EXPLANATION OF PAYMENT (EOP) CODES
Code
ARO BA BC BD BF BG BH BI BJ BL BN BO BR BV BW BX BY BZ B2 B3 CA CB CG CH CI CJ CK CL CM CN CO CP CQ CR CS
Description
Authorization for rental only Admission not authorized Part of surgical payment Services billed are not eligible for benefits Abortion certification not received Non-covered diagnosis Chiro codes not payable This Podiatric code not covered Member not eligible for services billed Sterilization form not received Authorization was not obtained for these services Duplicate of prior claim Service part of per diem Retraction of previous payment Invalid procedure code Member correction Provider correction Procedure correction Service is included in Lab CAP PCP Non-reimbursable service Duplicate bill Adjust—amount of payment Claim pending review Retraction—other insurance Forward claim to entry point Submit claim to mental health Paid to another O.B. Outreach bonus not payable Intake not timely Invalid DRG billed Please resubmit service on a completed EPSDT form Payment reduced by coinsurance amount Sanctioned provider PRIM payment > Health Partners payment No additional payment due
Code
CU CV CW CX DT DW EC EE EH EM EQ ES EU EV EX EY FH FI FJ FK FM FN FP FQ FY GA GB GC GE GG GI GR GS GU GY HA HC HF HG HH HI
Description
Part of IP payment Insufficient pharmacy data Payment reduced by co-payment amount This member is part of a COE group Delivery includes this service Payment reduced by deductible amount Claims appeal approved Claims appeal denied Appeal untimely filed Medical records required fo r outlier days Service included in VFC program Resubmit with invoice Unprocessable required info needed HB form required/more than 4 weeks from delivery Dual enrolled secondary claim Healthy Babies form required C&G (Complaints & Grievances) First Level Appeal approved C&G Second Level Appeal approved C&G First Level Appeal denied C&G Second Level Appeal denied Service not payable by Health Plan Authorization canceled Readmit within 7 days Acute level transfer Implants under $500—not covered Initial decision upheld CMS 1500 required Cost report needed Member info not received Completed EPSDT form has not been received No late charge payment due COB incorrect Resubmit with a valid DX (diagnosis) Provider info not received Submit this claim to Doral Provider not credentialed Non-HIPAA compliant. Rebill valid code. Outlier days under review Compliant EPSDT code required Outlier days denied Anesthesia records required
Code
HPR HS JA JB JM JN JO JP JS JU JV JY KC MSP MU N4 OC QS RG RI RPE RPM RT RU RV SB SK SL SM SR ST SW SX SZ XD XG XI XN
Description
HPR code translated to EOP code Claim is pending for review Prior payment via settlement Outpatient budget Nonpar in MA Program Medical records required for consideration Level of care not authorized Service level approved by Plan Therapy services not covered Invalid Revenue/Procedure code Rebill using CPT 90471/90472 Recipient statement not received Non-specific diagnosis Multiple surgical procedure pricing applies Baby claim paid under Mother’s ID Missing/incomplete/invalid prior insurance carrier EOB Service included in apnea payment Provider no longer participates Retraction of Health Partners’ overpayment identified by PCG Billed DRG not approved Rental purchase price exceeded Rental purchase price met Special project processing Correction of previously paid claim—internal audit Modifier invalid for service Service is included in case rate Service(s) processed correctly Claim reprocessed Claim forwarded to secondary insurance Pending UM case review Services billed are capitated Benefit applied to member copay Non-par service not authorized Post-partum care N/C after 6 weeks Duplicate of another charge Considered part of global service Incidental to primary procedure All inclusive code added for service
Code
XO XP XR XT XW 03 07 09 11 12 16 17 18 19 21 26 27 31 32 34 35 37 38 39 45 64 69 990 991
Description
One visit code allowed per day Primary code not included Part of more comprehensive code Code cannot be accepted twice Code includes multiple sessions Member not eligible on date of service Service/age conflict Service/sex conflict Rental exceeds purchase price Member not part of PCP’s panel on date of service Need primary insurance EOB Benefit/sex conflict Benefit/age conflict Billed units exceed authorization Service included in DRG payment Claim exceeds 180-day timely filing Prior to completion of service Member deductible has been satisfied Claim service reversals Diagnosis/age conflict Diagnosis/sex conflict Group coverage not effective on date of service Coverage dollar limit exceeded Coverage service limits exceeded Member not eligible on date of service Billed days not authorized Authorization was not obtained for these services Paid per contract fee schedule Reversal of previous item