LAC 40: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.