EXPLANATION OF PAYMENT (EOP)

An EOP will be sent to each provider once the claim has been processed. If multiple claims are processed under the same provider, a bulk payment will be made. Claim information will be listed alphabetically below the check. These are usually issued once a week.

When posting the EOP, each patient’s identifying information appears in the shaded box above the service line information. If a service line is rejected, a two or three character code appears next to the ineligible dollar amount. Explanation codes for rejected claims appear at the end of the remittance advice.

If a claim does not appear on an EOB within 60 days of submission, the claim should be statused prior to resubmittal.

The following is a list of the most common Explanation Codes that may appear on a provider’s EOP. For codes not appearing on this list, please refer to the end of the EOP for a detailed description.

Explanation/Rejection Codes

The following is a list of the explanation codes that may appear on a provider’s EOB:

CODE EXPLANATION
001 The Member has no eligibility effective during the Date(s) of Service.
002 The From date of service is after the termination date of an existing coverage eligibility entry.
003 A duplicate claim was found for this charge based on the member, provider, service dates, place of service, procedure code, and modifier.
005 The received date on the claim is outside of the timely claims filing limit.
006 The Utilization Review referral listed on the claim has a maximum visits limit. This claim would exceed that limit.
008 The referral listed on the claim is not valid for the claim, or no referral was listed. A valid referral that would cover the service has been found and is listed in the EOB information for the claim
009 The referral listed on the claim is not valid for the claim, or no referral was listed. A valid referral that would cover the service has been found and is listed in the EOB information for the claim
019 No Approved referral matched the claim information for Member ID, Referred to Provider ID, Facility ID, Effective and Service Dates, Diagnosis and Procedure Code.
020 The referral listed on the claim has an approved quantity limit for this procedure. This claim would exceed that limit.
022 The Member has no Benefit Contract effective during the Date(s) of Service.
024 The provider does not belong to a network for which this service is covered.
025 The member's eligibility coverage level does not include any Benefit Type specified on the Benefit Class.
028 The place of service designated on the claim is restricted from coverage in this Benefit Class/Exception.
036 The procedure has been performed multiple times during the same service date(s)
037 Prior Authorization on claim is not valid and no valid Referral is on file for this service.
050 The Benefit Class or Exception for this service specifies that the service is not covered.
072 Paid patient responsibility.
074 Deducted Member Share of Cost.
076 Secondary payment information not received.
1039 The DOS is after the end of the extended benefit period.
1124 The Fixed Period accumulator maximum has been reached.
1143 The per individual maximum number of visits set by the Visit accumulator has been reached.
1153 Provider payment is being reduced by the amount of insured/patient\'s overpayment.
1154 Refund amount due to subscriber/patient as a result of subscriber/patient overpayment.
1169 An ICD-10 Code may not be used with a Date of Service earlier than the ICD-10 implementation date.
1170 Claims may not be submitted with both ICD-9 and ICD-10 diagnosis codes.
1171 Claims may not be submitted with both ICD-9 and ICD-10 procedure codes.
1172 An ICD-9 Code may not be used with this Bill Type is not usable on/after ICD10 implementation date.
1173 Claims with this Bill Type may not span the ICD-10 implementation date and must be split into two separate claims that don't span both periods.
122 The Provider's fee for service Vendor ID could not be found so the Provider's Default Vendor ID has been assigned.
123 The Provider's capitation Vendor ID could not be found so the Provider's Default Vendor ID has been assigned.
300 This service was paid in error and requires a retroactive adjustment.The line has been negated.
310 This service was processed in error and requires a retroactive adjustment.The line has been added.
406 The member has Medicare, Medicaid, CHAMPUS, etc., or other insured information that indicates coordination of benefits.
408 The provider does not have a Default Vendor assigned.
409 The provider has multiple Default Vendors which cover the dates of service.
410 One or more diagnosis codes on this claim line are not coded to the highest level of specificity.
413 One or more diagnosis codes on this claim line are invalid.
460 Netpay reduced by Covered Amount Fee Schedule
502 The 'from date of service' is after the 'to date of service'.
504 No procedure code is specified on the claim detail line.
505 The net pay amount on the claim detail line is missing or set to 0.
506 The place of service on the claim detail line is missing or not recognized by the system.
507 No diagnosis code is specified on the claim detail line.
508 The units on the claim detail line is missing or set to 0.
624 The per individual maximum number of units defined in the Benefit Class or Exception for this set of services has been reached.
638 The limit of procedures listed in the Exception that can be performed in the period defined by the frequency on the Exception has been reached.
684 The diagnosis code is listed in the Fee Schedule Selector of the payment contract with Allowed set to No.
685 The procedure code is not listed in the Fee Schedule of the payment contract.
688 The submitted charges are less than the amount in the Payment Contract.
772 Net pay calculation rule used when contracted amount is greater than Coordination of Benefits amount.
773 Net pay calculation rule used when contracted amount is less than Coordination of Benefits amount.
774 Other carrier's COB amount, deductible and coinsurance are required on the COB Entry form when the Calculate Net Pay Due Based on Medicare COB Amount calculation rule is used.
901 A previous charge has been found for this service using a conflicting modifier (00, 26, 27, or TC).
920 The procedure code is listed in the Fee Schedule with a payment type of capitated.
926 The procedure code is not listed in the pricing table appropriate for the payment parameter given in the Fee Schedule (e.g. RBRVS table).
928 Evaluation and Management procedure codes may not have a professional/Technical modifier using the Std. Medicare payment type.
935 This procedure code requires a specific modifier to compute the RVUs and/or to compute the pricing.
APC APC Pricing Applied
APC70 Cost Outlier-adjust compensate addtn'l costs
N17 Charges are bundled into significant services. Incidental services not separately reimbursable

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