No Supporting Documentation. Resubmit Claim Once Election Form Requirements Are Met Per The Hospice Provider Handbook. Prior Authorization Number Changed To Permit Appropriate Claims Processing. WellCare 2016 NA_11_16 NA6PROGDE80121E_1116 . 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. Do Not Bill Intraoral Complete Series Components Separately. No Action Required on your part. Dispense Date Of Service(DOS) is invalid. The Billing Providers taxonomy code in the header is invalid. The Change In The Lens Formula Does Not Warrant Multiple Replacements. Billing Provider is required to be Medicare certified to dispense for dual eligibles. Purchase of a blood glucose monitor includes the first 30 days of supplies for the monitor. The total billed amount is missing or is less than the sum of the detail billed amounts. Fifth Diagnosis Code (dx) is not on file. Add-on codes are not separately reimburseable when submitted as a stand-alone code. Money Will Be Recouped From Your Account. New Prescription Required. The information on the claim isinvalid or not specific enough to assign a DRG. Reimbursement For This Certification, Test, Segment Has Already Been Issued ToYour NF. If not, the procedure code is not reimbursable. Claim Denied. Procedure Code is not allowed on the claim form/transaction submitted. Incorrect or invalid NDC/Procedure Code/Revenue Code billed. The Value Code(s) submitted require a revenue and HCPCS Code. The sum of all Value Code amounts must be numeric and less than or equal to 999.999.999. Claims may deny when a nerve conduction study is billed without a needle EMG, or a needle EMG is billed without a Nerve conduction study, and the only diagnosis is radiculopathy (ICD-10 codes M50.1-M50.23, M51.1-M51.27, M51.9, M53.80, M54.10-M54.18, M54.30-M54.42, and M79.2). Denied due to From Date Of Service(DOS)/date Filled Is Missing/invalid. Reimbursement For This Service Is Included In The Transportation Base Rate. Reimbursement For This Certification, Test, Segment Has Been Issued To AnotherNF. Rendering Provider is not a certified provider for Wisconsin Chronic Disease Program. Per Information From Insurer, Claim(s) Was (were) Not Submitted. Revenue code submitted is no longer valid. Service Denied, refer to Medicares Billing and/or Policy Guidelines. Bilateral Surgeries Reimbursed At 150% Of The Unilateral Rate. Denied. HIPAA EOB codes are returned on the 835 Remittance Advice file and are maintained by the Washington Publishing Company. One or more Diagnosis Codes are not applicable to the members gender. Claim Denied. To access the training video's in the portal, please register for an account and request access to your contract or medical group. Denied due to Provider Is Not Certified To Bill WCDP Claims. BY . This Procedure Code Is Denied As Incidental/Integral To Another Procedure CodeBilled On This Claim. Claim/adjustment/reconsideration Request Received After 730 Days From Date(s) of Service. There Is Evidence That The Member Is Not Detoxified From Alcohol And/or Other Drugs and is Therefore Not Currently Eligible For AODA Day Treatment. This detail is denied. Denied due to Medicare Allowed Amount Required. The diagnosis codes must be coded to the highest level of specificity. TPA Certification Required For Reimbursement For This Procedure. Condition Code 73 for self care cannot exceed a quantity of 15. Paid In Accordance With Dental Policy Guide Determined By DHS. Head imaging in the form of CT scans, MRI or MRA is allowed only when the service is medically reasonable and necessary. Revenue code billed with modifier GL must contain non-covered charges. Reimb Is Limited To The Average Montly NH Cost And Services Above that Amount Are Considered non-Covered Services. Please Check The Adjustment Icn For The Reprocessed Claim. Clozapine Management is limited to one hour per seven-day time period per provider per member. OA 14 The date of birth follows the date of service. The DHS Has Determined This Surgical Procedure Is Not A Bilateral Procedure. Procedure May Not Be Billed With A Quantity Of Less Than One. Claim Number Given Is Not The Most Recent Number. Has Recouped Payment For Service(s) Per Providers Request. This Diagnosis Code Has Encounter Indicator restrictions. Resubmit Claim With Corrected Tooth Number/letter Or With X-ray Documenting Tooth Placement. Member is not enrolled in the program submitted in the Plan ID field for the Dispense Date Of Service(DOS) or an invalid Plan ID was submitted. Recouped. A traditional dispensing fee may be allowed for this claim. Claim Explanation Codes. PATIENT PAID PORTION USED TOWARDS DEDUCTIBLE. Billing Provider is restricted from submitting electronic claims. Provider Not Authorized To Perform Procedure. Denied/cutback. Please Refer To Update No. Members I.d. This Is A Duplicate Request. A covered DRG cannot be assigned to the claim. Correct And Resubmit. Please submit claim to BadgerRX Gold. The National Drug Code (NDC) has an age restriction. The Revenue Code is not payable by Wisconsin Well Woman Program for the Date(s) of Service. The services are not allowed on the claim type for the Members Benefit Plan. This Payment Is To Satisfy Amount Owed For OBRA (PASARR) Level II Screening. Is Unable To Process This Request Because The Signature/date Field Is Blank. CRNAs, AAs, And Anesthesiologists Supervising CRNAs/AAs Must Bill AnesthesiA Services Using The Appropriate Modifier. If You Have Already Obtained SSOP, Please Disregard This Message. This Member Has Prior Authorization For Therapy Services. Detail Denied. Drug(s) Billed Are Not Refillable. 0300-0319 (Laboratory/Pathology). AODA Day Treatment Is Not A Covered Service For Members Who Are Residents Of Nursing Homes or Who Are Hospital Inpatients. Valid group codes for use on Medicare remittance advice are:. CO/96/N216. Dialysis/EPO treatment is limited to 13 or 14 services per calendar month. Reimbursement also may be subject to the application of Quantity indicated for this service exceeds the maximum quantity limit established by the National Correct Coding Initiative. LO DENIED - RCVD MORE THAN 60 DAYS AFTER DATE ON EOB FROM OTHER MA67 2D ADJUSTMENT - DENIAL UPHELD-TIMELINESS NOT JUSTIFIED: 31 N30 34: DENIED - NOT A PLAN MEMBER,PROVIDER MUST BILL E.D.S. A Qualified Provider Application Is Being Mailed To You. Incidental modifier was added to the secondary procedure code. The Surgical Procedure Code is restricted. Exceeds The 35 Treatment Days Per Spell Of Illness. Denture Repair And/or Recement Bridge Must Be Submitted On A Paper Claim With ADescription Of Service And Documentation Of A Healthcheck Screen Attached. Pricing Adjustment/ Medicare pricing cutbacks applied. A standard 12-lead electrocardiogram should be obtained first for patients with a diagnosis of syncope and collapse before performing advanced imaging procedures. A claim cannot contain only Not Otherwise Specified (NOS) Surgical Procedure Codes. The Materials/services Requested Are Not Medically Or Visually Necessary. Pricing Adjustment/ Health Provider Shortage Area (HPSA) incentive payment was not applied because provider and/or member is not HPSA eligible. Denied. Wk. Member is not enrolled for the detail Date(s) of Service. Watch FutureRemittance And Status Reports For Its Finalization Before Resubmitting. Contact Provider Services For Further Information. According to CMS policy and the American College of Radiology, a chest X-ray (CPT codes 71045, 71046) should not be performed for screening purposes in the absence of pertinent signs, symptoms or diseases. Prescribing Provider UPIN Or Provider Number Missing From Claim And Attachment. Only One Ventilator Allowed As Per Stated Condition Of The Member. Pricing Adjustment/ Inpatient Per-Diem pricing. The Hearing Aid Recommended Is Not Necessary; The Member Could Be Adequately Fitted With A Conventional Aid. Reimbursement for this procedure and a related procedure is limited to once per Date Of Service(DOS). Service (Procedure Code/Modifier Combination) is not reimbursable for Date Of Service(DOS). Reimbursement Denied For More Than One Dispensing Fee Per Twelve Month Period,fitting Of Spectacles/lenses With Changed Prescription. Medicare accepts any National Uniform Billing Committee (NUBC) approved revenue codes. Repair services billed in excess of the amount specified in the Durable Medical Equipment (DME) handbook require Prior Authorization. The Medical Necessity For The Hours Requested Is Not Supported By The Information Submitted In The Personal Care Assessment Tool. We have created a list of EOB reason codes for the help of people who are . The respiratory care services billed on this claim exceed the limit. 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. Denied. Primary Tooth Restorations Limited To Once Per Year Unless Claim Narrative Documents Medical Necessity. The Procedure Requested Is Not Allowable For The Process Type Indicated On TheRequest. Procedure Code Modifier(s) Invalid For Date Of Service(DOS) Or For Prior Authorization Date Of Receipt. Claim Previously/partially Paid. Scope Aid Code and an EPSDT Aid Code. Resubmit Claim Through Regular Claims Processing. Denied. Comprehension And Language Production Are Age-appropriate. Please Do Not Resubmit Your Claim. Wis Adm Code 106.04(3)(b) Requires Providers To Reimburse The Person/party (eg, County) That Previously. One or more Diagnosis Code(s) is invalid for the Date(s) of Service. Denied/Cutback. Amount Paid Reduced By Amount Of Other Insurance Payment. Provider Must Have A CLIA Number To Bill Laboratory Procedures. Ongoing assessment is not reimbursable when skilled nursing visits have been performed within the past sixty days. Pharmaceutical care code must be billed with a valid Level of Effort. Submit Claim To For Reimbursement. Services Must Be Submitted On Proper Claim/adjustment/reconsiderationRequest Form. ACCOM REV CODE QTY BILLED NOT EQUAL TO DTL DOS. Admission Denied In Accordance With Pre-admission Review Criteria. Condition code 80 is present without condition code 74. Denied due to Medicare Allowed Amount Is Greater Than Total Billed Amount. Please Add The Coinsurance Amount And Resubmit. Procedure not payable for Place of Service. No More Than 2 Medication Check Services (30 Minutes) Are Payable Per Date Of Service(DOS). Please Correct And Resubmit. Medicaid id number does not match patient name. A valid Prior Authorization is required. Explanation of Benefit codes (EOBs) Explanation of Benefit (EOB) codes are reported on your remittance statement. One or more Surgical Code Date(s) is invalid in positions seven through 24. Please Clarify. Prior Authorization is required to exceed this limit. Service is covered only during the first month of enrollment in the Home and Community Based Waiver. Pricing Adjustment/ Usual & Customary Charge (UCC) rate pricing applied. 10 Important Billing Tips for FQHC and RHC Providers. The Lens Formula Does Not Justify Replacement. Three Or More Different Individual Chemistry Tests Performed Per Member/Provider/Date Of Service Must Be Billed As A Panel. Members Aged 3 Through 21 Years Old Are Limited To One Healthcheck Screening per 12 months. Service(s) paid in accordance with program policy limitation. By continuing to use our site, you agree to our Privacy Policy and Terms of Use. View the Part C EOB materials in the Downloads section below. We Have Determined There Were (are) Several Home Health Agencies Willing To Provide Medically Necessary Skilled Nursing Services To This Member. The Request Does Not Meet Generally Accepted Conditions Requiring Fluoride Treatments. Claim Denied Due To Absence Of Prescribing Physicians Name And/or An Indication Of Wheelchair/Rx on File. Note: The Group, Reason and Remark Codes are HIPAA EOB codes and are cross-walked to L&I's EOB codes. Please Contact The Hospital Prior Resubmitting This Claim. Diagnosis of malignancies and inflammatory conditions frequently requires numerous biopsies of a particular organ or suspicious site. This drug/service is included in the Nursing Facility daily rate. An amount in the Gross Amount Due field and/or Usual and Customary Charge field is required. X . Surgical Procedure Code billed is not appropriate for members gender. Default Prescribing Physician Number XX5555555 Was Indicated. Denied due to The Members Last Name Is Missing. Up Denied. Modification Of The Request Is Necessitated By The Members Minimal Progress. The Service Performed Was Not The Same As That Authorized By . Pricing Adjustment/ Payment amount increased based on hospital access paymentpolicies. MLN Matters Number: MM6229 Related . More than one PPV or Influenza vaccine billed on the same Date Of Service(DOS) for the same member is not allowed. Hearing Aid Batteries Are Limited To 12 Monaural/24 Binaural Batteries Per 30-day Period, Per Provider, Per Hearing Aid. The Clinical Profile/Diagnosis Makes This Member Ineligible For AODA Services. Denied. Additional Psychotherapy Is Not Considered Appropriate Or Inline With More Effective, Available Services. The total of amounts billed for the DOS on the claim exceeds the allowed dailylimit for PDN services. Fourth Other Surgical Code Date is required. The To Date Of Service(DOS) for the Second Occurrence Span Code is invalid. Rqst For An Acute Episode Is Denied. Header From Date Of Service(DOS) is after the date of receipt of the claim. Denied due to Diagnosis Code Is Not Allowable. Pricing Adjustment/ Resource Based Relative Value Scale (RBRVS) pricing applied. Personal care subsequent and/or follow up visits limited to seven per Date Of Service(DOS) per member. Pricing Adjustment/ Medicare benefits are exhausted. Claim reimbursement has been cutback to reimbursement limits for denture repairs performed within 6 months. Acute Care General And Specialty Hospitals Are Subject To Pre-admission Requirements Or The Pre-admission Review Number Indicated Is Invalid. wellcare explanation of payment codes and comments. This CNAs Social Security Number, SSN, Is Not On The EDS Nurse Aide Registry File. Procedure Code Changed To Permit Appropriate Claims Processing. Contact Wisconsin s Billing And Policy Correspondence Unit. 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. Day Treatment Services For Members With Inpatient Status Limited To 20 Hours. Valid Numbers Are Important For DUR Purposes. Second Other Surgical Code Date is required. Denied. 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. Secondary Diagnosis Code(s) in positions 2-9 cannot duplicate the Primary Discharge Diagnosis. Insufficient Documentation To Support The Request. Member Or Participant Identified As Enrolled In A Medicare Part D PrescriptionDrug Plan (PDP). This National Drug Code is not covered under the Core Plan or Basic Plan for the diagnosis submitted. Previously Denied Claims Are To Be Resubmitted As New-day Claims. -OR- The claim contains value code 48, 49, or 68 but does not contain revenue codes 0634 or 0635. Admission Date is on or after date of receipt of claim. Denied. If you are still unable to resolve the login problem, read the troubleshooting steps or report your issue. Only non-innovator drugs are covered for the members program. Please Submit A Separate New Day Claim For Copayment Exempt Days/services. Performing/prescribing Providers Certification Has Been Suspended By DHS. Different Drug Benefit Programs. Third Diagnosis Code (dx) (dx) is not on file. Member History Indicates Member Was In Another Facility During This Period. This National Drug Code (NDC) has diagnosis restrictions. Adjustment Requested Member ID Change. The Materials/services Requested Are Principally Cosmetic In Nature. Physical Therapy, Occupational Therapy Or Speech Therapy Limited To 90 Min PerDay. The diagnosis code is not reimbursable for the claim type submitted. Description. This Report Was Mailed To You Separately. Pricing Adjustment/ Usual & Customary Charge (UCC) flat fee pricing applied. A Second Surgical Opinion Is Required For This Service. An ICD-9-CM Diagnosis Code of greater specificity must be used for the First Diagnosis Code. Effective With Claims Received On And After 10/01/03 , Occurrence Codes 50 And 51 Are Invalid. 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 Procedure Code is not reimbursable for the Rendering Provider Type and/or Specialty. Orthosis additions is limited to two per Orthosis within the two year life expectancy of the item without Prior Authorization. Services Billed Denied As Being Covered In The Payment For Day Rx Per Medical Day Treatment Guidelines. Prescription Drug Plan (PDP) payment/denial information is required on the claim to SeniorCare. Outside Lab,element 20 On CMS 1500 Claim Form Must Be Checked Yes When Handling Charges Are Billed. 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. Please Ask Prescriber To Update DEA Number On TheProvider File. When a provider submits an E&M level of service that exceeds the maximum level of E&M service level based on the diagnosis submitted, the E&M code is recoded (and allowed to pay) to match the maximum level of E&M service allowed based on the severity of the medical diagnosis submitted. Goals Are Not Realistic To The Members Way Of Life Or Home Situation, And Serve No Functional Or Maintenance Service. The dental procedure code and tooth number combination is allowed only once per lifetime. Was Unable To Process This Request. Copayment Should Not Be Deducted From Amount Billed. Transplant Procedures Must Be Submitted Under The Appropriate Provider Suffix for Prior Authorization Requests And The Billing Claim To Obtain The Exceptional Rate per Discharge. Received Beyond Special Filing Deadline For ThisType Of Claim Or Adjustment/reconsideration. NCPDP Format Error Found On Medicare Drug Claim. Please Submit On The Cms 1500 Using The Correct Hcpcs Code. 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. Member is not Medicare enrolled and/or provider is not Medicare certified. The Resident Or CNAs Name Is Missing. Care Does Not Meet Criteria For Complex Case Reimbursement. Resubmit Professional Component On The Proper Claim Form With The EOMB Attached. NFs Eligibility For Reimbursement Has Expired. Denials with solutions in Medical Billing; Denials Management - Causes of denials and solution in medical billing; Medical Coding denials with solutions The Narrative History Does Not Indicate the Members Functioning is Impaired due To AODA Usage. This claim/service is pending for program review. Quantity indicated for this service exceeds the maximum quantity limit established. Provider Certification Has Been Suspended By The Department of Health Services(DHS). Please Do Not Resubmit Your Claim, And Disregard Additional Informational Messages for this claim. Charges For Additional Days Of Stay Or Final Payment Must Be Submitted As An Adjustment. CORE Plan Members are limited to 25 non-emergency outpatient hospital visits per enrollment year. You can even print your chat history to reference later! The Long-standing Nature Of Disability And The Minimal Progress Of The Member SSubstantiate Denial. These Supplies/items Are Included In The Purchase Of The Dme Item Billed On The Same Date Of Service(DOS). Denied. Additional servcies may be billed with H0046 and will count toward mental health and/or substance abuse treatment policy limits for prior authorization. Capitation Payment Recouped Due To Member Disenrollment. The From Date Of Service(DOS) and To Date Of Service(DOS) must be in the same calendar month and year. Referring Provider is not currently certified. This ProviderMay Only Bill For Coinsurance And Deductible On A Medicare Crossover Claim. Prescribing Provider UPIN Or Provider Number Missing. A discrepancy exists between the Other Coverage Indicator and the Other Paid Amount. Ancillary Codes Dates Of Service And/or Quantity Billed Do Not Match Level Of Care authorized Dates. Pricing Adjustment/ Level of effort dispensing fee applied. Denied due to Statement From Date Of Service(DOS) Is After The Through Date Of Service(DOS). This list was formerly published as Part 6 of the administrative and billing instructions in Subchapter 5 of your MassHealth provider manual. The Primary Diagnosis Code is inappropriate for the Revenue Code. Claimchecks Editing And Your Supporting Documentation Was Reviewed By The DHS Medical Consultant. No Action Required. Documentation Indicates That Client Is Able To Direct Cares And Can Safely Direct A PCW. Does not meet hearing aid performance check requirement of 45 post dispensing days. Denied. Reimbursement For This Service Has Been Approved. A Training Payment Has Already Been Issued To Your NF For This CNA. Pricing Adjustment/ Maximum Flat Fee pricing applied. The Other Payer Amount Paid qualifier is invalid for . Pricing Adjustment/ Maximum Flat Fee Level 2 pricing applied. MassHealth List of EOB Codes Appearing on the Remittance Advice. Please correct and resubmit. Prospective DUR denial on original claim can not be overridden. Disposable medical supplies are payable only once per trip, per member, per provider. wellcare eob explanation codes. Denied. This claim has been adjusted due to Medicare Part D coverage. Restorative Nursing Involvement Should Be Increased. The Provider Type/specialty Is Not Recognized For These Date(s) Of Service. Denied due to Discharge Diagnosis 1 Missing Or Invalid, Denied due to Diagnosis Pointer To Diagnosis Code 1 Invalid, Denied due to Diagnosis Pointer To Diagnosis Code 2 Invalid, Denied due to Diagnosis Pointer To Diagnosis Code 3 Invalid, Denied due to Diagnosis Pointer To Diagnosis Code 4 Invalid, Denied due to Diagnosis Pointer To Diagnosis Code 5 Invalid, Denied due to Diagnosis Pointer(s) Are Invalid. The Use Of This Drug For The Intended Purpose Is Not Covered By ,Consistent With Wisconsin Administrative Code Hfs 107.10(4) And 1396r-8(d). The Surgical Procedure Code is not payable for Wisconsin Chronic Disease Program for the Date Of Service(DOS).

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