Maximum Reimbursement Amount Has Been Determined By Professional Consultant. AODA Day Treatment Is Not A Covered Service For Members Who Are Residents Of Nursing Homes or Who Are Hospital Inpatients. Member must receive this service from the state contractor if this is for incontinence or urological supplies. PNCC Risk Assessment Not Payable Without Assessment Score. NDC was reimbursed at State Maximum Allowable Cost (SMAC) rate. Certifying Agency Verified Member Was Not Eligible for Dates Of Services. The Reimbursement Code Assigned To This Certification Segment Does Not Authorize a Training Payment. There are approximately 20 Medicaid Explanation Codes which map to Denial Code 16. Supervising Nurse Name Or License Number Required. Reimbursement For This Certification, Test, Segment Has Already Been Issued ToYour NF. Denied/Cutback. Service Denied. Correct Claim Or Resubmit With X-ray. You Received A PaymentThat Should Have gone To Another Provider. One or more Diagnosis Code(s) is invalid in positions 10 through 25. . The second occurrence span from Date Of Service(DOS) is after to to Date Of Service(DOS). The Revenue Code is not reimbursable for the Date Of Service(DOS). This National Drug Code (NDC) is not covered. Request For Training Reimbursement Denied. Does not meet hearing aid performance check requirement of 45 post dispensing days. Submitted rendering provider NPI in the detail is invalid. The Procedure Code Indicated Is For Informational Purposes Only. Revenue codes 082X, 083X, 084X, 085X, 0800 or 0881 (X frequency not equal to 5) exist on an ESRD claim for a member who has selected method 1 or no method and the claim does not contain condition codes 71, 72, 73 ,74, 75, or 76. For RHCs, place of service is 72, however, you can bill lab services with a place of service 11. We encourage you to take advantage of this easy-to-use feature. Service is not reimbursable for Date(s) of Service. Quantity Billed is restricted for this Procedure Code. Day Treatment Services For Members With Inpatient Status Limited To 20 Hours. One or more From Date Of Service(DOS) (DOS) is invalid for Occurrence Span Codes in positions three through 24. The Member Has Shown No Ability Within 6 Months To Carry Over Abilities GainedFrom Treatment In A Facility To The Members Place Of Residence. The Member Has Received A 93 Day Supply Within The Past Twelve Months. Contact Wisconsin s Billing And Policy Correspondence Unit. Consent Form Is Missing, Incomplete, Or Contains Invalid Information. Adjustment/reconsideration Request Denied Due To Incorrect/insufficient Information. Remittance Advice Remark Codes (RARCs) are used to provide additional explanation for an adjustment already described by a CARC or to convey information about remittance processing; Search for a Reason or Remark Code. There is no action required. Gastrointestinal Surgery For The Purpose Of Weight Control Is Covered Only As An Emergency Procedure. Service Denied. Billing Provider is not certified for the Dispense Date. ACode With No Modifier Billed On The Same Day As A Code With Modifier 11 Are Viewed as the same trip. Medical Necessity For Food Supplements Has Not Been Documented. Principal Diagnosis 9 Not Applicable To Members Sex. Compound drugs not covered under this program. SMV Mileage Exceeding 40 Miles In Urban Counties Or 70 Miles In Rural CountiesRequires Prior Authorization. This Procedure Code Not Approved For Billing. Use The ICN which Is In An Allowed Or Paid Status When Filing An Adjustment/ReconsiderationRequest. Has Already Issued A Payment To Your NF For A Level I Screen With The Same Admission Date. If Required Information Is Not Received Within 60 Days,the claim will be denied. Amount Indicated In Current Processed Line On R&S Report Is The Manual Check You Recently Received. Denied. Req For Acute Episode Is Denied. These same rules are used by most healthcare claims payers and enforced by the Centers for Medicare and Medicaid Services. Please Refer To The PDL For Preferred Drugs In This Therapeutic Class. THE WELLCARE GROUP OF COMPANIES . Prosthodontic Services Appear To Have Started After Member EligibilityLapsed. Claim Denied. is unable to is process this claim at this time. RN Home Health visits and Supervisory visits are not reimbursable on the same Date Of Service(DOS) for same provider. NCTracks AVRS. Unable To Process Your Adjustment Request due to Provider ID Number On The Claim And On The Adjustment Request Do Not Match. Traditional dispensing fee may be allowed. Annual Physical Exam Limited To Once Per Year By The Same Provider. Per Information From Insurer, Requested Information Was Not Supplied By The Provider. Admit Diagnosis Code is invalid for the Date(s) of Service. EOB Codes List|Explanation of Benefit Reason Codes (2023) February 7, 2022 by medicalbillingrcm. Fourth Other Surgical Code Date is invalid. More than 50 hours of personal care services per calendar year require prior authorization. Claim Is Being Reprocessed, No Action On Your Part Required. Payment has been reduced or denied because the maximum allowance of this ESRD service has been reached. Denied. CNAs Eligibility For Training Reimbursement Has Expired. A Training Payment Has Already Been Issued For This Cna. Service Provided Before Prior Authorization Was Obtained Is Not Allowable. Please Indicate Mileage Traveled. The Diagnosis Code is not payable for the member. This Claim Is A Reissue of a Previous Claim. Third modifier code is invalid for Date Of Service(DOS). (part JHandbook). Less Expensive Alternative Services Are Available For This Member. Birth to 3 enhancement is not reimbursable for place of service billed. For example, a claim from a physician provider with place of service 11 (Office) would be considered incorrectly coded when a claim from an outpatient facility (e.g. WellCare Known Issues List EOP Denial Code or Rejection Reason Code Issue Description Impacted Provider Specialty . Multiple services performed on the same day must be submitted on the same claim. OA 11 The diagnosis is inconsistent with the procedure. Prior Authorization Is Required For Payment Of This Service With This Modifier. Explanation of Benefit codes (EOBs) Explanation of Benefit (EOB) codes are reported on your remittance statement. Disposable medical supplies are payable only once per trip, per member, per provider. Result of Service code is invalid. 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). Please Correct and Resubmit. NFs Eligibility For Reimbursement Has Expired. This Modifier has been discontinued by CMS or AMA for the Date Of Service(DOS)(s). Thank You For The Payment On Your Account. Denied. The Service Billed Does Not Match The Prior Authorized Service. Questionable Long-term Prognosis Due To Apparent Root Infection. Rental Only Allowed; Medical Need For Purchase Has Not Been Documented. A Version Of Software (PES) Was In Error. Procedimientos. Claim Denied. Requests For Training Reimbursement Denied Due To Late Billing. One or more Diagnosis Code(s) is not payable by Wisconsin Well Woman Program for the Date(s) of Service. Documentation Does Not Justify Reconsideration For Payment. Paid In Accordance With Dental Policy Guide Determined By DHS. Does not reimburse both the global service and the individual component parts of the service for the same Date Of Service(DOS). A Procedure Code without a modifier billed on the same day as a Procedure Codewith modifier 11 are viewed as the same trip. A Primary Occurrence Code Date is required. Prescribing Provider UPIN Or Provider Number Missing From Claim And Attachment. Prescription limit of five Opioid analgesics per month. Pricing Adjustment/ Payment reduced due to benefit plan limitations. NFs Eligibility For Reimbursement Has Expired. Do Not Bill Intraoral Complete Series Components Separately. Pharmaceutical care indicates the prescription was not filled. Supplemental Payment Authorized By Department of Health Services (DHS) Due to an Interim Rate Settlement. Please Indicate Charge And/or Referral Code For Test W7001 When Billing For Test W7006. The quantity billed of the NDC is not equally divisible by the NDC package size. Service(s) Billed Are Included In The Total Obstetrical Care Fee. Request Denied. The following are the most common reasons HCFA/CMS-1500 and UB/CMS-1450 paper claims for Veteran care are rejected: Requires the 17 alpha-numeric internal control number (ICN) [format: 10 digits + "V" + 6 digits] or 9-digit social security number (SSN) with no special characters. The Procedure(s) Requested Are Not Medical In Nature. Rebill Using Correct Procedure Code. Earn Money by doing small online tasks and surveys, What is Denials Management in Medical Billing? NUMBER IS MISSING OR INCORRECT 0002 01/01/1900 COULD NOT PROCESS CLAIM. Please Do Not File A Duplicate Claim. TPA Certification Required For Reimbursement For This Procedure. EOB for services that should be paid as primary by the Health Plan EPSDT: claims billed with EP modifier 3/28/2022 03/09/2022 2636 In Process DN018 . This Dms Item Is Limited To 12 Per 30 Days, Per Provider, Without Prior Authorization. Admission Date does not match the Header From Date Of Service(DOS). Diagnosis Code indicated is not valid as a primary diagnosis. If this is your first visit, be sure to check out the FAQ & read the forum rules.To view all forums, post or create a new thread, you must be an AAPC Member.If you are a member and have already registered for member area and forum access, you can log in by clicking here.If you've forgotten your username or password use our . An antipsychotic drug has recently been dispensed for this member. The Diagnosis Does Not Indicate A Significant Change In the Members Condition. Dispensing fee denied. Member is enrolled in a commercial health insurance on the Dispense Date Of Service(DOS). Service Denied, refer to Medicares Billing and/or Policy Guidelines. If A CNA Obtains his/her Certification After Theyve Been Hired By A NF, A NF Has A Year From Their Certification, Test, Date To Submit A Reimbursement Request To . Do Not Use Informational Code(s) When Submitting Billing Claim(s). We update the Code List to conform to the most recent publications of CPT and HCPCS . Designated codes for conditions such as fractures, burns, ulcers and certain neoplasms require documentation of the side/region of the body where the condition occurs. Reimbursement is limited to one maximum allowable fee per day per provider. Service Paid At The Maximum Amount Allowed By ReimbursementPolicies. Please Submit With Completed timely Filing Form In The All Provider Handbook And Supporting Documentation. Resubmit Claim Once Election Form Requirements Are Met Per The Hospice Provider Handbook. Services Requested Do Not Meet The Criteria for an Acute Episode. Day Treatment Exceeding 5 Hours/day Not Payable Regardless Of Prior Authorization. If laboratory costs exceed reimbursement, submit a claim adjustment request with lab bills for reconsideration. The From Date Of Service(DOS) for the Second Occurrence Span Code is required. Multiple Referral Charges To Same Provider Not Payble. Master Level Providers Must Bill Under A Mental Health Clinic Number; Not Under a Private Practice Or Supervisor Number. Subsequent surgical procedures are reimbursed at reduced rate. These materials include the HPMS memorandum titled, "Updates Regarding Final Part C EOB Model Templates and Implementation of the Part C EOB," the final templates and instructions, and Frequently Asked Questions regarding the Part C EOB requirements for Medicare Advantage . Pricing Adjustment/ SeniorCare claim cutback because of Patient Liability and/or other insurace paid amounts. Pricing Adjustment/ Third party liability deducible amount applied. Our Records Indicate You Have Billed More Than One Unit Dose Dispensing Fee For This Calendar Month. The sum of the Accommodation Days is not equal to the sum of Covered plus Non-Covered Days, or the From and To Dates of Service cannot be the same. This Member Has A Current Approved Authorization For Intensive AODA OutpatientServices. Member is not enrolled in /BadgerCare Plus for the Date(s) of Service. Revenue code 0850 thru 0859 is not allowed when billed with revenue codes 0820thru 0829, 0830 thru 0839, or 0840 thru 0849. Condition code 20, 21 or 32 is required when billing non-covered services. Contact Provider Services For Further Information. Insufficient Documentation To Support The Request. This service is not payable for the same Date Of Service(DOS) as another service included on this claim. Surgical Procedure Code billed is not appropriate for members gender. Reimbursement For Training Is One Time Only. Total Rental Payments For This Item Have Exceeded The Maximum Allowable Forthe Purchase Of This Item. The Submission Clarification Code is missing or invalid. Bilateral Procedures Must Be Billed On One Detail With Modifier 50, Quantity Of 1.detail With Modifier 50 May Be Adjusted If Necessary. This Member Is Receiving Concurrent AODA/Psychotherapy Services And Is Therefore Only Eligible For Maintenance Hours. A dispense as written indicator is not allowed for this generic drug. Review Has Determined No Adjustment Payment Allowed. Complex care of 17-plus hours and complex care of less than 17 hours are not allowed on the same Date Of Service(DOS). Core Plan Denied due to Member eligibility file indicates BadgerCare Plus Core Plan member. Claim Is Pended For 60 Days. The Documentation Submitted Indicates The Tasks Specified Can Be Completed During The Visits Approved. Purchase of additional DME/DMS item exceeding life expectancy rRequires Prior Authorization. For additional information on HIPAA EOB codes, visit the Code List section of the WPC website at www.wpc-edi.com. Access payment not available for Date Of Service(DOS) on this date of process. Ongoing assessment is not reimbursable when skilled nursing visits have been performed within the past sixty days. Please Resubmit. Dates Of Service Must Be Itemized. Secondary Diagnosis Code(s) in positions 2-9 cannot duplicate the Primary Discharge Diagnosis. Denied due to Medicare Allowed Amount Required. Denied. Medically Unbelievable Error. Description. Service Fails To Meet Program Requirements. Effective 04/01/09, the BadgerCare Plus Core Plan will limit coverage for Hypoglycemics-Insulin to Humalog and Lantus. Restorative Nursing Can Provide Follow-through, Based On Diagnosis Of Long-standing Nature, And The Amount Of Therapy. An explanation of benefits is a document from your insurance company outlining the services you received and how much they cost. Claims may deny when reported with mutually exclusive code combinations according to the ICD-10-CM Excludes 1 Notes guideline policy. Please Refer To The Original R&S. Name And Complete Address Of Destination. For over 40 years, Washington Publishing Company (WPC) has specialized in managing and distributing data integration information through publications, training, and consulting services. Claim Denied For No Consent And/or PA. Please Do Not Resubmit Your Claim, And Disregard Additional Informational Messages for this claim. This Payment Is To Satisfy The Amount Owed For OBRA Level 1. Only One Panel Code Within Same Category (CBC Or Chemistry) Maybe Performed Per Member/Provider/Date Of Service. Please Correct And Resubmit. Competency Test Date Is Not A Valid Date. Diag Restriction On ICD9 Coverage Rule edit. Services restricted to EPSDT clients valid only with a Full Scope, EPSDT-eligible Aid Code. Use The New Prior Authorization Number When Submitting Billing Claim. Compound Drug Service Denied. Please Resubmit Medicares Nursing Home Coinsurance Days As A New Claim RatherThan An Adjustment/reconsideration Request. Occupational therapy limited to 35 treatment days per lifetime without prior authorization. The procedure code has Family Planning restrictions. trevor lawrence 225 bench press; new internal . Quantity Would Always Be 00010 If Number Of Pounds Not Indicated. Please submit future claims with the appropriate NPI, taxonomy and/or Zip +4 Code. Pricing Adjustment/ Ambulatory Payment Classification (APC) pricing applied. Refer To Notice From DHS. Please Clarify. Service Denied. Authorization For Surgery Requiring Second Opinion Valid For 6Months After Date Approved. Denied due to Add Dates Not In Ascending Order Or DD/DD/DD Format. Member does not have commercial insurance for the Date(s) of Service. Homecare Services W/o PA Are Not Payable When Prior Authorized HomecAre Services Have Been Provided To The Same Member. Discharge Diagnosis 5 Is Not Applicable To Members Sex. It has now been removed from the provider manuals . A quantity dispensed is required. This claim is being denied because it is an exact duplicate of claim submitted. No Complete Program Enrollment Form Is On File For This Client Or The Client Is Not Eligible For The Date Of Service(DOS) On The Clai im. Denied/Cutback. One or more Surgical Code(s) is invalid in positions six through 23. Anesthesia and Moderate Sedation Services CPTs 00300, 00400, 00600, 01935-01936, 01991-01992, 99152-99153, 99156-99157, Pain Management Services CPTs 20552, 20553, 27096, 62273, 62320-62323, 64405, 64479, 64480, 64483, 64484, 64490-64495, 0228T, 0229T, 0230T, 0231T, G0260, Nerve Conduction Studies CPT 95907-95913, Needle electromyography (EMG)-CPT 95885, 95886. Procedure Not Payable for the Wisconsin Well Woman Program. Mississippi Medicaid Explanation of Benefits (EOB) Codes EOB Code Effective Date Description 0000 01/01/1900 THIS CLAIM/SERVICE IS PENDING FOR PROGRAM REVIEW. LTC hospital bedhold quantity must be equal to or less than occurrence code 75span date range(s). Description & Use Of Day RX Procedure Codes Based On Members Status-not the place Of Service Where Day Rx Service Performed. Please Contact The Hospital Prior Resubmitting This Claim. Service Denied. Request Denied Because The Screen Was Done More Than 90 Days Prior To The Admission Date. Claim Denied Due To Invalid Pre-admission Review Number. Denied due to Member Not Eligibile For All/partial Dates. Please Attach Copy Of Medicare Remittance. Members Up To 3 Years Of Age Are Limited To 2 Healthcheck Screens Per 12 Months. Diagnosis Indicated Is Not Allowable For Procedures Designated As Mycotic Procedures. Denied. Complete Refusal Detail Is Not Payable Without Referral/treatment Details. Providers should submit adequate medical record documentation that supports the claim (services) billed. The Medicare Paid Amount is missing or incorrect. Condition code 80 is present without condition code 74. A1 This claim was refused as the billing service provider submitted is: . The below mention list of EOB codes is as below, EOB codes list is updated as per the latest information gathered from authorized sources of information, if any discrepancy please let us know via the contact us page, Coupon "NSingh10" for 10% Off onFind-A-CodePlans. These are EOB codes, revised for NewMMIS, that may appear on your PDF remittance advice. Denied due to Service Is Not Covered For The Diagnosis Indicated. Please verify billing. -OR- The claim contains value code 49but does not contain revenue code 0636 and HCPCS Q4054. Time Spent In AODA Day Treatment By Affected Family Members Is Not Covered. Once medical records are received, medical review professionals will review the documentation to determine whether the claim is supported as submitted and pay or deny accordingly. A number is required in the Covered Days field. One or more Date(s) of Service is missing for Occurrence Span Codes in positions 9 through 24. Please Reference Payment Report Mailed Separately. Home Health, Personal Care And Private Duty Nursing Services Are Subject To A Monthly Cap. No Functional Regression Has Occurred To Warrant A Spell Of Illness; Submit AsA Prior Authorization Request. Fifth Other Surgical Code Date is required. Denied/Cuback. Valid group codes for use on Medicare remittance advice are:. To allow for multiple biopsies for investigation and diagnosis of certain disease entities, WellCare applies max units editing for CPT code 88305 based on gastrointestinal (GI) and prostate-related diagnoses. Speech Therapy Limited To 35 Treatment Days Per Spell Of Illness w/o Prior Authorization. The number of treatments/days reflected by the units entered with revenue code0821, 0831, 0841, 0851, 0880, 0881 exceeds the number of days included in the FROM and TO dates entered on this claim. Annual Nursing Home Member Oral Exam Is Allowed Once Per 355 Days Per Recip Per Prov. OA 13 The date of death precedes the date of service. This drug/service is included in the Nursing Facility daily rate. Please familiarize yourself with these new explanation codes and update your accounts receivable as indicated. Please Supply NDC Code, Name, Strength & Metric Quantity. Third Other Surgical Code Date is required. Speech Therapy Is Not Warranted. Additional Psychotherapy Is Not Considered Appropriate Or Inline With More Effective, Available Services. Training Request Denied Because Either The Training Date On The Request Is After The CNAs Certification Test Date Or Its Not Within A Year Of That Date. Payspan's Core Payment Network comes with a feature that allows payers to send members an electronic version of their Explanation of Benefits (eEOB). Other Amount Submitted Not Reimburseable. Please Disregard Additional Information Messages For This Claim. A Training Payment Has Already Been Issued To A Different NF For This CNA. Treatment With More Than One Drug Per Class Of Ulcer Treatment Drug At The Same Time Is Not Allowed Through Stat PA. Pharmacuetical care limitation exceeded. Claim Explanation Codes. The Billing Providers taxonomy code is invalid. The Maximum Prior Authorized Service Limitation Or Frequency Allowance Has Been Exceeded. Active Treatment Dose Is Only Approved Once In Six Month Period. Please Verify The Units And Dollars Billed. FL 44 HCPCS/Rates/HIPPS Rate Codes Required. An Individual CBC Or Chemistry Test With A CBC Or Chemistry Panel, Performed Per Member/Provider/Date Of Service Must Be Billed w/ Appropriate Panel Code. If you are still unable to resolve the login problem, read the troubleshooting steps or report your issue. This member is eligible for Medication Therapy Management services. Revenue Codes 0110 (N6) And 0946 (N7) Are Not Payable When Billed On The Same Dateof Service As Bedhold Days. The To Date Of Service(DOS) for the First Occurrence Span Code is invalid. The Revenue Code is not payable for the Date(s) of Service. Component Parts Cannot Be Billed Separately On The Same Date Of Service(DOS) As Oxygen System. Please Review The Cover Letter Attached To Your Claim, Any Informational Messages, And Provide The Requested Information BeforeResubmitting the Claim. Note: This PA Request Has Been Backdated A Maximum Of 3 Weeks Prior To Its First Receipt By EDS, Based Upon Difficulty In Obtaining The Physicians Written Prescription. Copyright 2023 Wellcare Health Plans, Inc. Pricing Adjustment/ Paid according to program policy. Prior Authorization is required for service(s) exceeding mental health and/or substance abuse benefit guidelines. Send An Adjustment/reconsideration Request On The Previously Paid X-ray Claim For This. This National Drug Code (NDC) is only payable as part of a compound drug. Restorative Nursing Involvement Should Be Increased. The Member Is School-age And Services Must Be Provided In The Public Schools. Denied. Level, Intensity Or Extent Of Service(s) Requested Has Been Modified Consistent With Medical Need As Defined In The Plan Of Care. A valid header Medicare Paid Date is required. Please File With Champus Carrier. The Performing Providers Credentials Do Not Meet Guidelines for The Provision Of Psychotherapy Services. No Matching, Complete Reporting Form Is On File For This Client. The Resident Or CNAs Name Is Missing. Unable To Process Your Adjustment Request due to Member Not Found. Billing Provider Name Does Not Match The Billing Provider Number. No More Than 2 Medication Check Services (30 Minutes) Are Payable Per Date Of Service(DOS). Pricing Adjustment/ Revenue code flat rate pricing applied. Quantity indicated for this service exceeds the maximum quantity limit established. Medicare Claim Copy And EOMB Have Been Submitte d For Processing Of Coinsurance And Deductible. Please Rebill Only CoveredDates. Reconsideration With Documentation Warranting More X-rays. Inpatient mental health services performed by masters level psychotherapists or substance abuse counselors are not covered. The member is locked-in to a pharmacy provider or enrolled in hospice. Please Review Remittance AndStatus Reports For More Recent Adjustment Claim Number, Correct And Resubmit. DRG cannotbe determined. No Reimbursement Rates on file for the Date(s) of Service. A Photocopy Of The PA Request Form Has Been Mailed Separately Identifying the Reimbursement Rate For The Procedure Codes Authorized. This National Drug Code (NDC) has diagnosis restrictions. A New Prior Authorization Number Has Been Assigned To This Request In Order ToProcess. Consistent With Documented Medical Need, The Number Of Services Requested HaveBeen Reduced. This Unbundled Procedure Code And Billed Charge Were Rebundled To Another Code, Which Was Either Billed By The Provider On This Claim Or Added By Claimcheck. Unable To Process Your Adjustment Request due to Member ID Not Present. Denied. Denied due to Claim Contains Future Dates Of Service. Maximum Number Of Outreach Refusals Has Been Reached For This Period. Etiology Diagnosis Code(s) (E-Codes) are invalid as the Admitting/Principal Diagnosis 1. For Revenue Code 0820, 0821, 0825 or 0829, HCPCS Code 90999 or Modifier G1-G6 must be present. Oral exams or prophylaxis is limited to once per year unless prior authorized. These Supplies/items Are Included In The Purchase Of The Dme Item Billed On The Same Date Of Service(DOS). Check Your Current/previous Payment Reports forPayment. Routine foot care Diagnoses must be billed with valid routine foot care Procedure Codes. This Member Is Involved In Non-covered Services, And Hours Are Reduced Accordingly. Compound Ingredient Quantity must be greater than zero. Has Already Issued A Payment To Your NF For This Level L Screen. Normal delivery reimbursement includes anesthesia services.

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