La. Admin. Code tit. 40 § I-5147

Current through Register Vol. 50, No. 11, November 20, 2024

Section I-5147 - Explanation of Medical Benefits (EOMB)

A. Carriers must provide an explanation of medical benefits (EOMB) to health care providers whenever the carrier's reimbursement differs from the amount billed by the provider. The EOMB must be provided with the reimbursement check.

1. A carrier must use the listed EOMB codes and descriptors to explain why a provider's charge has been reduced or disallowed.

2. A carrier may develop additional EOMB codes, if necessary, to explain the adjustment of a claim, but must furnish to the provider a written explanation of each EOMB code used.

3. The EOMB must contain appropriate identifying information so the provider can relate a specific reimbursement to the applicable claimant, the procedure billed and the date of service.

B. Acceptable EOMBs may include:

1. copies of the bill on which reimbursements and EOMB codes are listed;

2. manually produced or computerized forms which contain the EOMB codes, written explanations and the appropriate identifying information.

C. The following EOMB codes must be used by the carrier to explain to the provider why a procedure or service is not reimbursed as billed.

001	These services are not reimbursable under the Workers' Compensation Program.
002	Charges exceed maximum allowance.
003	Charge is included in the basic surgical allowance.
004	Surgical assistant is not routinely allowed for this procedure. Documentation of medical necessity required.
005	This procedure is included in the basic allowance of another procedure.
006	This procedure is not appropriate to the diagnosis.
007	This procedure is not within the scope of the license of the billing provider.
008	Equipment of services are not prescribed by a physician.
009	Exceeds reimbursement limitations.
010	This service is not reimbursable unless billed by a physician.
011	Incorrect billing form.
012	Incorrect or incomplete license number of billing provider.
013	Medical report required for payment.
014	Documentation does not justify level of service billed.
015	Place of service is inconsistent with procedure billed.
016	Invalid procedure code.

La. Admin. Code tit. 40, § I-5147

Promulgated by the Department of Labor, Office of Workers' Compensation, LR 19:54 (January 1993), repromulgated LR 19:212 (February 1993), amended LR 20:1299 (November 1994).

AUTHORITY NOTE: Promulgated in accordance with R.S. 23:1034.2.