What follows is a breakdown of common claim codes that may appear on your Explanation of Benefits.
Claim/Service lacks information which is needed for adjudication. You recently received a letter requesting additional information. Your claim will be processed when the information is received.
This is what you need to do: If you received a letter from us requesting information, complete it and drop it in the mail. If not, please call the Customer Service number listed on your ID card.
Submission/Billing Error(s). Our records indicate that the provider is a HealthEOS/Multiplan provider. We have forwarded this claim to HealthEOS/Multiplan and we will process the claim as soon as we receive the negotiated fee amount from them.
This is what you need to do: No action needed.
Non-covered Charge(s). The service provided is not a covered benefit under your policy. See your exclusions for more information (Members who have already registered to access their account can view a summary of their benefits by logging in)
This is what you need to do: Based on your plan benefits, you are responsible for these charges.
Requested information was not provided or was insufficient/incomplete. Several weeks ago, you received a letter asking for additional information. We have not received that information or it was insufficient/incomplete. Your claim will not be processed until the information is received.
This is what you need to do: If you received a letter from us requesting information, complete it and drop it in the mail. If not, contact us at 800-765-4977.
This care may be covered by another payer per coordination of benefits. Medicare has denied payment on this claim. Please work with Medicare to resolve this issue. Once you determine your benefits through Medicare, they will send you an updated benefit explanation which must be forwarded to us for processing.
This is what you need to do: Contact Medicare to resolve this issue. Then forward a copy of the updated Medicare Explanation of Benefits to us for processing.
This care may be covered by another payer per your coordination of benefits. This claim may be covered by Medicare; if so, send us Medicare's notice of payment or denial so we can appropriately process this claim.
This is what you need to do: Send us a copy of your Medicare Explanation of Benefits and we'll complete the processing of your claim.
Accident details requested from the enrollee not received. This file is being closed without payment. If the additional information previously requested is received at a later date and within plan limitations, then we will consider this claim for benefits.
This is what you need to do: If you received a letter from us requesting information, complete it and drop it in the mail or fill it out online. If you did not receive a letter from us, please contact us at the Customer Service number on your ID card.
This expense is excluded under your plan. Please see the general limitations/plan exclusion section of your plan document.
This is what you need to do: Based on your plan benefits, you are responsible for these charges.
Please submit an explanation of benefits from the other insurance carrier. When this is received, your claim will be considered. Please see the coordination of benefits section of your plan document.
This is what you need to do: Our information shows that you have other insurance available which would be the primary payer on this claim. We need their explanation of benefits in order to properly calculate your benefits under this plan. If you no longer have other insurance, please contact us at the Customer Service number on your ID card.
These services are not consistent with the diagnosis provided. Please see the covered medical expenses/medical benefits section of your plan document.
This is what you need to do: Your provider may file a corrected claim and/or additional information for review. You can contact them to see if they are doing that on your behalf.
Maximum benefits have been paid for this service, as described in the schedule of benefits section of your plan document.
This is what you need to do: Based on your plan benefits, you are responsible for these charges.
