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No policy override available for BadgerCare Plus Benchmark Plan, Core Plan or Basic Plan. Prior authorization requests for this drug are not accepted. Unable To Process Your Adjustment Request due to Original Claim ICN Not Found. A quantity dispensed is required. Recd Beyond 90 Days Special Filing Deadline FOr System Generated Adjmts/Medicare X-overs/Other Insurance Reconsideration/Cou rt Order/Fair Hearing. Continue ToUse Appropriate Codes On Billing Claim(s). Resubmit the Claim with the Appropriate Modifier for Provider Type andSpecialty. Code. Dental service is limited to once every six months. If some of the services were previously paid, submit an adjustment/reconsideration request for the paid claim. ambulatory surgical center, outpatient hospital) exists for the same member, same date of service and the same procedure or service. In general, the more complex the visit, the higher the E&M level of code you may bill within the appropriate category. Reimbursement For This Certification, Test, Segment Has Been Issued To AnotherNF. The Revenue code on the claim requires Condition code 70 to be present for this Type of Bill. Third Other Surgical Code Date is required. Provider Reminders: Claims Definitions. MassHealth List of EOB Codes Appearing on the Remittance Advice. Other Medicare Part B Response not received within 120 days for provider basedbill. The detail From Date Of Service(DOS) is required. Claims may deny when reported with incompatible ICD-10-CM Laterality policy for Diagnosis-to-Modifier comparison. Only One Ventilator Allowed As Per Stated Condition Of The Member. PDN Codes W9045/w9046 Are Not Payable On The Same Date As PDN Codes W9030/W9031 For The Same Provider And Member. Billing provider number was used to adjudicate the service(s). Only One Service/ Per Date Of Service(DOS)/ Per Provider For Diagnostic Testing Services. Here are just a few of them: EOB CODE. Multiple Referral Charges To Same Provider Not Payble. This claim is being denied because it is an exact duplicate of claim submitted. Procedure not allowed for the CLIA Certification Type. Pricing Adjustment/ The submitted charge exceeds the allowed charge. Provider Not Eligible For Outlier Payment. Unable To Process Your Adjustment Request due to Provider ID Not Present. Explanation of Benefit Codes (EOBs) Mar 14, 2022 4. We have redesigned our website to help you find the information you need more easily. Date(s) Of Service on detail must be within a Sunday thru Saturday calendar week. Physical Therapy Treatment Limited To One Modality, One Procedure, One Evaluation Or One Combination Per Day. Claim date(s) of service modified to adhere to Policy. Reimbursement For This Service Has Been Approved. Unable To Process Your Adjustment Request due to Member ID Not Present. Valid NCPDP Other Payer Reject Code(s) required. Because a claim can have edits and audits at both the header and detail levels, EOB codes are listed . Providers May Only Bill For Assessments And Care Plans Twice Per Calendar Year. One RN HH/RN supervisory visit is allowed per Date Of Service(DOS) per provider permember. Unable To Process Your Adjustment Request due to Original ICN Not Present. Second Rental Of Dme Requires Prior Authorization For Payment. 2434. Please Correct And Resubmit. The Automated Voice Response System is encouraged to obtain claims status using a touch-tone phone. PNCC Risk Assessment Not Payable Without Assessment Score. This National Drug Code (NDC) has diagnosis restrictions. Dispense Date Of Service(DOS) is required. This Procedure Code Is Denied As Incidental/Integral To Another Procedure CodeBilled On This Claim. 0001 01/01/1900 NOT USED - MEMBER'S DMAP I.D. One or more Date(s) of Service is missing for Occurrence Span Codes in positions 9 through 24. The Travel component for this service must be billed on the same claim as the associated service. Condition Code is missing/invalid or incorrect for the Revenue Code submitted. Please Itemize Services Including Date And Charges For Each Procedure Performed. These are EOB codes, revised for NewMMIS, that may appear on your PDF remittance advice. Payspan's Core Payment Network comes with a feature that allows payers to send members an electronic version of their Explanation of Benefits (eEOB). Private Duty Nursing Beyond 30 Hrs /Member Calendar Year Requires Prior Authorization. Procedimientos. Contactmembers hospice for payment of services or resubmit with documentation of unrelated Nature of Care. Up Certifying Agency Did Not Verify Member Eligibility within 70 Day Period. Do Not Use Informational Code(s) When Submitting Billing Claim(s). NFs Eligibility For Reimbursement Has Expired. that provide either supplemental explanation for a monetary adjustment or policy information are required in the remittance advice transaction. Providers must ensure that the E&M CPT codes selected reflect the services furnished. Claim Detail Is Pended For 60 Days. Payment Reduced Due To Patient Liability. Member is assigned to a Lock-in primary provider. A Fourth Occurrence Code Date is required. -OR- The claim contains value code 49but does not contain revenue code 0636 and HCPCS Q4054. The Member Has Shown No Ability Within 6 Months To Carry Over Abilities GainedFrom Treatment In A Facility To The Members Place Of Residence. For dates of service on or after 7/1/10 for TOB 72X an occurrence code 51 and value code D5 are required when the KT/V reading was performed. Please correct and resubmit. Invalid Service Facility Address. Discharge Diagnosis 4 Is Not Applicable To Members Sex. Dispensing replacement parts and complete appliance on same Date Of Service(DOS) not Allowed. Service Denied. Dates of Service reflected by the Quantity Billed for dialysis exceeds the Statement Covers Period. Denied. 191. Claim contains duplicate segments for Present on Admission (POA) indicator. Goals Are Not Realistic To The Members Way Of Life Or Home Situation, And Serve No Functional Or Maintenance Service. An Explanation of Benefits (EOB) code corresponds to a printed message about the status or action taken on a claim. Denied due to Per Division Review Of NDC. Pricing Adjustment/ Usual & Customary Charge (UCC) rate pricing applied. Please Attach Copy Of Medicare Remittance. Revenue Code 082X is present on an ESRD claim which also contains revenue codes 083X, 084X, or 085X. Value code 48 exceeds 13.0 or value code 49 exceeds 39.0 and HCPCS codes Q4081or J0882 are present but either modifer ED or EE are not present. Denied. Outside Lab,element 20 On CMS 1500 Claim Form Must Be Checked Yes When Handling Charges Are Billed. A Payment For The CNAs Competency Test Has Already Been Issued. Thank You For The Payment On Your Account. Payment Authorized By Department of Health Services (DHS) To Be Recouped at a Later Date. Pricing Adjustment/ Revenue code flat rate pricing applied. The Procedure Requested Is Not On s Files. The Pharmaceutical Care Code (PCC) does not have a rate on file for the Date Of Service(DOS). Medicare Part A Or B Charges Are Missing Or Incorrect. Invalid Provider Type To Claim Type/Electronic Transaction. This Surgical Code Has Encounter Indicator restrictions. Diagnosis of malignancies and inflammatory conditions frequently requires numerous biopsies of a particular organ or suspicious site. Unable To Process This Request Because The Competency Test Date And TrainingCompletion Date Fields Are Blank. Back-up dialysis sessions are limited to three per lifetime. Procedure Code is allowed once per member per lifetime. NDC- National Drug Code billed is not appropriate for members gender. All The Teeth Do Not Meet Generally Accepted Criteria Requiring Gingivectomy. Referring Physician With Credential Other Than Md Is Not Applicable To Type Of Service Provided. Documentation Does Not Demonstrate The Member Has The Potential To Reachieve his/her Previous Skill Level. That is why we support our provider partners with quality incentive programs, quicker claims payments and dedicated market support. Dispensing Two Lens Replacements On Same Date Of Service(DOS) Not Allowed. Handwritten Changes/corrections On The Medicare EOMB Are Not Acceptable. The canister, dressings and related supplies are included as part of the reimbursement for the negative pressure wound therapy pump. No Action On Your Part Required. This Service Is Not Payable Without A Modifier/referral Code. Admission Denied In Accordance With Pre-admission Review Criteria. Participant Is Enrolled In Medicare Part D. Beginning 09/01/06, Providers AreRequired To Bill Part D And Other Payers Prior To Seniorcare Or Seniorcare WillDeny The Claim. subsequent hospital care (CPT 99231-99233) or inpatient consultations (CPT 99251-99255) in the previous week. The From Date Of Service(DOS) and To Date Of Service(DOS) must be in the same calendar month and year. Services Beyond The Six Week Postpartum Period Are Not Covered, Per DHS. Dispense as Written indicator is not accepted by . Amount Recouped For Mother Baby Payment (newborn). Use Of Therapy Equipment Alone Is Not Sufficient To Justify Maintenance Therapy. Payment Recouped. When diagnoses 800.00 through 999.9 are present, an etiology (E-code) diagnosis must be submitted in the E-code field. The topic of Requirements for Compression Garments can be found in the Claims Section, Submission Chapter. Refer To The Wisconsin Website @ dhs.state.wi.us. Billing Provider Type and Specialty is not allowable for the Place of Service. The To Date Of Service(DOS) for the First Occurrence Span Code is required. Panel And Individual Test Not Payable For Same Member/Provider/ Date Of Service(DOS). Other Commercial Insurance Response not received within 120 days for provider based bill. Computed tomography (CT) of the head or brain (CPT 70450, 70460, 70470), Computed tomographic angiography (CTA) of the head (CPT 70496), Magnetic resonance angiography (MRA) of the head (CPT 70544, 70545, 70546), Magnetic resonance imaging (MRI) of the brain (CPT 70551, 70552, 70553), Duplex scan of extracranial arteries (CPT 93880,93882), Computed tomographic angiography (CTA) of the neck(CPT 70498), Magnetic resonance angiography (MRA) of the neck(CPT 70547, 70548, 70549), ICD-10 Diagnosis codes G43.009, G43.109, G43.709, G43.809, G43.829, G43.909. Adjustment and original claim do not have the same finanical payer, 6355 replacing 635R diagnosis (For use of Category of Service only), 6360 replacing 635S diagnosis (For use of Category of Service only), 6365 replacing 635T diagnosis (For use of Category of Service only). Health (3 days ago) Webwellcare explanation of payment codes and comments. Backdating Allowed Only In Cases Of Retroactive Member/provider Eligibility. This Revenue Code has Encounter Indicator restrictions. Prescriber ID and Prescriber ID Qualifier do not match. Claims With Dollar Amounts Greater Than 9 Digits. Pricing Adjustment/ Maximum allowable fee pricing applied. Also, to ensure claims process and pay accurately, Staywell may deny a claim and ask for pertinent medical documentation from the provider or supplier who submitted the claim. Psych Evaluation And/or Functional Assessment Ser. Do Not Submit Claims With Zero Or Negative Net Billed. Billing Provider is not certified for the Date(s) of Service. This Member Has Completed Intensive AODA Treatment Within The Past 12 Months and Documentation Provided Is Not Adequate To Justify Intensive Treatment at this time. Ninth Diagnosis Code (dx) is not on file. Cannot Be Reprocessed Unless There Is Change In Eligibility Status. Medically Needy Claim Denied. Condition code 20, 21 or 32 is required when billing non-covered services. 51.42 Board Directors Or Designees Statement & Signature Required OnThe Claim Form For Payment Of Functional Assessment. Effective September 1, 2021: Benefit Changes to Total Disc Arthroplasty for Medicaid and CHIP. The Medicare Claims Processing Manual and the UB-04 Data Specifications Manual outlines requirements for billing outpatient claims including that (HCPCS) codes are required on outpatient claims (UB-04) with related revenue codes. Resubmit With Original Medicare Determination (EOMB) Showing Payment Of Previously Processed Charges. A six week healing period is required after last extraction, prior to obtaining impressions for denture. Claim Denied Due To Incorrect Accommodation. is unable to is process this claim at this time. Based on reimbursement guidelines it is not appropriate for providers to bill inpatient Evaluation and Management (E/M) services while the patient is in an observation status. Denied due to The Members Last Name Is Incorrect. Service Allowed Once Per Lifetime, Per Tooth. (Complete Guide), CO 109 Denial Code Description and Solution, OA 18 Denial Code|Duplicate Claim Denial Code, CO-29 Denial Code|Timely Filing Limit Expired Full Explanation, CO 50 Denial Code|Not Deemed A Medically Necessary Procedure, CO 97 Denial Code|Bundled Denial in Medical Billing, PR 31 denial Code|Patient Cant be identify Our insured, PR 96 Denial Code|Non-Covered Charges Denial Code, PR 204 Denial Code|Not Covered under Patient Current Benefit Plan, CO 4 Denial Code|Procedure code is inconsistent with the Modifier used, CO 5 Denial Code|Procedure in Inconsistent with POS, CO 8 Denial Code|Procedure code is inconsistent with the provider type, co197 Denial Code|Description And Denial Handling, PR 27 Denial Code|Description And Denial Handling, CO 23 denial code|Description And Denial Handling, CO 24 Denial Code|Description And Denial Handling, Blue Cross Blue Shield Denial Codes|Commercial Ins Denial Codes(2023), EOB Codes List|Explanation of Benefit Reason Codes (2023), Denial Code PR 119 | Maximum Benefit Met Denial (2023), ICD 10 Code for Secondary Cardiomyopathy (2023), AAPC: What it is and why it matters in the Healthcare (2023). No Supporting Documentation. The Provider Type/specialty Is Not Recognized For These Date(s) Of Service. An ICD-9-CM Diagnosis Code of greater specificity must be used for the Second Diagnosis Code. Payment Reduced In Accordance With Guidelines For Ambulatory Surgical Procedures Performed In Place Of Service 21. Provider Is Not A Qualified Provider For presumptively Eligible Recipients. The Clinical Profile, Narrative History, And Treatment History Indicate The Recipient Is Only Eligible For Maintenance Hours. Members I.d. Crossover Claims/adjustments Must Be Received Within 180 Days Of The Medicare Paid Date. Medication checks by a Psychiatrist and/or Registered Nurse are limited to four services per calendar month. Recip Does Not Meet The Reqs For An Exempt. Sixth Diagnosis Code (dx) is not on file. Please Correct And Resubmit. Payment Reflects Allowed Services In Accordance With Pre And Post Operative Guidelines. Pregnancy Indicator must be "Y" for this aid code. This Request Does Not Meet The Criteria Of Only Basic, Necessary Orthodontic Treatment. This Is An Adjustment of a Previous Claim. No action required. Member is enrolled in a commercial health insurance on the Dispense Date Of Service(DOS). Service billed is bundled with another service and cannot be reimbursed separately. Service(s) exceeds four hour per day prolonged/critical care policy. Pricing Adjustment/ Claim has pricing cutback amount applied. 0; No matching Reporting Form on file for the detail Date Of Service(DOS). Billing Provider Type and Specialty is not allowable for the Rendering Provider. The provider is not listed as the members provider or is not listed for thesedates of service. Intermittent Peritoneal Dialysis hours must be entered for this revenue code. Scope Aid Code and an EPSDT Aid Code. Policy override must be granted by the Drug Authorizationand Policy Override Center to dispense early. Claim/adjustment/reconsideration Request Received After 730 Days From Date(s) of Service. A code with no Trip Modifier billed on same day as a code with Modifier U1 are considered the same trip. Member is in a divestment penalty period. This National Drug Code is not covered under the Core Plan or Basic Plan for the diagnosis submitted. When the nerve conduction study or the needle EMG is performed on its own, the results can be misleading and important diagnoses may be missed. Claim Is Pended For 60 Days. Claim Denied Due To Invalid Pre-admission Review Number. Header Rendering Provider number is not found. EOB Code: EOB Description: 0000: This claim/service is pending for program review. WCDP member enrolled in Medicare Part D. Claim is excluded from Drug Rebate Invoicing. Policy override must be granted by the Drug Authorization and Policy Override Center to dispense less than a 100 day supply. Request Denied Because The Screen Date Is After The Admission Date. Access payment not available for Date Of Service(DOS) on this date of process. They are used to provide information about the current status of . Resubmit Claim With Copyof A Temporary ID Card, EVS Printed Response Or Indicate The AVR Transaction Log Number. Submit Claim To Insurance Carrier. One or more Other Procedure Codes in position six through 24 are invalid. Eyeglasses limited to original plus 1 replacement pair, lens or frame in 12 wit hout Prior Authorization. Dosings for Narcotic Treatment Service program are limited to six per Sunday thru Saturday calendar week. Wk. Claim reimbursement has been cutback to reimbursement limits for denture repairs performed within 6 months. Medicare Copayment Out Of Balance. The Service Requested Is Not A Covered Benefit As Determined By . Previously Denied Claims Are To Be Resubmitted As New-day Claims. Only One Outpatient Claim Per Date Of Service(DOS) Allowed. wellcare eob explanation codes. Adjustment/reconsideration Request Denied Due To Incorrect/insufficient Information. Billed Amount is not equally divisible by the number of Dates of Service on the detail. Denied. Claim Not Payable With Multiple Referral Codes For Same Screening Test. Timely Filing Deadline Exceeded. Default Prescribing Physician Number XX5555555 Was Indicated. Escalations. Abortion Dx Code Inappropriate To This Procedure. Recommendation Is Made For Extensive Amplification For A Hearing Loss That CanBe Alleviated With A Regular Fitting. Refer to the DME area of the Online Handbook for claims submission requirements for compression garments. Denied. The Member Has Been Totally Without Teeth And An Appliance For 5 Years. Fifth Other Surgical Code Date is required. There is no action required. Denied. Denied. Please Correct And Resubmit. Member is enrolled in Medicare Part B on the Date(s) of Service. Copyright 2023 Wellcare Health Plans, Inc. RN Home Health visits and Supervisory visits are not reimbursable on the same Date Of Service(DOS) for same provider. Admission Date is on or after date of receipt of claim. Unable To Process Your Adjustment Request due to. The diagnosis codes must be coded to the highest level of specificity. Procedure Code is not covered for members with a Nursing Home Authorization onthe Date(s) of Service. Live-agent chat is the easiest and fastest way to get real-time support for an array of topics, including: Member Eligibility. ACTION DESCRIPTION. Example: Diagnosis code 285.21 is entered as 28521, without a period or space. The detail From Date Of Service(DOS) is invalid. Healthcheck screenings or outreach limited to two per year for members betweenthe ages of two and three years. TPA Certification Required For Reimbursement For This Procedure. Diag Restriction On ICD9 Coverage Rule edit. Pricing Adjustment/ Resource Based Relative Value Scale (RBRVS) pricing applied. Please Bill Your Medicare Intermediary Prior To Submitting To . Billed Procedure Not Covered By WWWP. Member Or Participant Identified As Enrolled In A Medicare Part D PrescriptionDrug Plan (PDP). Member is enrolled in Medicare Part A on the Date(s) of Service. Good Faith Claim Denied Because Of Provider Billing Error. Maximum Number Of Outreach Refusals Has Been Reached For This Period. Please Correct And Resubmit. Claim Denied. The revenue accomodation billing code on the claim does not match the revenue accomodation billing code on the member file or does not match for these dates of service. An ICD-9-CM Diagnosis Code of greater specificity must be used for the Fifth Diagnosis Code. Medicare Deductible Is Paid In Full. Revenue code billed with modifier GL must contain non-covered charges. 2. Permanent Tooth Restoration/sealant, Limited To Once Every 3 Years Unless Narrative Documents Medical Necessity. Benefit code These codes are submitted by the provider to identify state programs. Service is reimbursable only once per calendar month. CNAs Eligibility For Training Reimbursement Has Expired. Other Payer Coverage Type is missing or invalid. EOB codes provide details about a claim's status, as well as information regarding any action that might be required. One or more Occurrence Code(s) is invalid in positions nine through 24. Outpatient Services To Be Billed As Inpatient Ancillaries When Same Day Stay Occurs Please File An Adjustment/reconsideration Request To Correct Inpatiet Billing. Reimbursement Is At The Unilateral Rate. The Members Profile Indicates This Member Is Possibly Alcoholic And/or Chemically Dependent, And Intensive Aoda Treatment Appears Warranted. Other Medicare Part A Response not received within 120 days for provider basedbill. Please Correct and Resubmit. $150.00 Reimbursement Limit Has Been Reached For Individual And Group Pncc Health Education/nutritional Counseling. Denied. Condition code 70-76 is required on an ESRD claim when Influenza/PPV/HEP B HCPCS codes are the only codes being billed with condition code A6. Please Correct And Resubmit. The Existing Appliance Has Not Been Worn For Three Years. Please Rebill Inpatient Dialysis Only. Etiology Diagnosis Code(s) (E-Codes) are invalid as the Admitting/Principal Diagnosis 1. The maximum number of details is exceeded. Header and/or Detail Dates of Service are missing, incorrect or contain futuredates. CPT/HCPCS codes are not reimbursable on this type of bill. Program guidelines or coverage were exceeded. If it is medically necessary to exceed the limitation, submit an Adjustment/Reconsideration request with supporting documentation. Denied. wellcare eob explanation codes. All services should be coordinated with the primary provider. Fifth Diagnosis Code (dx) is not on file. If you haven't created an account yet, register now. Speech Therapy Evaluations Are Limited To 4 Hours Per 6 Months. This Claim Has Been Excluded From Home Care Cap To Allow For Acute Episode. Pricing Adjustment/ Paid according to program policy. Original Payment/denial Processed Correctly. Anesthesia and moderate sedation services billed with pain management services for a patient age 18 or older may deny unless a surgical procedure CPT code range 10021-69990 (other than pain management procedures) is also billed on the claim. Combine Like Details And Resubmit. Pricing Adjustment/ Maximum Flat Fee Level 2 pricing applied. Denied. Member Has Already Been Granted Actute Episode for 3 Months In This Cal Yr. Reimb Is Limited To Average Monthy NH Cost And Services Above That Are Consider Non-covered Services. To Continue Treatment With Two Anti-ulcer Drugs Beyond Authorized Limit Please Submit Request On Paper With Clinical Documentation Clearly Indicating medical necessity. Prior authorization is required for Maxalt when Maxalt or sumatriptan productshave not been reimbursed within 365 days. Only one antipsychotic drug is allowed without an Attestation to Prescribe More Than One Antipsychotic Drug for a Member 16 Years of Age or Younger. This Program Does Not Appear To Meet The Minimum Requirement For AODA Day Treatment Programming (10hrs) And Does Not Qualify For Aoda Day Treatment. The Revenue Code is not reimbursable for the Date Of Service(DOS). Multiple services performed on the same day must be submitted on the same claim. Drug(s) Billed Are Not Refillable. Quantity Would Always Be 00010 If Number Of Pounds Not Indicated. Service paid in accordance with program requirements. A Rendering Provider is not required but was submitted on the claim. This Dms Item Is Limited To 12 Per 30 Days, Per Provider, Without Prior Authorization. Please Contact Your District Nurse To Have This Corrected. Due To Non-covered Services Billed, The Claim Does Not Meet The Outlier Trim Point. This Payment Is A Refund For An Overpayment Of A Provider Assessment, Thank You For Your Assessment Payment By Check, In Accordance With Your Request, EDS Has Deducted Your Assessment From This Payment. 1. If you are having difficulties registering please . Denied/Cutback. These codes provide additional explanation for an adjustment already described by a Claim Adjustment Reason Code (CARC) or convey information about remittance processing. Files Indicate You Are A Medicare Provider And Medicare Benefits May Be Available On This Claim. Do Not Indicate A Hcpcs Or Cpt Procedure Code On An Inpatient Claim. The Member Is School-age And Services Must Be Provided In The Public Schools. Adjustment To Crossover Paid Prior To Aim Implementation Date. Rqst For An Exempt Denied. Not A WCDP Benefit. PDN services billed on this claim exceed 12 hours/day per nurse, PDN services billed on this claim exceed 60 hours/week per nurse, PDN services billed on this claim exceed 24 hours/day per member. Seventh Occurrence Code Date is required. Claim Is Being Reprocessed Through The System. LTC hospital bedhold quantity must be equal to or less than occurrence code 75span date range(s).