Invalid Admission Date. Member is enrolled in Medicare Part B on the Date(s) of Service. Policy override must be granted by the Drug Authorization and Policy Override Center to dispense less than a 100 day supply. Please Verify That Physician Has No DEA Number. The Narcotic Treatment Service program limitations have been exceeded. Please Select A Procedure Code In The 58980-58988 Range That Best Describes The Procedure Being Performed. Dispense Date Of Service(DOS) is after Date of Receipt of claim. Members File Shows Other Insurance. Missing or invalid level of effort submitted and/or reason for service, professional service, or result of service code billed in error. One or more Condition Code(s) is invalid in positions eight through 24. Diagnosis Indicated Is Not Allowable For Procedures Designated As Mycotic Procedures. Denied. Will Not Authorize New Dentures Under Such Circumstances. EOB Any EOB code that applies to the entire claim (header level) prints here. Men. A Trading Partner Agreement/profile Form(s) Authorizing Electronic Claims Submission Is Required. Claim Denied. 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. Denied. 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. The detail From Date Of Service(DOS) is required. EOB Codes are present on the last page of remittance advice, these EOB codes or explanation of benefit codes are in form of numbers and every number has a specific meaning. Claim cannot contain both Condition Codes A5 and X0 on the same claim. No Extractions Performed. The Seventh Diagnosis Code (dx) is invalid. Wis Adm Code 106.04(3)(b) Requires Providers To Reimburse The Person/party (eg, County) That Previously. The Member Was Not Eligible For On The Date Received the Request. Claims may deny when reported and not meeting the ICD-10-CM Laterality policy for Diagnosis-to-Diagnosis comparison. One or more Diagnosis Code(s) is invalid in positions 10 through 25. Member does not meet the age restriction for this Procedure Code. Review Billing Instructions. The Total Number Of Hours Per Day Requested For AODA Day Treatment Exceeds Guidelines And The Request Has Been Adjusted Accordingly. According to the American Society of Anesthesiologists and the International Spine Intervention Society, minor pain procedures such as epidural steroid injections, epidural blood patch, trigger point injections, sacroiliac joint injection, bursal injections, occipital nerve block and facet injections under most routine circumstances, require only local anesthesia. We Have Determined There Were (are) Several Home Health Agencies Willing To Provide Medically Necessary Skilled Nursing Services To This Member. Department of Health Services (DHS) Authorized Payment Is Being Withheld Due toan Audit. Pharmacuetical care limitation exceeded. Information Required For Claim Processing Is Missing. Denied/Cutback. Billing Provider does not have required Certification Addendum on file. Compound Drug Service Denied. It Must Be In MM/DD/YY Format AndCan Not Be A Future Date. Home Health services for CORE plan members are covered only following an inpatient hospital stay. Indiana Medicaid: Providers: Explanation of Benefits (EOB) this Procedure Code Is Denied As Mutually Exclusive To Another Code Billed On This Claim. Independent RHCs Must Bill Codes W6251, W6252, W6253, W6254 Or W6255. According to the American Association of Neuromuscular & Electro-Diagnostic Medicine and CMS Policy, nerve conduction studies and a needle electromyography (EMG) must both be performed in order to diagnose radiculopathy (pinched nerve in back or neck). Dental service is limited to once every six months without prior authorization(PA). Denied. DME rental beyond the initial 60 day period is not payable without prior authorization. Claim Denied For Invalid Billing Type Frequency Code, Claim Type, Or SubmittedAdjustment Provider Number Does Not Match Original Claims Provider Number. For more information on which codes are considered "Mutually Exclusive", see the "ICD-10 2019 The Complete Official Codebook. The service is not reimbursable for the members benefit plan. Child Care Coordination services are reimbursable only if both the member and provider are located in Milwaukee County. Second modifier code is invalid for Date Of Service(DOS) (DOS). Compound drugs require a minimum of two components with at least one payable FowardHealth covered drug. Billing provider number was used to adjudicate the service(s). Speech Therapy Limited To 45 Treatment Days Per Spell Of Illness W/o Prior Authorization. Pricing AdjustmentUB92 Hospice LTC Pricing. Please Request A Corrected EOMB Through The Medicare Carrier And Adjust With The Corrected EOMB. The Competency Test Date On The Request Does Not Match The CNAs Test Date OnThe WI Nurse Aide Registry. Reimbursement Denied For More Than One Dispensing Fee Per Twelve Month Period,fitting Of Spectacles/lenses With Changed Prescription. The American College of Emergency Physicians (ACEP) also indicates that it is not appropriate to perform screening with advanced imaging for syncope patients, however be guided by the patients history and physical exam findings. Wk. Service is covered only during the first month of enrollment in the Home and Community Based Waiver. Service billed is bundled with another service and cannot be reimbursed separately. Denied/Cutback. Live-agent chat is the easiest and fastest way to get real-time support for an array of topics, including: Member Eligibility. 0001 01/01/1900 NOT USED - MEMBER'S DMAP I.D. Denied due to Procedure Or Revenue Code(s) Are Missing On The Claim. If you are having difficulties registering please . A SeniorCare drug rebate agreement is not on file for this drug for the Date Of Service(DOS). Money Will Be Recouped From Your Account. Service(s) Denied By DHS Transportation Consultant. The Clinical Profile/Diagnosis Makes This Member Ineligible For AODA Services. Member has Medicare Managed Care for the Date(s) of Service. Denied due to Claim Or Adjustment Received After The Late Billing Filing Limit. Please Reference Payment Report Mailed Separately. This Dental Service Limited To Once A Year. Outside Lab Indicator Must Be Y For The Procedure Code Billed. Home Health visits (Nursing and therapy) in excess of 30 visits per calendar year per member require Prior Authorization. Denied. To access the training video's in the portal, please register for an account and request access to your contract or medical group. Quantity submitted matches original claim. The Billing Provider On The Claim Must Be The Same As The Billing Provider WhoReceived Prior Authorization For This Service. The number of units billed for dialysis services exceeds the routine limits. An Explanation of Benefits (EOB) code corresponds to a printed message about the status or action taken on a claim. The Documentation Submitted Does Not Substantiate Additional Care. Day Treatment exceeding 120 hours per month is not payable regardless of PriorAuthorzation. Request Denied Due To Late Billing. The Skills Of A Therapist Are Not Required To Maintain The Member. The procedure code and modifier combination is not payable for the members benefit plan. This Is A Duplicate Request. Multiple Providers Of Treatment Are Not Indicated For This Member. Unable To Process Your Adjustment Request due to Provider ID Number On The Claim And On The Adjustment Request Do Not Match. NFs Eligibility For Reimbursement Has Expired. This procedure is limited to once per day. The diagnosis code is not reimbursable for the claim type submitted. Pricing Adjustment/ Payment amount increased based on hospital access paymentpolicies. Code. The Second Other Provider ID is missing or invalid. The Change In The Lens Formula Does Not Warrant Multiple Replacements. Voided Claim Has Been Credited To Your 1099 Liability. All services should be coordinated with the Hospice provider. The Member Appears To Be At A Maximum Level For Age, Diagnosis, And Living Arrangement. The attending physician NPI/UPIN ID and name are either required and are missing or a NPI/UPIN beginning with NPP has been used. Multiple Requests Received For This Ssn With The Same Screen Date. 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. Escalations. If You Have Already Obtained SSOP, Please Disregard This Message. CO/96/N216. Well-baby visits are limited to 12 visits in the first year of life. For Revenue Code 0820, 0821, 0825 or 0829, HCPCS Code 90999 or Modifier G1-G6 must be present. Pricing Adjustment/ Maximum Allowable Fee pricing used. Timely Filing Deadline Exceeded. Prospective DUR denial on original claim can not be overridden. Unable To Process Your Adjustment Request due to A Different Adjustment Is Pending For This Claim. Pricing Adjustment/ Level of effort dispensing fee applied. Members age does not fall within the approved age range. Denied. Principle Surgical Procedure Code Date is missing. EOB. The Member Is Only Eligible For Maintenance Hours. Revenue Code 0001 Can Only Be Indicated Once. Annual Physical Exam Limited To Once Per Year By The Same Provider. Copyright 2023 Wellcare Health Plans, Inc. Claims may deny when reported with mutually exclusive code combinations according to the ICD-10-CM Excludes 1 Notes guideline policy. The value code 48 (Hemoglobin reading) or 49 (Hematocrit) is required for the revenue code/HCPCS code combination. Please Resubmit. Services have been determined by DHCAA to be non-emergency. Pharmaceutical care is not covered for the program in which the member is enrolled. Invalid Procedure Code For Dx Indicated. Use Of Therapy Equipment Alone Is Not Sufficient To Justify Maintenance Therapy. Prescriptions Or Services Must Be Billed As ASeparate Claim. Service Denied. Summarize Claim To A One Page Billing And Resubmit. The Medical Records Submitted With The Current Request Conflict Or Disagree With Our Medical Records On This Member. Services Requested Do Not Meet The Criteria for an Acute Episode. Denied. A1 This claim was refused as the billing service provider submitted is: . Contact Wisconsin s Billing And Policy Correspondence Unit. Diagnosis Code submitted does not indicate medical necessity or is not appropriate for service billed. Member is enrolled in Medicare Part D for the Dispense Date Of Service(DOS). The Evaluation Was Received By Fiscal Agent More Than Two Weeks After The Evaluation Date. Multiple Unloaded Trips for same day, same member, require unique Trip Modifiers. Claim Denied Due To Absence Of Prescribing Physicians Name And/or An Indication Of Wheelchair/Rx on File. This change to be effective 4/1/2008: Submission/billing error(s). By continuing to use our site, you agree to our Privacy Policy and Terms of Use. Denied. The HCPCS procedure code listed for revenue code 0624 is either invalid or non-reimburseable. The Duration Of Treatment Sessions Exceed Current Guidelines. An ICD-9-CM Diagnosis Code of greater specificity must be used for the Second Diagnosis Code. Claim Is Pended For 60 Days. One or more Diagnosis Code(s) is not payable for the Date Of Service(DOS). An ICD-9-CM Diagnosis Code of greater specificity must be used for the First Diagnosis Code. Our Records Indicate This Tooth Previously Extracted. Correct And Resubmit. Check Your Current/previous Payment Reports forPayment. The Service Billed Does Not Match The Prior Authorized Service. The Revenue code on the claim requires Condition code 70 to be present for this Type of Bill. Abortion Dx Code Inappropriate To This Procedure. This HMO Capitation Payment Is Being Recouped It Was Inappropriately Paid During The Inital February HMO Capitation Cycle. What steps can we take to avoid this denial? Qty And/or Detail Charge Do Not Divide Out Equally For Dates Of Service and/orQty Given. A covered DRG cannot be assigned to the claim. Claim Denied for implementation of new Wisconsin Medicaid Interchange System.Resubmission of the claim is required due to new claim submission guidelines. An approved PA was not found matching the provider, member, and service information on the claim. A: This denial is received when Medicare records indicate that Medicare is the beneficiary's secondary payer. The Procedure Code Indicated Is For Informational Purposes Only. Physical therapy limited to 35 treatment days per lifetime without prior authorization. Denied due to Detail Add Dates Not In MM/DD Format. Anesthesia Modifying Services Must Be Billed Separately From The Charge For Anesthesia Base And Time Units. Quantity Billed is not equally divisible by the number of Dates of Service on the detail. Dosings for Narcotic Treatment Service program are limited to six per Sunday thru Saturday calendar week. Denied. Explanation of Benefit Codes (EOBs) Mar 14, 2022 1 EOB EOB DESCRIPTION. This ProviderMay Only Bill For Coinsurance And Deductible On A Medicare Crossover Claim. Pricing Adjustment/ Medicare benefits are exhausted. A Payment For The CNAs Competency Test Has Already Been Issued. Pharmaceutical Care Codes Are Billable On Non-compound Drug Claims Only. Admit Date and From Date Of Service(DOS) must match. Prior Authorization Is Required For Payment Of This Service With This Modifier. Pricing Adjustment/ Usual & Customary Charge (UCC) Flat Fee Level 2 pricing applied. NDC- National Drug Code billed is not appropriate for members gender. Denied due to Provider Is Not Certified To Bill WCDP Claims. The Non-contracted Frame Is Not Medically Justified. Service(s) exceeds four hour per day prolonged/critical care policy. This claim is a duplicate of a claim currently in process. First modifier code is invalid for Date Of Service(DOS). No Separate Payment For IUD. Service Denied. Start: 01/01/2000 | Last Modified: 03/06/2012 Notes: (Modified 2/28/03, 3/6/2012) N5: Immunization Questions A And B Are Required For Federal Reporting. Resubmit Your Services Using The Appropriate Modifier After YouReceive A Update Providing Additional Billing Information. Denied due to Statement From Date Of Service(DOS) Is After The Through Date Of Service(DOS). No policy override available for BadgerCare Plus Benchmark Plan, Core Plan or Basic Plan. Verify billed amount and quantity billed. Please Correct And Resubmit. Revenue code requires submission of associated HCPCS code. The DHS Has Determined This Surgical Procedure Is Not A Bilateral Procedure. Claim Corrected. The Procedure Code/Modifier combination is not payable for the Date Of Service(DOS). The Service Requested Is Not A Covered Benefit Of The Program. This National Drug Code Has Diagnosis Restrictions. Medicare denial codes, reason, action and Medical billing appeal NFs Eligibility For Reimbursement Has Expired. 191. Benefit Payment Determined By Fiscal Agent Review. Separate reimbursement for drugs included in the composite rate is not allowed. Lab Procedures Billed In Conjunction With Family Planning Pharmacy Visit Denied as not a Benefit. ACode With No Modifier Billed On The Same Day As A Code With Modifier 11 Are Viewed as the same trip. Member is enrolled in Medicare Part A and/or Part B on the on the Dispense Dateof Service. Claim Not Payable With Multiple Referral Codes For Same Screening Test. Only non-innovator drugs are covered for the members program. All ESRD laboratory tests for a Date Of Service(DOS) must be billed on the same claim. Copyright 2023 Wellcare Health Plans, Inc. New Coding Integrity Reimbursement Guidelines. Denied. Discharge Diagnosis 5 Is Not Applicable To Members Sex. NDC was reimbursed at brand WAC (Wholesale Acquisition Cost) (Wholesale Acquisition Cost) rate. Please Provide Copy Of Medicare Explanation Of Benefits/medicare Remittance Advice Attached To Claim. Exceeds The 35 Treatment Days Per Spell Of Illness. Claim Detail Is Pended For 60 Days. A Rendering Provider is not required but was submitted on the claim. Does not reimburse both the global service and the individual component parts of the service for the same Date Of Service(DOS). Determinations as to whether services are reasonable and necessary for an individual patient should be made on the same basis as all other such determinations: with reference to accepted standards of medical practice and the medical circumstances of the individual case. Previously Denied Claims Are To Be Resubmitted As New Day Claims. . Invalid Service Facility Address. Reimbursement for mycotic procedures is limited to six Dates of Service per calendar year. A Training Payment Has Already Been Issued For This Cna. Service(s) Billed Are Included In The Total Obstetrical Care Fee. Please Rebill Only CoveredDates. Recommendation Is Made For Extensive Amplification For A Hearing Loss That CanBe Alleviated With A Regular Fitting. Claim Explanation Codes | Providers | Univera Healthcare Denied due to The Members Last Name Is Missing. One Visit Allowed Per Day, Service Denied As Duplicate. If required information is not received within 60 days, the claim will be. Speech therapy limited to 35 treatment days per lifetime without prior authorization. 2. Claim Denied/cutback. Service Paid At The Maximum Amount Allowed By ReimbursementPolicies. Denied. This Unbundled Procedure Code Remains Denied. Claim Is Being Special Handled, No Action On Your Part Required. Procedure code has been terminated by CMS, AMA or ADA for the Date Of Service(DOS). Only Medicare Crossover claims are reimbursed for coinsurance, copayment, and deductible. Once Therapy Is Prior Authorized, All Therapy Must Be Billed With A Valid Prior Authorization Number. Resubmit With All Appropriate Diagnoses Or Use Correct HCPCS Code. Claim Is For A Member With Retro Ma Eligibility. Dispensing Two Lens Replacements On Same Date Of Service(DOS) Not Allowed. Endurance Activities Do Not Require The Skills Of A Therapist. Incidental modifier was added to the secondary procedure code. Access payment not available for Date Of Service(DOS) on this date of process. Denied due to Detail Dates Are Not Within Statement Covered Period. The Reimbursement Code Assigned To This CNA Does Not Authorize A NAT Payment. Billing Provider is restricted from submitting electronic claims. Please Refer To The PDL For Preferred Drugs In This Therapeutic Class. Additional Encounter Service(s) Denied. Combine Like Details And Resubmit. 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.
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