Explanation of Benefit (EOB) Reasons for Claim Denial

What’s an EOB?

TMHP is required to provide the subscriber with an Explanation of Benefits (EOB) in response to the filing of a claim.  These EOBs provide information about claim disposition and/or payment. TMHP provides many different messages to assist the subscriber with further filing instructions on a processed claim. 

The following are examples of reasons that prompt an EOB message:

• Service rendered by a nonparticipating provider.
  
• Services denied based on the participating provider’s failure to follow the protocol for coverage.
  
• The service denied due to failure to obtain prior authorization where it is the provider’s obligation to obtain such approval.
  
• Coverage for the insured or subscriber was no longer in effect on the date of the service.
  
• Under the Managed Care arena, participating provider bills for covered services for which the provider has not contracted with the insurer.

More Information

There are many other examples of messages that are placed on the Remittance and Status report to providers.  For more information regarding these messages, please feel free to contact the TMHP Contact Center at 1-800-925-9126.