Please verify the accuracy of the procedure code and the presence of the appropriate procedure code modifier before cont acting ACS for assistance. Do not insert a period in the ICD-9-CM or ICD-10-CM codes. More than 6 hours of evaluation/assessment in a 2 year period must be billed astreatment services and count toward the MH/SA policy limits for prior authorization. Good Faith Claim Denied For Timely Filing. Procedure Code and modifiers billed must match approved PA. Speech Therapy Is Not Warranted. Service(s) Denied By DHS Transportation Consultant. and other medical information at your current address. Member is enrolled in Medicare Part A and/or Part B on the on the Dispense Dateof Service. Denied. Please Review All Provider Handbook For Allowable Exception. The Primary Diagnosis Code is inappropriate for the Procedure Code. This member is eligible for Medication Therapy Management services. Refer To Provider Handbook. 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. Please Correct And Resubmit. Timely Filing Deadline Exceeded. Explanation of Benefit Codes (EOBs) Mar 14, 2022 4. 1. Provider Reminders: Claims Definitions. The Functional Assessment Indicates This Member Has Less Than A 50% Likelihoodof Benefit, Therefore Day Treatment Is Not Appropriate. Please Correct And Resubmit. Denied due to Member Is Eligible For Medicare. Prior authorization is required for Advair or Symbicort if no other Glucocorticoid Inhaled product has been reimbursed within 90 days. One or more Condition Code(s) is invalid in positions eight through 24. Because a claim can have edits and audits at both the header and detail levels, EOB codes are listed . Pharmaceutical Care is not covered by the Wisconsin Chronic Disease Program. Reimbursement Based On Members County Of Residence. Resubmit the Claim with the Appropriate Modifier for Provider Type andSpecialty. Acute Care General And Specialty Hospitals Are Subject To Pre-admission Requirements Or The Pre-admission Review Number Indicated Is Invalid. wellcare eob explanation codes. Procedure Code Changed To Permit Appropriate Claims Processing. Please Contact The Hospital Prior Resubmitting This Claim. Missing Or Invalid Level Of Effort And/or Reason For Service Code, Professional Service Code, Result Of Service Code Billed In Error. WI Can Not Issue A NAT Payment Without A Valid Hire Date. Up Members Age 3 And Older Must Have An Oral Assessment And Blood Pressure Check.With Appropriate Referral Codes, For Payment Of A Screening. Claim Denied. Denied. Claims may deny for procedures billed with modifier 79 when the same or different 0-, 10- or 90-day procedure code has not been billed on the same date of service. Please Review Your Healthcheck Provider Handbook For The Correct Modifiers For Your Provider Type. Reimbursement Rate Applied To Allowed Amount. The Member Has Received A 93 Day Supply Within The Past Twelve Months. Routine foot care is limited to no more than once every 61days per member. Denied. Denied. Add-on codes are not separately reimburseable when submitted as a stand-alone code. An approved PA was not found matching the provider, member, and service information on the claim. Training Completion Date Must Be Prior To And Within A Year Of The CNAs Certification Date. General Assistance Payments Should Not Be Indicated On Claims. Claimchecks Editing And Your Supporting Documentation Was Reviewed By The DHS Medical Consultant. Denied due to Procedure/Revenue Code Is Not Allowable. Denied. Invalid Admission Date. Service(s) Billed Are Included In The Total Obstetrical Care Fee. Procedure Code billed is not appropriate for members gender. Third Diagnosis Code (dx) (dx) is not on file. This service is not payable for the same Date Of Service(DOS) as another service included on the same claim, according to the National Correct Coding Initiative. First Other Surgical Code Date is invalid. MedicalBillingRCM.com is a participant in the Amazon Services LLC Associates Program, an affiliate advertising program designed to provide a means for sites to earn advertising fees by advertising and linking to Amazon.com. Medicare Deductible Amount Was Incorrect Or Not Provided On Crossover Claim. Billing Provider Name Does Not Match The Billing Provider Number. Service Denied. Pricing Adjustment/ Payment amount decreased based on Pay for Performance policies. Contact Provider Services For Further Information. Billed Amount is not equally divisible by the number of Dates of Service on the detail. Denied due to Procedure Billed Not A Covered Service For Dates Indicated. If it is medical necessary for more than 13 or 14 services per calendar month, submit an adjustment request with supporting documentation. Recoding/adjusting claim may result in a different DRG code assignmentand reimbursement. This Is An Adjustment of a Previous Claim. This Service Is Not Payable Without A Modifier/referral Code. This Procedure Code Is Denied As Incidental/Integral To Another Procedure CodeBilled On This Claim. Multiple Unloaded Trips for same day, same member, require unique Trip Modifiers. Payment(s) For Capital Or Medical Education Are Generated By EDS And May Not Be Billed By The Provider. Pricing Adjustment/ Third party liability deducible amount applied. Service Denied. Basic Knowledge of Explanation of Benefits (EOB) interpretation. The National Drug Code (NDC) is not on file for the Dispense Date Of Service(DOS). The Documentation Submitted Indicates The Tasks Specified Can Be Completed During The Visits Approved. Please correct and resubmit. This HMO Capitation Payment Is Being Recouped It Was Inappropriately Paid During The Inital February HMO Capitation Cycle. Initial Visit/Exam limited to once per lifetime per provider. Documentation Does Not Justify Reconsideration For Payment. Wellcare uses cookies. A Second Surgical Opinion Is Required For This Service. An amount in the Gross Amount Due field and/or Usual and Customary Charge field is required. Referral/treatment Procedures Are Not Payable When Billed With A Complete Refusal Detail. Level, Intensity Or Extent Of Service(s) Requested Has Been Modified Consistent With Medical Need As Defined In The Plan Of Care. PDN Codes W9045/w9046 Are Not Payable On The Same Date As PDN Codes W9030/W9031 For The Same Provider And Member. This Member Appears To Continue To Abuse Alcohol And/or Other Drugs And Is Therefore Not Eligible For Day Treatment. WellCare Known Issues List Please be advised: Claims that have either rejected or denied . Third Other Surgical Code Date is required. You can view these EOBs online by following these steps: Log in to your bcbsm.com account to view your prescriptions coverage. Claim Denied. Does not reimburse both the global service and the individual component parts of the service for the same Date Of Service(DOS). Crosswalk - Adjustment Reason Codes and Remittance Advice (RA) Remark Codes to PHC Explanation (EX) Codes Revised 11/16/2020 Page 1 Key: If RA has . Qty And/or Detail Charge Do Not Divide Out Equally For Dates Of Service and/orQty Given. Prior Authorization Is Required For Payment Of This Service With This Modifier. Procedure Added Due To Alt Code Replacement (age), Procedure Added Due To Alt Code Replacement (sex), Denied Duplicate- Includes Unilateral Or Bilat, Denied Duplicate/ Only Done XX Times In Lifetime, Denied Duplicate/ Only Done XX Times In A Day, Procedure Added Due To Duplicate Rebundling. Service Fails To Meet Program Requirements. Revenue Code Required. Phone: 800-723-4337. Member is enrolled in Medicare Part D for the Dispense Date Of Service(DOS). Take care to review your EOB to ensure you understand recent charges and they all are accurate. Each month you fill a prescription, your Medicare Prescription Drug Plan mails you an "Explanation of Benefits" (EOB). Denied due to Detail Fill Date Is A Future Date. The Member Is Enrolled In An HMO. CPT/HCPCS codes are not reimbursable on this type of bill. Rendering Provider is not certified for the From Date Of Service(DOS). Your 1099 Liability Has Been Credited. 2434. Prospective DUR denial on original claim can not be overridden. A National Provider Identifier (NPI) is required for the Rendering Provider listed in the header. 2004-79 For Instructions. If not, the procedure code is not reimbursable. HMO Payment Equals Or Exceeds Hospital Rate Per Discharge. Medicare Disclaimer Code invalid. Service(s) Approved By DHS Transportation Consultant. Extended Care Is Limited To 20 Hrs Per Day. Denied/Cutback. The first occurrence span from Date Of Service(DOS) is after the to Date Of Service(DOS). Will Not Authorize New Dentures Under Such Circumstances. Prescriber ID and Prescriber ID Qualifier do not match. Established in 1975 and incorporated in 1987, WPC is widely recognized as a leading expert in supporting the development, publishing, and licensing of complex . Single Bitewing X-rays Limited To Once Per Day And No More Than Two InA Six Month Period. No Action Required. Prescribing Provider UPIN Or Provider Number Missing. I'm getting a 2% CMS Mandate on my Wellcare EOB's. What is that? Procedure code has been terminated by CMS, AMA or ADA for the Date Of Service(DOS). The maximum number of details is exceeded. Timely Filing Request Denied. Prior Authorization is required to exceed this limit. An antipsychotic drug has recently been dispensed for this member. Revenue code requires submission of associated HCPCS code. Member Name Missing. Resubmit Private Duty Nursing Services For Complex Children With Documentation Supporting The Level Of Care. To access the training video's in the portal . Rqst For An Exempt Denied. Denied. Services Denied In Accordance With Hearing Aid Policies. Dispense as Written indicator is not accepted by . Adjustment Requested Member ID Change. Denied. Outside Lab Indicator Must Be Y For The Procedure Code 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. Refer To Your Pharmacy Handbook For Policy Limitations. Requests For Training Reimbursement Denied Due To Late Billing. The Value Code and/or value code amount is missing, invalid or incorrect. WellCare Known Issues List EOP Denial Code or Rejection Reason Code Issue Description Impacted Provider Specialty . Avoiding denial reason code CO 22 FAQ Q: We received a denial with claim adjustment reason code (CARC) CO 22. Denied. One or more Diagnosis Code(s) in positions 10 through 25 is not on file. Description. POS codes are required under the provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA). PA required for payment of this service. Fifth Other Surgical Code Date is required. Policy override must be granted by the Drug Authorization and Policy Override Center to dispense less than a 100 day supply. Individual Test Paid. A Valid Level Of Effort Is Required For Billing Compound Drugs Or Pharmaceutical Care. This National Drug Code (NDC) requires a whole number for the Quantity Billed. Service Denied. Pricing Adjustment/ SeniorCare claim cutback because of Patient Liability and/or other insurace paid amounts. Claims may deny when DXA bone density studies (CPT 77080 or 77081) are billed and the only diagnosis on the claim is osteoporosis screening (ICD-10 code Z13.820) for a woman who is under age 65 or for a man who is under age 70. Home Health visits (Nursing and therapy) in excess of 30 visits per calendar year per member require Prior Authorization. We have created a list of EOB reason codes for the help of people who are working on denials, AR-follow-up, medical coding, etc. Service Not Covered For Members Medical Status Code. The sum of the Medicare paid, deductible(s), coinsurance, copayment and psychiatric reduction amounts does not equal the Medicare allowed amount. Denials with solutions in Medical Billing; Denials Management - Causes of denials and solution in medical billing; Medical Coding denials with solutions Requires A Unique Modifier. This drug is not covered for Core Plan members. Has Processed This Claim With A Medicare Part D Attestation Form. Rn Visit Every Other Week Is Sufficient For Med Set-up. The Rendering Providers taxonomy code is missing in the header. Denied/Cutback. Claim count of Present on Admission (POA) indicators does not match count of non-admitting and non-emergency diagnosis codes. Adequate Justification For Starting Member In AODA Day Treatment Prior To Authorization being Obtained Has Not Been Provided. Additional Reimbursement Is Denied. This Procedure Code Is Not Valid In The Pharmacy Pos System. Normal delivery payment includes the induction of labor. The From Date Of Service(DOS) for the First Occurrence Span Code is required. Only Medicare Crossover claims are reimbursed for coinsurance, copayment, and deductible. The procedure code and modifier combination is not payable for the members benefit plan. Early Refill Alert. Reason Code 234 | Remark Codes N20. Previously Denied Claims Are To Be Resubmitted As New Day Claims. The Revenue Code is not payable for the Date Of Service(DOS). Adjustment/reconsideration Request Denied Due To Incorrect/insufficient Information. FFS CLAIM PROFESSIONAL ASC X12N VERSION . Per Information From Insurer, Claim(s) Was (were) Not Submitted. All Requests Must Have A 9 Digit Social Security Number. Procedure Denied Per DHS Medical Consultant Review. Description. Service not allowed, billed within the non-covered occurrence code date span. 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 . This Claim Is A Reissue of a Previous Claim. A quantity dispensed is required. DME rental is limited to 90 days without Prior Authorization. Plan options will be available in 25 states, including plans in Missouri . 1 PC Dispensing Fee Allowed Per Date Of Service(DOS). Medical Billing and Coding Information Guide. A more specific Diagnosis Code(s) is required. An ICD-9-CM Diagnosis Code of greater specificity must be used for the Fourth Diagnosis Code. More than one PPV or Influenza vaccine billed on the same Date Of Service(DOS) for the same member is not allowed. Follow specific Core Plan policy for PA submission. This Payment Is To Satisfy Amount Owed For A Drug Rebate Prior Quarter Correction. Denied. 0300-0319 (Laboratory/Pathology). A Version Of Software (PES) Was In Error. Payment Recouped. Hearing Aid Batteries Are Limited To 12 Monaural/24 Binaural Batteries Per 30-day Period, Per Provider, Per Hearing Aid. Speech Therapy Limited To 45 Treatment Days Per Spell Of Illness W/o Prior Authorization. Occurrence Codes 50 And 51 Are Invalid When Billed Together. Do not resubmit. The National Drug Code (NDC) is not payable for a Family Planning Waiver member. What steps can we take to avoid this denial? By continuing to use our site, you agree to our Privacy Policy and Terms of Use. Denied due to The Members Last Name Is Incorrect. Restorative Nursing Involvement Should Be Increased. Refer To Dental HandbookOn Billing Emergency Procedures. The changes in the brain that happen during a migraine cannot be seen by the imaging studies since a migraine is caused by a complicated interaction between the brain and the blood vessels in the face and head. Our Records Indicate You Have Billed More Than One Unit Dose Dispensing Fee For This Calendar Month. Patient Status Code is incorrect for Long Term Care claims. Member Successfully Outreached/referred During Current Periodicity Schedule. Authorizations. Discharge Diagnosis 3 Is Not Applicable To Members Sex. Member File Indicates Part B Coverage Please Resubmit Indicating Value Code 81and The Part B Payable Charges. Do Not Indicate NS On The Claim When The NDC Billed Is For A Generic Drug. Rebill Using Correct Procedure Code. Proposed Orthodontic Service Denied; Examination/study Models Are Approved. Frequency or number of injections exceed program policy guidelines. This CNAs Social Security Number, SSN, Is Not On The EDS Nurse Aide Registry File. wellcare explanation of payment codes and comments. Denied. Please Clarify. Medicare Part A Services Must Be Resubmitted. The drug code has Family Planning restrictions. Billing Provider is not certified for the detail From Date Of Service(DOS). Out-of-State non-emergency services require Prior Authorization. Claim Denied. Denied due to Diagnosis Not Allowable For Claim Type.