannot exceed the allowance for this service. Alert: Payments will cease for services rendered by this US Government debarred or excluded provider after the 30 day grace period as previously notified.
Alert: Services for predetermination and services requesting payment are being processed separately. Alert: This represents your scheduled payment for this service. Record fees are the patient's responsibility and limited to the specified co-payment.
Alert: To obtain information on the process to file an appeal in Arizona, call the Department's Consumer Assistance Office at or Alert: The provider acting on the Member's behalf, may file an appeal with the Payer.
Alert: In the event you disagree with the Dental Advisor's opinion and have additional information relative to the case, you may submit radiographs to the Dental Advisor Unit at the subscriber's dental insurance carrier for a second Independent Dental Advisor Review.
Alert: Under 32 CFR The patient was not residing in a long-term care facility during all or part of the service dates billed. The original claim was denied. The patient was not in a hospice program during all or part of the service dates billed. The rate changed during the dates of service billed. Missing screening document. Long term care case mix or per diem rate cannot be determined because the patient ID number is missing, incomplete, or invalid on the assignment request.
Rebill all applicable services on a single claim. Telephone contact services will not be paid until the face-to-face contact requirement has been met. Alert: This payment was delayed for correction of provider's mailing address. Alert: Our records do not indicate that other insurance is on file. Alert: The patient is responsible for the difference between the approved treatment and the elective treatment.
Transportation in a vehicle other than an ambulance is not covered. Medical record does not support code billed per the code definition. Charges exceed the post-transplant coverage limit. Payment for repair or replacement is not covered or has exceeded the purchase price.
No qualifying hospital stay dates were provided for this episode of care. Missing review organization approval. Services provided aboard a ship are covered only when the ship is of United States registry and is in United States waters.
Alert: We did not send this claim to patient's other insurer. Additional information has been requested from the member. This item or service does not meet the criteria for the category under which it was billed. Additional information is required from another provider involved in this service. Alert: This is a predetermination advisory message, when this service is submitted for payment additional documentation as specified in plan documents will be required to process benefits.
Rebill technical and professional components separately. Alert: You may request a review in writing within the required time limits following receipt of this notice by following the instructions included in your contract or plan benefit documents. The approved level of care does not match the procedure code submitted. Alert: This service has been paid as a one-time exception to the plan's benefit restrictions. Missing contract indicator. The provider must update insurance information directly with payer.
Technical component not paid if provider does not own the equipment used. The technical component must be billed separately. Alert: Patient eligible to apply for other coverage which may be primary. The subscriber must update insurance information directly with payer. Rendering provider must be affiliated with the pay-to provider. The professional component must be billed separately. Services under review for possible pre-existing condition.
Information provided was illegible. The supporting documentation does not match the information sent on the claim. Alert: You may appeal this decision. Alert: You may not appeal this decision. Charges processed under a Point of Service benefit. Alert: A payer providing supplemental or secondary coverage shall not require a claims determination for this service from a primary payer as a condition of making its own claims determination.
We do not offer coverage for this type of service or the patient is not enrolled in this portion of our benefit package. We pay only one site of service per provider per claim. You must furnish and service this item for as long as the patient continues to need it.
Payment based on previous payer's allowed amount. Alert: See the payer's web site or contact the payer's Customer Service department to obtain forms and instructions for filing a provider dispute. Missing Admitting History and Physical report. Missing documentation of benefit to the patient during initial treatment period. State regulated patient payment limitations apply to this service.
Date range not valid with units submitted. Your claim for a referred or purchased service cannot be paid because payment has already been made for this same service to another provider by a payment contractor representing the payer.
The administration method and drug must be reported to adjudicate this service. Service date outside of the approved treatment plan service dates.
Alert: There are no scheduled payments for this service. Alert: Benefits have been estimated, when the actual services have been rendered, additional payment will be considered based on the submitted claim.
Alert: The law permits exceptions to the refund requirement in two cases: - If you did not know, and could not have reasonably been expected to know, that we would not pay for this service; or - If you notified the patient in writing before providing the service that you believed that we were likely to deny the service, and the patient signed a statement agreeing to pay for the service. Not covered when performed with, or subsequent to, a non-covered service.
Alert: This decision may be reviewed if additional documentation as described in the contract or plan benefit documents is submitted. Alert: Coordination of benefits has not been calculated when estimating benefits for this pre-determination. The number of Days or Units of Service exceeds our acceptable maximum. This procedure code is not payable.
Requested information not provided. Alert: The claim information has been forwarded to a Consumer Spending Account processor for review; for example, flexible spending account or health savings account. You must appeal the determination of the previously adjudicated claim. Alert: title of this equipment must be transferred to the patient. It has been determined that another payer paid the services as primary when they were not the primary payer. Payment based on a processed replacement claim.
Claim level information does not match line level information. The original claim has been processed, submit a corrected claim. Not covered when deemed cosmetic. Notification of admission was not timely according to published plan procedures. Alert: Submit this claim to the patient's other insurer for potential payment of supplemental benefits. Duplicate prescription number submitted.
Missing emergency department records. Missing laboratory report. Missing elective consent form. Alert: Electronically enabled providers should submit claims electronically. Missing periodontal charting. Missing facility certification. This service is only covered when the donor's insurer s do not provide coverage for the service. This service is only covered when the recipient's insurer s do not provide coverage for the service. You are not an approved submitter for this transmission format.
This payer does not cover deductibles assessed by a previous payer. This service is related to an accidental injury and is not covered unless provided within a specific time frame from the date of the accident. Not covered unless the prescription changes. This service is allowed one time in a 6-month period. This service is allowed 2 times in a month period. This service is allowed 2 times in a benefit year.
This service is allowed 4 times in a month period. This service is allowed 1 time in an month period. This service is allowed 1 time in a 3-year period. This service is allowed 1 time in a 5-year period. Misrouted claim. Claim payment was the result of a payer's retroactive adjustment due to a retroactive rate change.
Claim payment was the result of a payer's retroactive adjustment due to a Coordination of Benefits or Third Party Liability Recovery. Claim payment was the result of a payer's retroactive adjustment due to a review organization decision. Claim payment was the result of a payer's retroactive adjustment due to a payer's contract incentive program. Claim payment was the result of a payer's retroactive adjustment due to a non standard program.
Patient does not reside in the geographic area required for this type of payment. Statutorily excluded service s. No coverage when self-administered. Payment for eyeglasses or contact lenses can be made only after cataract surgery. Not covered when performed in this place of service.
Not covered when considered routine. Procedure code is inconsistent with the units billed. Not covered with this procedure. Alert: Adjustment based on a Recovery Audit.
The injury claim has not been accepted and a mandatory medical reimbursement has been made. Alert: If the injury claim is accepted, these charges will be reconsidered. This jurisdiction only accepts paper claims.
Payment based on an alternate fee schedule. Missing document for actual cost or paid amount. Payment is based on a generic equivalent as required documentation was not provided. Covered only when performed by the primary treating physician or the designee. Missing Admission Summary Report. Missing Consultation Report. Missing Diagnostic Report. Missing Discharge Summary. Missing support data for claim. Missing Tests and Analysis Report.
This payment will complete the mandatory medical reimbursement limit. Payment for this service has been issued to another provider.
Missing completed referral form. Missing Periodontal Charts. Missing Physical Therapy Certification. Missing Prosthetics or Orthotics Certification. Alert: A network provider may bill the member for this service if the member requested the service and agreed in writing, prior to receiving the service, to be financially responsible for the billed charge.
Missing Doctor First Report of Injury. Missing Supplemental Medical Report. Missing Medical Legal Report. Missing Vocational Report. Missing Work Status Report. Alert: This response includes only services that could be estimated in real-time. Alert: This is an estimate of the member's liability based on the information available at the time the estimate was processed.
Plan distance requirements have not been met. Alert: This real-time claim adjudication response represents the member responsibility to the provider for services reported. Alert: This is the initial remit of a non-NCPDP claim originally submitted real-time without change to the adjudication.
Alert: This is the initial remit of a non-NCPDP claim originally submitted real-time with a change to the adjudication. Resubmit a new claim with the requested information. No separate payment for accessories when furnished for use with oxygen equipment. Alert: Payment made from a Consumer Spending Account. Mismatch between the submitted provider information and the provider information stored in our system. Duplicate of a claim processed, or to be processed, as a crossover claim.
The limitation on outlier payments defined by this payer for this service period has been met. Based on policy this payment constitutes payment in full. These services are not covered when performed within the global period of another service. Not qualified for recovery based on employer size. We processed this claim as the primary payer prior to receiving the recovery demand.
Patient is entitled to benefits for Institutional Services only. Patient is entitled to benefits for Professional Services only. Not Qualified for Recovery based on enrollment information. Not qualified for recovery based on direct payment of premium. Not qualified for recovery based on disability and working status.
This is an individual policy, the employer does not participate in plan sponsorship. Payment is adjusted when procedure is performed in this place of service based on the submitted procedure code and place of service. We are not changing the prior payer's determination of patient responsibility, which you may collect, as this service is not covered by us. We have examined claims history and no records of the services have been found.
Payment adjusted based on the interrupted stay policy. Mismatch between the submitted insurance type code and the information stored in our system. Missing income verification. Payment reduced based on status as an unsuccessful eprescriber per the Electronic Prescribing eRx Incentive Program.
A refund request Frequency Type Code 8 was processed previously. Alert: Patient's calendar year deductible has been met. Alert: Patient's calendar year out-of-pocket maximum has been met. The pilot program requires an interim or final claim within 60 days of the Notice of Admission. The bundled claim originally submitted for this episode of care includes related readmissions. The provider number of your incoming claim does not match the provider number on the processed Notice of Admission NOA for this bundled payment.
Patient did not meet the inclusion criteria for the demonstration project or pilot program. Alert: This non-payable reporting code requires a modifier. Alert: This procedure code requires functional reporting. Not covered when considered preventative. Not covered when performed for the reported diagnosis. This procedure is not payable unless appropriate non-payable reporting codes and associated modifiers are submitted.
Alert: You have been overpaid and must refund the overpayment. Coverages do not apply to this loss. Determination based on the provisions of the insurance policy. Investigation of coverage eligibility is pending. Benefits suspended pending the patient's cooperation. Patient was not an occupant of our insured vehicle and therefore, is not an eligible injured person.
Not covered based on the insured's noncompliance with policy or statutory conditions. Benefits are no longer available based on a final injury settlement. The injured party does not qualify for benefits. Policy benefits have been exhausted. Coverage is excluded to any person injured as a result of operating a motor vehicle while in an intoxicated condition or while the ability to operate such a vehicle is impaired by the use of a drug.
Missing independent medical exam detailing the cause of injuries sustained and medical necessity of services rendered. Adjusted because this is not the initial prescription or exceeds the amount allowed for the initial prescription. Records reflect the injured party did not complete an Application for Benefits for this loss.
Records reflect the injured party did not complete an Assignment of Benefits for this loss. Records reflect the injured party did not complete a Medical Authorization for this loss. Health care policy coverage is primary. Our payment for this service is based upon a reasonable amount pursuant to both the terms and conditions of the policy of insurance under which the subject claim is being made as well as the Florida No-Fault Statute, which permits, when determining a reasonable charge for a service, an insurer to consider usual and customary charges and payments accepted by the provider, reimbursement levels in the community and various federal and state fee schedules applicable to automobile and other insurance coverages, and other information relevant to the reasonableness of the reimbursement for the service.
Adjusted based on the applicable fee schedule for the region in which the service was rendered. Adjusted based on the Redbook maximum allowance. Service provided for non-compensable condition s. Alert: Payment based on an appropriate level of care. Claim in litigation. Alert: Although this was paid, you have billed with an ordering provider that needs to update their enrollment record. Alert: This enrollee receiving advance payments of the premium tax credit is in the grace period of three consecutive months for non-payment of premium.
Alert: This enrollee is in the first month of the advance premium tax credit grace period. This enrollee is in the second or third month of the advance premium tax credit grace period. Alert: This claim will automatically be reprocessed if the enrollee pays their premiums. Coverage terminated for non-payment of premium. Charges for Jurisdiction required forms, reports, or chart notes are not payable. The associated Workers' Compensation claim has been withdrawn.
Service not payable per managed care contract. Out-patient follow up visits on the same date of service as a scheduled test or treatment is disallowed. Referral not authorized by attending physician.
Medical Fee Schedule does not list this code. According to the Official Medical Fee Schedule this service has a relative value of zero and therefore no payment is due. Additional anesthesia time units are not allowed. The allowance is calculated based on anesthesia time units. The Allowance is calculated based on the anesthesia base units plus time. Adjusted because this is reimbursable only once per injury. Consultations are not allowed once treatment has been rendered by the same provider.
Reimbursement has been made according to the home health fee schedule. Reimbursement has been made according to the inpatient rehabilitation facilities fee schedule. Reimbursement has been based on the number of body areas rated.
Adjusted when billed as individual tests instead of as a panel. Reimbursement has been made according to the bilateral procedure rule.
Mark-up allowance. Reimbursement has been adjusted based on the guidelines for an assistant. Adjusted based on diagnosis-related group DRG. Adjusted based on Stop Loss. This policy was not in effect for this date of loss. The date of service is before the date of loss. The date of injury does not match the reported date of loss.
Adjusted based on achievement of maximum medical improvement MMI.