Section 20-2-V - EXPLANATION OF REVIEW (EOR)A. Payers must provide an explanation of review (EOR) to health care providers for each bill whenever the payer's reimbursement differs from the amount billed by the provider, or when an original claim is altered or adjusted by the payer. The EOR must be provided within thirty (30) days of receipt of the bill, and must accompany any payment that is being made.B. A payer may use the listed EOR codes and descriptors or may develop codes of their own to explain why a provider's charge has been reduced or disallowed, or why a claim has been altered or adjusted in some other way. In all cases, the payer must clearly and specifically detail the reasons for adjusting or altering a bill, including references to the applicable provisions of the Fee Schedule or CPT book, or other source(s) used as the basis for the EOR. Should the EOR include an alteration in the codes submitted on the original claim, it must be based on a review of the medical records documenting the service. C. The EOR must contain appropriate identifying information to enable the provider to relate a specific reimbursement to the applicable claimant, the procedure billed, and the date of service.D. Acceptable EORs may include manually produced or computerized forms that contain the EOR codes, written explanations, and the appropriate identifying information.E. The following EOR codes may be used by the payer to explain to the provider why a procedure or service is not reimbursed as billed, provided clear and specific detail is included, along with references to the applicable provisions of the Fee Schedule or CPT book, or other source(s) used as the basis for the EOR: 001 | These services are not reimbursable under the Workers' Compensation Law for the following reason(s): [Provide specific reason(s) why services are not reimbursable under the Workers' Compensation Law] |
002 | Charges exceed maximum allowable reimbursement [Specify] |
003 | Charge is included in the basic surgical allowance [Specify] |
004 | Surgical assistant is not routinely allowed for this procedure. Documentation of medical necessity required [Specify] |
005 | This procedure is included in the basic allowance of another procedure [Specify the other procedure] |
006 | This procedure is not appropriate to the diagnosis [Specify] |
007 | This procedure is not within the scope of the license of the billing provider [Specify] |
008 | Equipment or services are not prescribed by a physician [Specify] |
009 | This service exceeds reimbursement limitations [Specify] |
010 | This service is not reimbursable unless billed by a physician [Specify] |
011 | Incorrect billing form [Specify] |
012 | Incorrect or incomplete identification number of billing provider [Specify] |
013 | Medical report required for payment [Specify] |
014 | Documentation does not justify level of service billed [Specify] |
015 | Place of service is inconsistent with procedure billed [Specify] |
016 | Invalid procedure code [Specify] |
017 | Prior authorization was not obtained [Specify] |