Louisiana Administrative Code
Title 40 - LABOR AND EMPLOYMENT
Part I - Workers' Compensation Administration
Subpart 2 - Medical Guidelines
Chapter 51 - Medical Reimbursement Schedule
Section I-5147 - Explanation of Medical Benefits (EOMB)

Universal Citation: LA Admin Code I-5147

Current through Register Vol. 50, No. 9, September 20, 2024

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.

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

Disclaimer: These regulations may not be the most recent version. Louisiana may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.