What Is an MMIS EOB Code?

MMIS stands for the Medicaid Management Information System. This is an automatic claims-processing and informational system set up by Medicaid. All states have access to MMIS to check patient benefits, get preauthorization and submit claims for payment. EOB is defined as an explanation of benefits.

Billing Process

• When a patient is seen in the physician's office, the patient's insurance is then charged for the office visit and any procedures or medications administered during the encounter. The insurance company pays the eligible claims and sends the patient an EOB, informing him of the status of the most recently paid claims. This EOB statement has a column for resource codes as to why a claim may have been denied. The physician's medical coder and biller must correct the claim, if possible, and resubmit.

Denied Claims

• Health insurance claims can be denied for many different reasons. The visit may have involved a previously existing condition not covered by insurance. It could have involved a procedure which was not covered by insurance without prior authorization. All of these events would be cited on the EOB.

Codes

• Since MMIS EOB codes are not standard, check with your insurance company or refer to its website for that company's specific explanations of EOB codes. Health insurance companies typically have what is referred to as a "Crosswalk" of insurance and EOB reason codes to provide explanations to subscribers (see Resources).