wellcare eob explanation codes

Denied. Pricing Adjustment/ Paid according to program policy. This Service Is A Resubmission Of A Service Previously Denied For Prior Authorization. CNAs Eligibility For Training Reimbursement Has Expired. 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. Continue ToUse Appropriate Codes On Billing Claim(s). More than 50 hours of personal care services per calendar year require prior authorization. 0001: Member's . Dispensing replacement parts and complete appliance on same Date Of Service(DOS) not Allowed. Copayment Should Not Be Deducted From Amount Billed. Diagnosis Indicated Is Not Allowable For Procedures Designated As Mycotic Procedures. Combine Like Details And Resubmit. Basic Knowledge of Explanation of Benefits (EOB) interpretation. This revenue code requires value code 68 to be present on the claim. Pricing Adjustment/ Ambulatory Surgery pricing applied. Occupational Therapy Limited To 45 Treatment Days Per Spell Of Illness w/o Prior Authorization. We have created a list of EOB reason codes for the help of people who are . Services Denied. Procedue Code is allowed once per member per calendar year. Services Must Be Submitted On Proper Claim/adjustment/reconsiderationRequest Form. Member is assigned to a Hospice provider. A New Prior Authorization Number Has Been Assigned To This Request In Order ToProcess. Please Complete Information. Claim cannot contain both Condition Codes A5 and X0 on the same claim. EOB Codes List|Explanation of Benefit Reason Codes (2023) February 7, 2022 by medicalbillingrcm. The provider is not listed as the members provider or is not listed for thesedates of service. Header To Date Of Service(DOS) is invalid. 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. Services Not Provided Under Primary Provider Program. Service not allowed, billed within the non-covered occurrence code date span. The Value Code and/or value code amount is missing, invalid or incorrect. Consultation or surgical procedures are not reimbursable in conjuctions with Emergency Room services. Original Payment/denial Processed Correctly. 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. The Members Clinical Profile/diagnosis Is Not Within Diagnostic Limitations for Psychotherapy Services. Billing Provider ID is missing or unidentifiable. Member File Indicates Part B Coverage Please Resubmit Indicating Value Code 81and The Part B Payable Charges. This Dental Service Limited To Once Every Six Months, Unless Prior Authorized. Level Of Care/accommodation Code Billed Is Not Applicable To Your Provider Specialty. If required information is not received within 60 days, the claim will be. The Duration Of Treatment Sessions Exceed Current Guidelines. This Is A Manual Decrease To Your Accounts Receivable Balance. Modifiers submitted are invalid for the Date Of Service(DOS) or are missing.. An ICD-9-CM Diagnosis Code of greater specificity must be used for the Sixth Diagnosis Code. Member enrolled in Tuberculosis-Related Services Only Benefit Plan. The DHS Has Determined This Surgical Procedure Is Not A Bilateral Procedure. This Procedure Is Denied Per Medical Consultant Review. Real time pharmacy claims require the use of the NCPDP Plan ID. Timely Filing Deadline Exceeded. As a provider, you have access to a portal that streamlines your work, keeps you up-to-date more than ever before and provides critical information. Claims For Sterilization Procedures Must Reflect ICD-9 Diagnosis Code V25.2. Abortion Dx Code Inappropriate To This Procedure. This claim has been adjusted because a service on this claim is not payable inconjunction with a separate paid service on the same Date Of Service(DOS) due to National Correct Coding Initiative. The total billed amount is missing or is less than the sum of the detail billed amounts. Denied. Only One Federally Required Annual Therapy Evaluation Per Calendar Year, Per Member, Per Provider. Non-scheduled drugs are limited to the original dispensing plus 11 refills or 12 months. From Date Of Service(DOS) is before Admission Date. Cannot bill for both Assay of Lab and other handling/conveyance of specimen. This Modifier has been discontinued by CMS or AMA for the Date Of Service(DOS)(s). The Service Requested Is Covered By The HMO. Quantity Billed is restricted for this Procedure Code. Treatment With More Than One Drug Per Class Of Ulcer Treatment Drug At The Same Time Is Not Allowed Through Stat PA. Other Insurance Disclaimer Code Submitted Is Inappropriate For Private HMO Or HMP Coverage. Please Correct Claim And Resubmit. This Claim Is A Reissue of a Previous Claim. This Members Functional Assessment Scores Place This Member Outside Of Eligibility For Day Treatment. $150.00 Reimbursement Limit Has Been Reached For Individual And Group Pncc Health Education/nutritional Counseling. Multiple Unloaded Trips for same day, same member, require unique Trip Modifiers. Formal Speech Therapy Is Not Needed. A National Provider Identifier (NPI) is required for the Rendering Provider listed in the header. Please submit claim to BadgerRX Gold. Contact Wisconsin s Billing And Policy Correspondence Unit. Explanation . Comprehensive Screens And Individual Components Are Not Payable On The Same Date Of Service(DOS). The Revenue Code is not payable by Wisconsin Chronic Disease Program for the Date Of Service(DOS). Schedule 3, 4 or 5 drugs are limited to the original dispensing plus 5 refillsor 6 months. Detail Quantity Billed must be greater than zero. Home Health, Personal Care And Private Duty Nursing Services Are Subject To A Monthly Cap. Service(s) paid at the maximum daily amount per provider per member. A discrepancy exists between the Other Coverage Indicator and the Other Paid Amount. A National Drug Code (NDC) is required for this HCPCS code. This Claim Has Been Excluded From Home Care Cap To Allow For Acute Episode. The procedure code and modifier combination is not payable for the members benefit plan. Claim Detail Denied For Invalid CPT, Invalid CPT/modifier Combination, Or Invalid Type Of Quantity Billed. Submit Claim To Insurance Carrier. 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. Provider Reminders: Claims Definitions. Continuous home care and routine home care may not be billed for the same member on the same Date Of Service(DOS). Denied. Refer To Your Pharmacy Handbook For Policy Limitations. No Financial Needs Statement On File. Pricing Adjustment/ Pharmacy dispensing fee applied. Competency Test Date Is Not A Valid Date. Denied. Other Insurance Disclaimer Code Used Is Inappropriate For This Members Insurance Coverage. This Report Was Mailed To You Separately. All services should be coordinated with the Hospice provider. This list was formerly published as Part 6 of the administrative and billing instructions in Subchapter 5 of your MassHealth provider manual. Please Resubmit. No Extractions Performed. PATIENT PAID PORTION USED TOWARDS DEDUCTIBLE. Claim Denied. The Procedure Requested Is Not Allowable For The Process Type Indicated On TheRequest. Service Denied. Claim or Adjustment received beyond 730-day filing deadline. Non-preferred Drug Is Being Dispensed. The Performing Provider Id, Member Id, And Date Of Service(DOS) Must Match The Completion Certificate Received From Ddes. The From Date Of Service(DOS) for the First Occurrence Span Code is invalid. Ninth Diagnosis Code (dx) is not on file. Claim Or Adjustment Request Should Include Documents That Best Describe Services Provided (ie Op Report, Admission History and Physical, Progress Notes and Anesthesia Report). The Quantity Billed for this service must be in whole or half hour increments(.5) Increments. Billing Provider is not certified for the detail From Date Of Service(DOS). Phone: 800-723-4337. Occurrence Code is required when an Occurrence Date is present. Multiple Tooth Extract On Same Date Of Service(DOS) Must Be Billed As Single And Additional Tooth Extract In Same Quadrant. Medicare Part A Services Must Be Resubmitted. The Other Payer Amount Paid qualifier is invalid for . Service (Procedure Code/Modifier Combination) is not reimbursable for Date Of Service(DOS). Referring Provider ID is invalid. Other Medicare Part A Response not received within 120 days for provider basedbill. 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. Procedure Dates Do Not Fall Within Statement Covers Period. Please Review Remittance AndStatus Reports For More Recent Adjustment Claim Number, Correct And Resubmit. Service Denied. Denied. Reimbursement For This Certification, Test, Segment Has Already Been Issued ToYour NF. Unable To Process Your Adjustment Request due to Provider ID Number On The Claim And On The Adjustment Request Do Not Match. This Request Can Only Be Backdated To The Date EDS First Receives The Request In The Mailroom. Pricing Adjustment/ Maximum Allowable Fee pricing used. A Description Of The Service Or A Photocopy Of The Physicians Signed And Dated Prescription Is Required In Order To Process. Claim Corrected. Remark Codes: N20. Avoiding denial reason code CO 22 FAQ Q: We received a denial with claim adjustment reason code (CARC) CO 22. Hospital And Nursing Home Stays Are Not Payable For The Same DOS Unless The Nursing Home Claim Indicated Hospital Bedhold Days. Denied due to Diagnosis Code Is Not Allowable. Please Resubmit. Home Health services for CORE plan members are covered only following an inpatient hospital stay. Denied. is unable to is process this claim at this time. The Maximum Allowable Was Previously Approved/authorized. Four X-rays are allowed per spell of illness per provider. WWWP Does Not Process Interim Bills. The likelihood of a central nervous system (CNS) cause of the event is extremely low, and patient outcomes are not improved with brain imaging studies. NDC was reimbursed at brand WAC (Wholesale Acquisition Cost) (Wholesale Acquisition Cost) rate. These Individual Vaccines Must Be Billed Under The Appropriate Combination Injection Code. Please Verify The Units And Dollars Billed. The Skills Of A Therapist Are Not Required To Maintain The Member. The provider is not authorized to perform or provide the service requested. Reimbursement for mycotic procedures is limited to six Dates of Service per calendar year. To bill any code, the services furnished must meet the definition of the code. FL 44 HCPCS/Rates/HIPPS Rate Codes Required. Personal Care In Excess Of 250 Hrs Per Calendar Year Requires Prior Authorization. Submitted referring provider NPI in the header is invalid. A more specific Diagnosis Code(s) is required. Discharge Diagnosis 4 Is Not Applicable To Members Sex. You Must Adjust The Nursing Home Coinsurance Claim. Quantity indicated for this service exceeds the maximum quantity limit established by the National Correct Coding Initiative. Services Billed On This Claim/adjustment Have Been Split to Facilitate Processing. Claims With Dollar Amounts Greater Than 9 Digits. Second Surgical Opinion Guidelines Not Met. Please Resubmit. Other Amount Submitted Not Reimburseable. Admission Denied In Accordance With Pre-admission Review Criteria. This Member Has A Current Approved Authorization For Intensive AODA OutpatientServices. Good Faith Claim Has Previously Been Denied By Certifying Agency. Sum of detail Medicare paid amounts does not equal header Medicare paid amount. One or more To Date(s) of Service is invalid for Occurrence Span Codes in positions three through 24. Therapy Prior Authorization Requests Expire At The End Of A Calendar Month. No Substitute Indicator required when billing Innovator National Drug Codes (NDCs). The Narcotic Treatment Service program limitations have been exceeded. Admit Diagnosis Code is invalid for the Date(s) of Service. Submit copy of the dated and signed evaluation and indicate if this is an initial Evaluation. Contact. Claim Denied Due To Incorrect Accommodation. The Competency Test Date On The Request Does Not Match The CNAs Test Date OnThe WI Nurse Aide Registry. Denied. A Total Charge Was Added To Your Claim. Revenue Code 0001 Can Only Be Indicated Once. Wellcare uses cookies. An ICD-9-CM Diagnosis Code of greater specificity must be used for the Third Diagnosis Code. Service(s) paid in accordance with program policy limitation. Member Name Missing. Prior Authorization Is Required For Payment Of This Service With This Modifier. Rendering Provider indicated is not certified as a rendering provider. Diagnosis 635-635.92 May Only Be Used When Billing For Abortion Procedures. The revenue code and HCPCS code are incorrect for the type of bill. the patient (or parent or guardian) at the address noted on the claim, be sure your doctor has updated your records with your current address. Denied. Please Clarify The Number Of Allergy Tests Performed. Third modifier code is invalid for Date Of Service(DOS). Claim Denied. Compound Drug Service Denied. Please Rebill Inpatient Dialysis Only. This Is Not A Reimbursable Level I Screen. Service Allowed Once Per Lifetime, Per Tooth. The From Date Of Service(DOS) for the Second Occurrence Span Code is invalid. 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. Reason Code 160: Attachment referenced on the claim was not received. Quantity Billed is not equally divisible by the number of Dates of Service on the detail. Member is enrolled in Medicare Part D for the Dispense Date Of Service(DOS). Total billed amount is less than the sum of the detail billed amounts. No Complete WWWP Participation Agreement Is On File For This Provider. This Member Has Completed Primary Intensive Services And Is Now Only Eligible For after Care/follow-up Hours. Claims adjustments. Service billed is bundled with another service and cannot be reimbursed separately. Result of Service code is invalid. Claim Denied. Providers must ensure that the E&M CPT codes selected reflect the services furnished. The detail From Date Of Service(DOS) is required. Other Insurance Disclaimer Code Invalid. According to CMS Medicare Claims Processing Manual, Place of Service codes (POS) are used to identify where, i.e., physician office, inpatient hospital, a procedure or service is furnished to a patient. Billing Provider is restricted from submitting electronic claims. Adequate Justification For Starting Member In AODA Day Treatment Prior To Authorization being Obtained Has Not Been Provided. Only One Outpatient Claim Per Date Of Service(DOS) Allowed. Allowed Amount On Detail Paid By WWWP. Compound drugs not covered under this program. More Than 5 Consecutive Calendar Days Of Continuous Care Are Not Payable. Additional rental of a negative pressure wound therapy pump is limited to 90 days in a 12 month period. Pricing Adjustment/ SeniorCare claim cutback because of Patient Liability and/or other insurace paid amounts. Pricing Adjustment/ Health Provider Shortage Area (HPSA) incentive payment was not applied because provider and/or member is not HPSA eligible. Please Do Not Resubmit Your Claim, And Disregard Additional Informational Messages for this claim. Requests For Training Reimbursement Denied Due To Late Billing. Split Decision Was Rendered On Expansion Of Units. Denied. Rendering Provider is not certified for the Date(s) of Service. 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 . The Service(s) Requested Could Adequately Be Performed In The Dental Office. Please submit claim to HIRSP or BadgerRX Gold. this Procedure Code Is Denied As Mutually Exclusive To Another Code Billed On This Claim. For Revenue Code 0820, 0821, 0825 or 0829, HCPCS Code 90999 or Modifier G1-G6 must be present. Procedure Code and modifiers billed must match approved PA. Has Already Issued A Payment To Your NF For A Level I Screen With The Same Admission Date. Claim Denied For No Provider Agreement On File Or Not Certified For Date Of Service(DOS). These case coordination services exceed the limit. Quantity Would Always Be 00010 If Number Of Pounds Not Indicated. Two different providers cannot be reimbursed for the same procedure for the same member on the same Date Of Service(DOS). OA 10 The diagnosis is inconsistent with the patient's gender. Claim Denied Due To Invalid Occurrence Code(s). Pricing Adjustment/ Pharmacy pricing applied. 2004-79 For Instructions. Drug(s) Billed Are Not Refillable. This claim must contain at least one specified Surgical Procedure Code. Claims may be denied if the only reported diagnosis is syncope and collapse when any of the listed diagnostic head, brain, carotid artery or neck imaging procedures are billed. Documentation Indicates That Client Is Able To Direct Cares And Can Safely Direct A PCW. One or more To Date(s) of Service is missing for Occurrence Span Codes in positions three through 24. Pricing Adjustment/ Inpatient Per-Diem pricing. ACCOM REV CODE QTY BILLED NOT EQUAL TO DTL DOS. A Hospital Stay Has Been Paid For DOS Indicated. subsequent hospital care (CPT 99231-99233) or inpatient consultations (CPT 99251-99255) in the previous week. 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 . Sixth Diagnosis Code (dx) is not on file. Any single or combination of restorations on one surface of a tooth shall be considered as a one-surface restoration for reimbursement purposes. The Second Occurrence Code Date is invalid. It Corrects A Mispayment FoundDuring Claims Processing Or Resulting From Retroactive File Changes. Revenue Code 082X is present on an ESRD claim which also contains revenue codes 083X, 084X, or 085X. Performed After Therapy/dayTreatment Have Begun Must Be Billed As Therapy Or Limit-exceed Psych/aoda/func. This claim/service is pending for program review. Principle Surgical Procedure Code Date is missing. Insufficient Documentation To Support The Request. There are approximately 20 Medicaid Explanation Codes which map to Denial Code 16. Referring Provider is not currently certified. Resubmit Claim With Copyof A Temporary ID Card, EVS Printed Response Or Indicate The AVR Transaction Log Number. Purchase of additional DME/DMS item exceeding life expectancy rRequires Prior Authorization. The Reimbursement Code Assigned To This Certification Segment Does Not Authorize a Training Payment. 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 Procedure Requested Is Not Appropriate To The Members Sex. A Pharmaceutical Care Code (PCC) must include a valid diagnosis code. Rendering Provider may not submit claims for reimbursement as both the Surgeonand Assistant Surgeon For The Same Member On The Same DOS. Please Resubmit With The Costs For Sterilization Related Charges Identified As Non-covered Charges On The Claim. MassHealth List of EOB Codes Appearing on the Remittance Advice. Provider Is Not A Qualified Provider For presumptively Eligible Recipients. Prior authorization is required for Maxalt when Maxalt or sumatriptan productshave not been reimbursed within 365 days. Wis Adm Code 106.04(3)(b) Requires Providers To Reimburse The Person/party (eg, County) That Previously. Medically Needy Claim Denied. Denied due to Procedure/Revenue Code Is Not Allowable. Please Resubmit As A Regular Claim If Payment Desired. Please Request A Corrected EOMB Through The Medicare Carrier And Adjust With The Corrected EOMB. Multiple Service Location Found For the Billing Provider NPI. Please Furnish An ICD-9 Surgical Code And Corresponding Description. Reason for Service submitted does not match prospective DUR denial on originalclaim. The Total Number Of Hours Per Day Requested For AODA Day Treatment Exceeds Guidelines And The Request Has Been Adjusted Accordingly. Reimbursement For IUD Insertion Includes The Office Visit. Denied/Cutback. Denied. Routine foot care Diagnoses must be billed with valid routine foot care Procedure Codes. The canister, dressings and related supplies are included as part of the reimbursement for the negative pressure wound therapy pump. Previously Paid Individual Test May Be Adjusted Under a Panel Code. Description & Use Of Day RX Procedure Codes Based On Members Status-not the place Of Service Where Day Rx Service Performed. These Services Paid In Same Group on a Previous Claim. Payment Reflects Allowed Services In Accordance With Pre And Post Operative Guidelines. Pricing Adjustment/ Claim has pricing cutback amount applied. Care Does Not Meet Criteria For Complex Case Reimbursement. EPSDT/healthcheck Indicator Submitted Is Incorrect. Revenue Codes 0110 (N6) And 0946 (N7) Are Not Payable When Billed On The Same Dateof Service As Bedhold Days. Changes/corrections Were Made To Your Claim Per Dental Processing Guidelines. Prior Authorization (PA) required for payment of this service. The procedure code has Family Planning restrictions. Services Billed Denied As Being Covered In The Payment For Day Rx Per Medical Day Treatment Guidelines. Claim Detail from Date Of Service(DOS) And to Date Of Service(DOS) Are Required And Must Be Within The Same Calendar Month. Patient Status Code is incorrect for Long Term Care claims.

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