01 - Charges prior to your effective date are not covered.
02 - Charges after your termination date are not covered.
03 - No coverage in force. Dates of service fall within coverage gap.
04 - TRICARE reduced payment for failure to obtain Pre-Authorization. The provider cannot bill for the difference.
05 - This is a non-covered expense under your plan.
06 - Plan pays inpatient charges only.
07 - Plan pays TRICARE Prime co-pays only.
08 - This claim is currently on file pending pre-existing condition investigation. Information has been requested from the member or provider.
09 - Dental expenses are not covered.
10 - Pharmacy receipt shows the total cost. Submit TRICARE co-pay receipt or Explanation of Benefits for reimbursement.
11 - Pharmacy submission must include the name of drug, prescribing physician, date, fee, and co-pay.
12 - CHAMPVA eligible charges for Mental/Nervous conditions are limited to amount specified in your policy. Benefits are exhausted.
13 - Catastrophic Cap reached. Cost shares and deductibles no longer apply. Submit your TRICARE/CHAMPVA ANNUAL BENEFIT SUMMARY for a review.
14 - This is your Excess Benefit.
15 - Please submit an itemized bill for services rendered by this provider.
16 - The CHAMPVA Explanation of Benefits is required for further consideration of prescription charges.
17 - MEDICARE eligible beneficiaries are not eligible for coverage.
18 - Claim previously processed. Any benefit due was issued to provider.
19 - Claim previously processed. Any benefit due was paid to member.
20 - Submit diagnosis for charges.
21 - Pre-existing conditions prior to your effective date are not covered. See Pre-Existing Condition provision of your policy.
22 - Pre-existing conditions prior to the effective date of your increased benefits are not covered. See Pre-Existing Condition provision of your policy.
23 - Please submit proof of payment to provider over $1000 in order to reimburse member.
24 - Patient name and date of birth do not match our records. Please resubmit.
25 - Your hospital charges cross calendar years. Please submit a complete breakdown of TRICARE/CHAMPVA benefits, including billed amounts, allowed amounts, paid amounts and co-insurance amounts, for each year.
28 - Amount paid by primary payer.
29 - Reimbursement of the standard TRICARE Rx copay.
30 - Plan deductible amount.
31 - Charges previously considered and applied to plan deductible.
32 - The charges were previously denied as your policy does not reimburse the TRICARE/CHAMPVA deductible.
33 - TRICARE/CHAMPVA deductible not covered.
34 - The maximum TRICARE deductible benefit covered under this policy has been exhausted. The charge(s) are patient responsibility.
35 - The TRICARE Point of Service deductible is not a covered expense under your plan.
36 - The maximum TRICARE deductible covered under your plan was applied to your plan deductible
40 - This is an adjustment audit to consider additional benefits.
41 - The charges previously denied have been reconsidered and the attached check represents the benefits.
50 - This plan supplements TRICARE/CHAMPVA only.
51 - Please submit the corresponding TRICARE/CHAMPVA Explanation of Benefits for consideration for your claim
.
52 - The TRICARE/CHAMPVA Explanation of Benefits is incomplete. Submit original for further consideration of your claim.
53 - Duplicate charges previously considered.
54 - Claims must be submitted within 24 months of the TRICARE/CHAMPVA process date.
55 - Your policy does not provide benefits for services denied by TRICARE/CHAMPVA.
56 - TRICARE/CHAMPVA denied as duplicate. Submit the original statement showing payment.
57 - Charges were paid in full by TRICARE/CHAMPVA; no payment is due.
58 - The TRICARE/CHAMPVA EOB received is illegible. A better copy is required for further processing of your claim.
59 - TRICARE coverage is not compatible with your Hartford TRICARE supplemental coverage. Please contact your premium administrator to research and resolve this issue.
60 - Charge represents payment by your Other Insurance Carrier.
61 - The TRICARE/CHAMPVA Explanation of Benefits does not indicate a cost share or copayment to be considered.
62 - File your claim with your TRICARE contractor for reimbursement.
70 - Benefits not assigned to provider; Tax ID number and/or address missing.
71 - Your claim was separated for processing purposes. You will receive more than one Explanation of Benefits.
72 - Due to lack of response to our request for additional information, your file is being closed. Letter of explanation will follow.
73 - A letter of explanation will follow under separate cover.
99 - Within 180 days after receipt of this Explanation of Benefits, you may request a review of the handling of this claim in connection with charges which were denied in accordance to plan provisions and limitations. If there are any such questions, please submit your comments in writing, or request a review of pertinent documents upon which the decision was based, and the matter will be given further consideration. Be sure to refer to the Claim Submission Number.