Please Resubmit A New Adjustment/reconsideration Request Form And Indicate TheMost Recent Cclaim Number Where Payment Was Made Or Allowed. This Member Is Involved In Intensive Day Treatment, Which Is To Include Psychotherapy Services. Header Bill Date is before the Header From Date Of Service(DOS). Previously Paid Individual Test May Be Adjusted Under a Panel Code. This service is not payable with another service on the same Date Of Service(DOS) due to National Correct Coding Initiative. Less Expensive Alternative Services Are Available For This Member. Phone: 800-723-4337. Department of Health Services (DHS) Authorized Payment Is Being Withheld Due toan Audit. The Information Provided Indicates This Member Is Not Willing Or Able To Participate Inaftercare/continuing Care Services And Is Therefore Not Eligible For AODA Day Treatment. Denial Codes. CPT Code 88305 (Level IV Surgical pathology, gross and microscopic examination) includes different types of biopsies. This Is A Duplicate Request. Condition Code is missing/invalid or incorrect for the Revenue Code submitted. Anesthesia Modifying Services Must Be Billed Separately From The Charge For Anesthesia Base And Time Units. Copayment Should Not Be Deducted From Amount Billed. If the KT/V reading was not performed, then the value code D5 with 9.99 must be present without the occurrence code 51. Denied due to Provider Signature Date Is Missing Or Invalid. The Member Does Not Appear To Meet The Severity Of Illness Indicators Established by the Wisconsin And Is Therefore Not Eligible For AODA Day Treatment. The Materials/services Requested Are Principally Cosmetic In Nature. The Service Requested Is Not A Covered Benefit As Determined By . CPT Code And Service Date For Memberis Identical To Another Claim Detail On File For Another WWWP Provider. Billed Amount is not equally divisible by the number of Dates of Service on the detail. Additional Psychotherapy Is Not Considered Appropriate Or Inline With More Effective, Available Services. Result of Service submitted indicates the prescription was not filled. A new set of Generic Reason codes and statements for Part A, Part B and DME have been added and approved for use across all Prior Authorization (PA), Claim reviews . Amount Recouped For Mother Baby Payment (newborn). Reconsideration With Documentation Warranting More X-rays. The Surgical Procedure Code is not payable for the Date Of Service(DOS). Medicare Coinsurance Amount Was Not Provided On Crossover Claim. Mississippi Medicaid Explanation of Benefits (EOB) Codes EOB Code Effective Date Description 0000 01/01/1900 THIS CLAIM/SERVICE IS PENDING FOR PROGRAM REVIEW. Newborn Care Must Be Billed Under Newborn Name And Number; Occurrence Codes 50& 51 Cannotbe Present if Billing Under Newborn Name. qatar to toronto flight status. The Related Surgical Procedure is not a covered service under Wisconsin Medicaid or BadgerCare Plus. Prior authorization is required for Advair or Symbicort if no other Glucocorticoid Inhaled product has been reimbursed within 90 days. WellCare has established maximum frequency per day (MFD) values, which are the highest number of units eligible for reimbursement of services on a single date of service. The Member Has Received A 93 Day Supply Within The Past Twelve Months. Service (Procedure Code/Modifier Combination) is not reimbursable for Date Of Service(DOS). Member is not enrolled for the detail Date(s) of Service. Hospice Member Services Related To The Terminal Illness Must Be Billed By Hospice Or Attending Physician. Billing Provider does not have required Certification Addendum on file. Training Completion Date Must Be Within A Year Of The CNAs Certification, Test, Date. Only Medicare Crossover claims are reimbursed for coinsurance, copayment, and deductible. The Non-contracted Frame Is Not Medically Justified. The procedure code has Family Planning restrictions. CPT Code 88305 (Level IV - Surgical pathology, gross and microscopic examination) includes different types of biopsies. Please Review All Provider Handbook For Allowable Exception. (8 days ago) WebMassHealth List of EOB Codes Appearing on the Remittance Advice. Other Insurance Or Medicare Response Not Received Within 120 Days For ProviderBased Bill. The Members Gait Is Not Functional And Cannot Be Carried Over To Nursing. Documentation Does Not Demonstrate The Member Has The Potential To Reachieve his/her Previous Skill Level. An Explanation of Benefits (EOB) code corresponds to a printed message about the status or action taken on a claim. Other Coverage Code is missing or invalid. Outside Lab Indicator Must Be Y For The Procedure Code Billed. The Rendering Providers taxonomy code in the detail is not valid. Denied due to Member Is Eligible For Medicare. Denied due to Detail Fill Date Is A Future Date. Whenever claim denied with CO 197 denial code, we need to follow the steps to resolve and reimburse the claim from insurance company: First step is to verify the denial reason and get the denial date. A Payment For The CNAs Competency Test Has Already Been Issued. Your latest EOB will be under Claims on the top menu. Services Requiring Prior Authorization Cannot Be Submitted For Payment On A Claim In Conjunction With Non Prior Authorized Services. Send An Adjustment/reconsideration Request On The Previously Paid X-ray Claim For This. HMO Capitation Claim Greater Than 120 Days. Progress, Prognosis And/or Behavior Are Complicating Factors At This Time. Payment For Immunotherapy Service Included In Reimbursement For Allergy Extract Injection. Reimbursement Based On Members County Of Residence. Only One Panoramic Film Or Intraoral Radiograph Series, By The Same Provider, Per Year Allowed. Member In TB Benefit Plan. 51.42 Board Directors Or Designees Statement & Signature Required OnThe Claim Form For Payment Of Functional Assessment. NDC- National Drug Code is restricted by member age. Claim Denied For No Consent And/or PA. These case coordination services exceed the limit. The revenue code has Family Planning restrictions. Pricing Adjustment/ Prior Authorization pricing applied. Revenue Code 0001 Can Only Be Indicated Once. ACode With No Modifier Billed On The Same Day As A Code With Modifier 11 Are Viewed as the same trip. The second occurrence span from Date Of Service(DOS) is after to to Date Of Service(DOS). Pediatric Community Care is limited to 12 hours per DOS. The Members Profile Indicates This Member Is Possibly Alcoholic And/or Chemically Dependent, And Intensive Aoda Treatment Appears Warranted. Supervising Nurse Name Or License Number Required. Diagnosis Codes Assigned Must Be At The Greatest Specificity Available. Real time pharmacy claims require the use of the NCPDP Plan ID. Reimbursement Is Limited To The Average Monthly Nursing Home Cost And Services Above That Amount Are Considered Non-covered Services. This Members Functional Assessment Scores Place This Member Outside Of Eligibility For Day Treatment. Room And Board Is Only Reimbursable If Member Has A BQC Nursing Home Authorization. One or more Diagnosis Code(s) in positions 10 through 25 is not on file. Modifiers are required for reimbursement of these services. Member is assigned to an Inpatient Hospital provider. Reimbursement For This Certification, Test, Segment Has Been Issued To AnotherNF. One or more Condition Code(s) is invalid in positions eight through 24. Please Complete Information. Has Processed This Claim With A Medicare Part D Attestation Form. Services In Excess Of This Cap Are Not Reimbursable for this Member. The Clinical Status Of The Member Does Not Meet Standards Accepted By The Department Of Health And Family Services For Transplant. Principal Diagnosis 6 Not Applicable To Members Sex. The From Date Of Service(DOS) for the First Occurrence Span Code is invalid. SMV Or Prescribing Provider Description Code(s) Missing OrInvalid. Revenue code requires submission of associated HCPCS code. Member has Medicare Managed Care for the Date(s) of Service. Provider Not Authorized To Perform Procedure. Reimbursement Is At The Unilateral Rate. Quantity Would Always Be 00010 If Number Of Pounds Not Indicated. Denied due to Some Charges Billed Are Non-covered. Please Furnish Length Of Time For Services Rendered. Medicare RA/EOMB And Claim Dates And/or Charges Do Not Match. Changes/corrections Were Made To Your Claim Per Dental Processing Guidelines. Denied. Insufficient Documentation To Support The Request. Dispensing fee denied. Please Request Prior Authorization For Additional Days. DME rental is limited to 90 days without Prior Authorization. Submit copy of the dated and signed evaluation and indicate if this is an initial Evaluation. All rental payments have been deducted from the purchase costsince the DME item was rented and subsequently purchased for the member. The Fifth Diagnosis Code (dx) is invalid. An ICD-9-CM Diagnosis Code of greater specificity must be used for the Fifth Diagnosis Code. Extended Care Is Limited To 20 Hrs Per Day. Use The New Prior Authorization Number When Submitting Billing Claim. Claimchecks Editing And Your Supporting Documentation Was Reviewed By The DHS Medical Consultant. Documentation Does Not Justify Medically Needy Override. Incorrect Or Invalid National Drug Code Billed. A Less Than 6 Week Healing Period Has Been Specified For This PA. Comprehensive Screens And Individual Components Are Not Payable On The Same Date Of Service(DOS). A Google Certified Publishing Partner. Amount Recouped For Duplicate Payment on a Previous Claim. Detail Denied. Review Billing Instructions. This Is Not A Reimbursable Level I Screen. Purchase of a blood glucose monitor includes the first 30 days of supplies for the monitor. Other Payer Date can not be after claim receipt date. Purchase of additional DME/DMS item exceeding life expectancy rRequires Prior Authorization. Adjustment Requested Member ID Change. Service(s) Billed Are Included In The Total Obstetrical Care Fee. This National Drug Code (NDC) has diagnosis restrictions. The Tooth Is Not Essential For Support Of A Partial Denture. Denied. Use The ICN which Is In An Allowed Or Paid Status When Filing An Adjustment/ReconsiderationRequest. This detail is denied. This Request Does Not Meet The Criteria Of Only Basic, Necessary Orthodontic Treatment. This Service Is Not Payable Without A Modifier/referral Code. Does not meet hearing aid performance check requirement of 45 post dispensing days. Billing provider number was used to adjudicate the service(s). The Comprehensive Community Support Program reimbursement limitations have been exceeded. Please Review The Cover Letter Attached To Your Claim, Any Informational Messages, And Provide The Requested Information BeforeResubmitting the Claim. Please Resubmit. Denied due to Provider Signature Is Missing. The Provider Type/specialty Is Not Recognized For These Date(s) Of Service. Only One Ventilator Allowed As Per Stated Condition Of The Member. Header Rendering Provider number is not found. Reading your EOB. Denied. Dental service limited to twice in a six month period. The Pharmaceutical Care Code (PCC) does not have a rate on file for the Date Of Service(DOS). Procedure not payable for Place of Service. Please Disregard Additional Information Messages For This Claim. Denied. Supplemental tests billed on the same Date Of Service(DOS) as vision examination are not payable. The Procedure Code is not reimbursable for the Rendering Provider Type and/or Specialty. flora funeral home rocky mount va. Jun 5th, 2022 . Only Healthcheck Modifiers Can Be Billed With Healthcheck Services. Pricing Adjustment/ Resource Based Relative Value Scale (RBRVS) pricing applied. Mail-to name and address - We mail the TRICARE EOB directly to. The Insurance EOB Does Not Correspond To The Dates Of Service/servicesBeing Billed. This drug is a Brand Medically Necessary (BMN) drug. A Previously Submitted Adjustment Request Is Currently In Process. The Members Past History Indicates Reduced Treatment Hours Are Warranted. Member does not meet the age restriction for this Procedure Code. Providers will find a list of all EOB codes used with the corresponding description on the last page of the Remittance Advice. Therefore itIs Not Necessary To Wait The Full 6 Weeks After Extractions Before Taking Denture Impressions. The Automated Voice Response System is encouraged to obtain claims status using a touch-tone phone. Pricing Adjustment/ Maximum Flat Fee Level 2 pricing applied. Pricing Adjustment. If Required Information Is Not Received Within 60 Days,the claim will be denied. Please Refer To Update No. Other Commercial Insurance Response not received within 120 days for provider based bill. Child Care Coordination services are reimbursable only if both the member and provider are located in Milwaukee County. A1 This claim was refused as the billing service provider submitted is: . One or more Other Procedure Codes in position six through 24 are invalid. Only non-innovator drugs are covered for the members program. If Required Information Is not received within 60 days, the claim detail will be denied. To access the training video's in the portal . OA 12 The diagnosis is inconsistent with the provider type. Research Has Determined That The Member Does Not Qualify For Retroactive Eligibility According To Hfs 106.03(3)(b) Of The Wisconsin Administrative Code. Denied due to Claim Contains Future Dates Of Service. According To Our Records, The Surgeon For This Sterilization Procedure Has NotSubmitted The Members Consent Form. A group code is a code identifying the general category of payment adjustment. Early Refill Alert. No Action Required. Pricing Adjustment. Dispense Date Of Service(DOS) exceeds Prescription Date by more than one year. WI Can Not Issue A NAT Payment Without A Valid Hire Date. This claim/service is pending for program review. Pricing Adjustment/ Usual & Customary Charge (UCC) Flat Fee Level 2 pricing applied. The Maximum Prior Authorized Service Limitation Or Frequency Allowance Has Been Exceeded. This Member, As Indicated By Narrative History, Does Not Agree To Abstinence from Alcohol Or Other Drugs And Is Ineligible For AODA Treatment. Claim or line denied. Please Correct Claim And Resubmit. Admission Denied In Accordance With Pre-admission Review Criteria. Please Indicate Computation For Unloaded Mileage. Here are just a few of them: EOB CODE. Please Submit A Separate New Day Claim For Copayment Exempt Days/services. A National Drug Code (NDC) is required for this HCPCS code. Recd Beyond 90 Days Special Filing Deadline FOr System Generated Adjmts/Medicare X-overs/Other Insurance Reconsideration/Cou rt Order/Fair Hearing. Claim Paid In Accordance With Family Planning Contraceptive Services Guidelines. This Adjustment Was Initiated By . Denied/Cutback. 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. Maximum Reimbursement Amount Has Been Determined By Professional Consultant. The To Date Of Service(DOS) for the First Occurrence Span Code is invalid. Level, Intensity Or Extent Of Service(s) Requested Has Been Modified Consistent With Medical Need As Defined In The Plan Of Care. Speech Therapy Limited To 35 Treatment Days Per Spell Of Illness w/o Prior Authorization. Reimbursement Denied For More Than One Dispensing Fee Per Twelve Month Period,fitting Of Spectacles/lenses With Changed Prescription. The Quantity Allowed Was Reduced To A Multiple Of The Products Package Size. See Physicians Handbook For Details. Medicare accepts any National Uniform Billing Committee (NUBC) approved revenue codes. The Lens Formula Does Not Justify Replacement. (part JHandbook). Explanation of Benefits (EOB) The four-digit explanation of benefits (EOB) codes and the corresponding narratives indicate that the submitted claim paid as billed or describe the reason the claim suspended, was denied, or did not pay in full. MLN Matters Number: MM6229 Related . Service(s) paid in accordance with program policy limitation. Member is enrolled in Medicare Part B on the Date(s) of Service. NDC- National Drug Code is not covered on a pharmacy claim. The Service Requested Was Performed Less Than 3 Years Ago. Qty And/or Detail Charge Do Not Divide Out Equally For Dates Of Service and/orQty Given. The Primary Diagnosis Code is inappropriate for the Surgical Procedure Code. Questionable Long-term Prognosis Due To Decay History. Adjustment/reconsideration Request Denied Due To Incorrect/insufficient Information. Individual Vaccines And Combination Vaccine Code May Not Be Billed For The Same Dates Of ervice. Services Cutback/denied, Charges Greater Than Patient Liability, Not Responsible For Noncovered Services In Excess Of Patient Liability. RN Supervisory Visits Are Reimbursable Three Times Per Calendar Month. Pharmacuetical care limitation exceeded. Service Billed Limited To Three Per Pregnancy Per Guidelines. Part A Reason Codes are maintained by the Part A processing system. If authorization number available . Policy override must be granted by the Drug Authorization and Policy Override Center to dispense less than a 100 day supply. Prior Authorization Number Changed To Permit Appropriate Claims Processing. Service(s) paid at the maximum daily amount per provider per member. Personal Care Services Exceeding 30 Hours Per 12 Month Period Per Member Require Prior Authorization. Continuous home care and routine home care may not be billed for the same member on the same Date Of Service(DOS). Services Billed Denied As Being Covered In The Payment For Day Rx Per Medical Day Treatment Guidelines. Newsroom. RN Home Health visits and Supervisory visits are not reimbursable on the same Date Of Service(DOS) for same provider. Services Not Provided Under Primary Provider Program. Claims Cannot Exceed 28 Details. A National Provider Identifier (NPI) is required for the Rendering Provider listed in the header. ACTION DESCRIPTION: ACTION TYPE. Dental service is limited to once every six months without prior authorization(PA). Claim Denied. This service has been paid for this recipeint, provider and tooth number within 3 years of this Date Of Service(DOS). Claim or Adjustment received beyond 365-day filing deadline. Etiology Diagnosis Code(s) (E-Codes) are invalid as the Admitting/Principal Diagnosis 1. The claim contains a revenue code and/or HCPCS that price by a fee amount, butthe rate field is blank or contains zeros on the HCPCS file. BMN prior authorization may be submitted for Mental Health drugs for which a Core Plan transitioned member has been previously grandfathered. Each month you fill a prescription, your Medicare Prescription Drug Plan mails you an "Explanation of Benefits" (EOB). Pricing Adjustment/ Payment reduced due to the inpatient or outpatient deductible. I'm getting a 2% CMS Mandate on my Wellcare EOB's. What is that? Revenue code 082X is present on an ESRD claim which also contains revenue code088X (X frequency non equal to 9). Indicated Diagnosis Is Not Applicable To Members Sex. Pricing Adjustment/ Maximum Flat Fee pricing applied. Please Correct And Resubmit. Timely Filing Deadline Exceeded. Questionable Long-term Prognosis Due To Poor Oral Hygiene. Master Level Providers Must Bill Under A Mental Health Clinic Number; Not Under a Private Practice Or Supervisor Number. Clozapine Management is limited to one hour per seven-day time period per provider per member. Revenue Codes 0110 (N6) And 0946 (N7) Are Not Payable When Billed On The Same Dateof Service As Bedhold Days. Once you register and have access to the provider portal, you will find a variety of video training available in the Resources section of the portal. Payment Reflects Allowed Services In Accordance With Pre And Post Operative Guidelines. Claim paid according to Medicares reimbursement methodology. Denied/cutback. Per Information From Insurer, Claim(s) Was (were) Not Submitted. The condition code is not allowed for the revenue code. Procedimientos. The Screen Date Is Either Missing Or Invalid. Unable To Process Your Adjustment Request due to Original Claim ICN Not Found. A Valid Level Of Effort Is Required For Billing Compound Drugs Or Pharmaceutical Care. You can even print your chat history to reference later! Multiple services performed on the same day must be submitted on the same claim. Condition code 80 is present without condition code 74. The Service Requested Was Performed Less Than 5 Years Ago. Please Supply NDC Code, Name, Strength & Metric Quantity. Due To Non-covered Services Billed, The Claim Does Not Meet The Outlier Trim Point. Claim Explanation Codes View Fee Schedules Electronic Payments and Remittances Submit Behavioral Health Claim Durable Medical Equipment - Rental/Purchase Grid Claims Submission Process Procedure Code Modifiers Submitting Medical Records Submitting Medicare Part D Claims . The Services Requested Are Not Reasonable Or Appropriate For The AODA-affectedmember. FFS CLAIM PROFESSIONAL ASC X12N VERSION . Bill The Single Appropriate Code That Describes The Total Quantity Of Tests Performed. wellcare eob explanation codes. The Hearing Aid Recommended Is Not Necessary; The Member Could Be Adequately Fitted With A Conventional Aid. Denied. Services Submitted On Improper Claim Form. Ancillary Billing Not Authorized By State. Dental X-rays Indicate A Dental Cleaning, Followed By Good Dental Care At Home, Would Be Sufficient To Maintain Healthy Gums. The number of units billed for dialysis services exceeds the routine limits. Total billed amount is less than the sum of the detail billed amounts. The Service/procedure Proposed Is Not Supported By Submitted Documentation. Charges Paid At Reduced Rate Based Upon Your Usual And Customary Pricing Profile. Please Clarify. 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. Revenue code submitted with the total charge not equal to the rate times number of units. Member enrolled in Tuberculosis-Related Services Only Benefit Plan. 690 Canon Eb R-FRAME-EB Service Denied. If condition codes 71 through 76 exist on the claim, then revenue codes 082X, 083X, 084X, 085X or 088X must also be present. Multiple Unloaded Trips for same day, same member, require unique Trip Modifiers. Handwritten Changes/corrections On The Medicare EOMB Are Not Acceptable. The diagnosis codes must be coded to the highest level of specificity. This service is payable at a frequency of once per 12-month period, per provider, per hearing aid. Claim Denied For Invalid Billing Type Frequency Code, Claim Type, Or SubmittedAdjustment Provider Number Does Not Match Original Claims Provider Number. 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. Payment(s) For Capital Or Medical Education Are Generated By EDS And May Not Be Billed By The Provider. The Member Appears To Be At A Maximum Level For Age, Diagnosis, And Living Arrangement. Claim Detail Is Pended For 60 Days. Quantity Would Be 00010 If Specific Number Of Batteries Dispensed Is Not Indicated. The Documentation Submitted Does Not Indicate Medically Oriented Tasks Are Medically Necessary, Therefore Personal Care Services Have Been Approved. Previously Denied Claims Are To Be Resubmitted As New Day Claims. Dispensing fee denied. Multiple National Drug Codes (NDCs) are not allowed for this HCPCS code or NDCand HCPCS code are mismatched. One or more To Date(s) of Service is missing for Occurrence Span Codes in positions three through 24. Principle Surgical Procedure Code Date is missing. Other Medicare Part A Response not received within 120 days for provider basedbill. Members Age 3 And Older Must Have An Oral Assessment And Blood Pressure Check.With Appropriate Referral Codes, For Payment Of A Screening. The National Drug Code (NDC) has an age restriction. Second Other Surgical Code Date is required. The Medical Need For This Service Is Not Supported By The Submitted Documentation. Per Information From Insurer, Requested Information Was Not Supplied By The Provider. AODA Day Treatment Is Not A Covered Service For Members Who Are Residents Of Nursing Homes or Who Are Hospital Inpatients. Claim Denied For Future Date Of Service(DOS). Please familiarize yourself with these new explanation codes and update your accounts receivable as indicated. Copyright 2023 Wellcare Health Plans, Inc. New Coding Integrity Reimbursement Guidelines. Pricing Adjustment/ Pharmacy dispensing fee applied. This procedure is age restricted. . Dispensing Two Lens Replacements On Same Date Of Service(DOS) Not Allowed. 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. Billed Procedure Not Covered By WWWP. Procedure Not Payable As Submitted. Claim Paid Under DRG Reimbursement, Except For Transplants Billed Using Suffixes 05 Through 09.