The Procedure Requested Is Not Allowable For The Process Type Indicated On TheRequest. The Procedure Requested Is Not On ForwardHealth's Files. The Service Requested Is Not A Covered Benefit Of The ForwardHealth Program. The Service Requested Is Covered By The HMO. Consent Form Is Missing, Incomplete, Or Contains Invalid Information. Payment For Immunotherapy Service Included In Reimbursement For Allergy Extract Injection.Ĭlaim Denied. Service Billed Limited To Three Per Pregnancy Per ForwardHealth Guidelines.Ĭlaim Denied Due To Invalid Pre-admission Review Number. ![]() Contact Wisconsin ForwardHealth's Billing And Policy Correspondence Unit. The Member Was Not Eligible For ForwardHealth On The Date ForwardHealth Received the Request. Reimbursement Rate Applied To Allowed Amount. Referring Provider is not currently certified. Member last name does not match Member ID. Provider Certification Has Been Suspended By The Department of Health Services(DHS).īilling or Rendering Provider certification is cancelled for the From Date of Service. Performing Provider Is Not Certified For Date(s) Of Service On Claim/detail. Service(s) Must Be Submitted On Paper Claim Form Along With Preoperative History And Physical Report And Operation Report. Procedure Code is allowed once per member per lifetime. Medicare Paid The Total Allowable For The Service.Ĭlaim Reduced Due To Member/participant Spenddown. The Evaluation Was Received By ForwardHealth Fiscal Agent More Than Two Weeks After The Evaluation Date.įorwardHealth Allowance For Coinsurance Is Limited To ForwardHealth Allowable Amount Less Medicare's Payment. Multiple Prescriptions For Same Drug/ Same Fill Date, Not Allowed. Pediatric Community Care is limited to 12 hours per DOS.ĭrug Dispensed Under Another Prescription Number. ![]() Service Paid At The Maximum Amount Allowed By ForwardHealth ReimbursementPolicies.ĭollar Amount Of Claim Was Adjusted To Correct Mathematical Error.Ī discrepancy exists between the Other Coverage Indicator and the Other Paid Amount. Please Attach Copy Of Medicare Remittance. Medicare Part A Services Must Be Resubmitted. Member is enrolled in Medicare Part A and/or Part B on the on the Dispense Dateof Service. The Number Of Weeks Has Been Reduced Consistent With Goals And Progress Documented. Information inadequate to establish medical necessity of procedure performed.Please resubmit with additional supporting documentation. Number Is Missing Or IncorrectįorwardHealth Number On Claim Does Not Match ForwardHealth Number On Prior Authorization Request.ĭME rental beyond the initial 30 day period is not payable without prior authorization.Ĭharges Paid At Reduced Rate Based Upon Your Usual And Customary Pricing Profile.Īmount Paid Reduced By Amount Of Other Insurance Payment. This claim/service is pending for program review. On the last page of the Remittance Advice. Providers will find a list of all EOB codes used with the corresponding description An Explanation of Benefits (EOB) code corresponds to a printed message about the status or action taken on a claim.
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