wellcare eob explanation codes

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One or more To Date(s) of Service is invalid for Occurrence Span Codes in positions three through 24. Rebill On Pharmacy Claim Form. Subsequently hospital care services (CPT 99221-99223 or 99231-99233) will be denied when billed for the same date of service as observation services (CPT G0378, 99218-99220 or 99224-99226) for Bill Type 0130-013Z (hospital outpatient). Other Insurance/TPL Indicator On Claim Was Incorrect. DRG cannotbe determined. Services Must Be Submitted On Proper Claim/adjustment/reconsiderationRequest Form. Pharmaceutical Care is not covered by the Wisconsin Chronic Disease Program. An antipsychotic drug has recently been dispensed for this member. Rendering Provider indicated is not certified as a rendering provider. The Value Code(s) submitted require a revenue and HCPCS Code. 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. Will Only Pay For One. The Diagnosis Is Not Covered By WWWP. Non-Reimbursable Service. Pricing Adjustment/ Maximum Flat Fee Level 2 pricing applied. Denied. Denied. Request Denied Because The Screen Date Is After The Admission Date. Voided Claim Has Been Credited To Your 1099 Liability. Claim Denied/cutback. 1. Excessive height and/or weight reported on claim. Contact. Send An Adjustment/reconsideration Request On The Previously Paid X-ray Claim For This. Denied. First Other Surgical Code Date is required. One Visit Allowed Per Day, Service Denied As Duplicate. wellcare eob explanation codes. Outside Lab Indicator Must Be Y For The Procedure Code Billed. One or more Diagnosis Code(s) is invalid for the Date(s) of Service. Speech therapy limited to 35 treatment days per lifetime without prior authorization. This notice gives you a summary of your prescription drug claims and costs. Denied. CPT Code And Service Date For Memberis Identical To Another Claim Detail On File For Another WWWP Provider. The National Drug Code (NDC) is not payable for the Provider Type and/or Specialty. MassHealth List of EOB Codes Appearing on the Remittance Advice. This service is not payable for the same Date Of Service(DOS) as another service included on this claim. Please Contact The Hospital Prior Resubmitting This Claim. Please Complete Information. To bill any code, the services furnished must meet the definition of the code. Previously Denied Claims Are To Be Resubmitted As New-day Claims. RN Home Health visits and Supervisory visits are not reimbursable on the same Date Of Service(DOS) for same provider. Room And Board Is Only Reimbursable If Member Has A BQC Nursing Home Authorization. Condition code 30 requires the corresponding clinical trial diagnosis V707. A Less Than 6 Week Healing Period Has Been Specified For This PA. Please Refer To The Original R&S. Printable . These are EOB codes, revised for NewMMIS, that may appear on your PDF remittance advice. Member has Medicare Managed Care for the Date(s) of Service. Medical Billing and Coding Information Guide. CPT Code 88305 (Level IV - Surgical pathology, gross and microscopic examination) includes different types of biopsies. Copayment Should Not Be Deducted From Amount Billed. Please Clarify Services Rendered/provide A Complete Description Of Service. Timeframe Between The CNAs Training Date And Test Date Exceeds 365 Days. Timely Filing Deadline Exceeded. Condition code 80 is present without condition code 74. Claim Corrected. The diagnosis codes must be coded to the highest level of specificity. Pharmaceutical care code must be billed with a valid Level of Effort. 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. If you are still unable to resolve the login problem, read the troubleshooting steps or report your issue. These are EOB codes, revised for NewMMIS, that may appear on your PDF remittance advice. Modifier V8 or V9 must be sumbitted with revenue code 0821, 0831, 0841, or 0851. Training Completion Date Is Not A Valid Date. The Members Profile Indicates This Member Is Possibly Alcoholic And/or Chemically Dependent, And Intensive Aoda Treatment Appears Warranted. Information inadequate to establish medical necessity of procedure performed.Please resubmit with additional supporting documentation. Surgical Procedure Code billed is not appropriate for members gender. The Timeframe Between Certification, Test, Date And Hire Date Exceeds A Year. Questionable Long-term Prognosis Due To Poor Oral Hygiene. Effective 04/01/09, the BadgerCare Plus Core Plan will limit coverage for Hypoglycemics-Insulin to Humalog and Lantus. Other Medicare Part B Response not received within 120 days for provider basedbill. The taxonomy code for the attending provider is missing or invalid. Normal delivery reimbursement includes anesthesia services. Third Other Surgical Code Date is required. A valid Level of Effort is also required for pharmacuetical care reimbursement. Documentation Does Not Justify Reconsideration For Payment. If laboratory costs exceed reimbursement, submit a claim adjustment request with lab bills for reconsideration. DME rental beyond the initial 30 day period is not payable without prior authorization. The Medical Records Submitted With The Current Request Conflict Or Disagree With Our Medical Records On This Member. Service (Procedure Code/Modifier Combination) is not reimbursable for Date Of Service(DOS). Per Information From Insurer, Claims(s) Was (were) Paid. Claim Explanation Codes. Dates Of Service Must Be Itemized. This Mutually Exclusive Procedure Code Remains Denied. Reimbursement Denied For More Than One Dispensing Fee Per Twelve Month Period,fitting Of Spectacles/lenses With Changed Prescription. Four X-rays are allowed per spell of illness per provider. Amount Recouped For Duplicate Payment on a Previous Claim. Pricing Adjustment/ Prescription reduction applied. The Procedure Requested Is Not On s Files. 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. Service Denied. Wis Adm Code 106.04(3)(b) Requires Providers To Reimburse The Person/party (eg, County) That Previously. This Dental Service Limited To Once Every Six Months, Unless Prior Authorized. The Procedure(s) Requested Are Not Medical In Nature. Discharge Diagnosis 5 Is Not Applicable To Members Sex. 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. Denied/Cuback. No matching Reporting Form on file for the detail Date Of Service(DOS). The header total billed amount is invalid. Discharge Diagnosis 4 Is Not Applicable To Members Sex. Edentulous Alveoloplasty Requires Prior Authotization. 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. Please Review The Covered Services Appendices Of The Dental Handbook. Multiple Unloaded Trips For Same Day/same Recip. Please Indicate One Prior Authorization Number Per Claim. Service Billed Exceeds Restoration Policy Limitation. Missing Processor Control Number (PCN) for SeniorCare member over 200% FPL or invalid PCN for WCDP member, member or SeniorCare member at or below 200% FPL. CPT Code 88305 (Level IV Surgical pathology, gross and microscopic examination) includes different types of biopsies. . One or more Diagnosis Codes are not applicable to the members gender. Not A WCDP Benefit. 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 services are not allowed on the claim type for the Members Benefit Plan. Good Faith Claim Denied For Timely Filing. Pricing Adjustment/ Medicare Pricing information. Patient Status Code is incorrect for Long Term Care claims. Quick Tip: In Microsoft Excel, use the " Ctrl + F " search function to look up specific denial codes. All Requests Must Have A 9 Digit Social Security Number. Routine foot care Diagnoses must be billed with valid routine foot care Procedure Codes. Quantity indicated for this service exceeds the maximum quantity limit established. Requested Documentation Has Not Been Submitted. Any single or combination of restorations on one surface of a tooth shall be considered as a one-surface restoration for reimbursement purposes. Homecare Services W/o PA Are Not Payable When Prior Authorized HomecAre Services Have Been Provided To The Same Member. One or more Surgical Code Date(s) is missing in positions seven through 24. Computed tomography (CT) of the head or brain (CPT 70450, 70460, 70470), Computed tomographic angiography (CTA) of the head (CPT 70496), Magnetic resonance angiography (MRA) of the head (CPT 70544, 70545, 70546), Magnetic resonance imaging (MRI) of the brain (CPT 70551, 70552, 70553), Duplex scan of extracranial arteries (CPT 93880,93882), Computed tomographic angiography (CTA) of the neck(CPT 70498), Magnetic resonance angiography (MRA) of the neck(CPT 70547, 70548, 70549), ICD-10 Diagnosis codes G43.009, G43.109, G43.709, G43.809, G43.829, G43.909. Second Rental Of Dme Requires Prior Authorization For Payment. Claim Or Adjustment/reconsideration Request Should Include An Operative Or Pathology Report For This Procedure. Occurance code or occurance date is invalid. Please Review Remittance And Status Report. This National Drug Code (NDC) has diagnosis restrictions. 2D3D CODES: Radiation treatment delivery, superficial and/or ortho voltage, per day 77401 Radiation treatment delivery, >1 MeV; simple 77402 . Split Decision Was Rendered On Expansion Of Units. WCDP is the payer of last resort. This Claim Cannot Be Processed. The Rendering Providers taxonomy code in the detail is not valid. Master Level Providers Must Bill Under A Mental Health Clinic Number; Not Under a Private Practice Or Supervisor Number. Earn Money by doing small online tasks and surveys, What is Denials Management in Medical Billing? Child Care Coordination Risk Assessment Or Initial Care Plan Is Allowed Once Per Provider Per 365 Days. Pharmacy Clm Submitted Exceeds The Number Of Clms Allowed Per Cal. General Assistance Payments Should Not Be Indicated On Claims. The Narrative History Does Not Indicate the Members Functioning is Impaired due To AODA Usage. This Diagnosis Code Has Encounter Indicator restrictions. Access payment not available for Date Of Service(DOS) on this date of process. Number On Claim Does Not Match Number On Prior Authorization Request. ambulatory surgical center, outpatient hospital) exists for the same member, same date of service and the same procedure or service. Prior Authorization (PA) is required for this service. Please Resubmit Your Non-healthcheck Services Using The Appropriate Claim SortIndicator Or Electronic Format. At Least One Of The Compounded Drugs Must Be A Covered Drug. Prior Authorization is needed for additional services. No Complete Program Enrollment Form Is On File For This Client Or The Client Is Not Eligible For The Date Of Service(DOS) On The Clai im. This Unbundled Procedure Code And Billed Charge Were Rebundled To Another Code, Which Was Either Billed By The Provider On This Claim Or Added By Claimcheck. First modifier code is invalid for Date Of Service(DOS). Denied due to Services Billed On Wrong Claim Form. Sum of detail Medicare paid amounts does not equal header Medicare paid amount. EOB Any EOB code that applies to the entire claim (header level) prints here. Claim Denied. The Members Demonstrated Response To Current Therapy Does Not Warrant The Intense Freqency Requested. This Individual Is Either Not On The Registry Or The SSN On The Request D oesnt Match The SSN Thats Been Inputted On The Registry. Claim date(s) of service modified to adhere to Policy. Individual Replacements Reimbursed As Dispensing A Complete Appliance. This Is A Duplicate Request. Detail Denied. Request Denied Due To Late Billing. Payspan's Core Payment Network comes with a feature that allows payers to send members an electronic version of their Explanation of Benefits (eEOB). A National Provider Identifier (NPI) is required for the Billing Provider. Member is enrolled in Medicare Part D for the Dispense Date Of Service(DOS). The Procedure Code/Modifier combination is not payable for the Date Of Service(DOS). All ESRD laboratory tests for a Date Of Service(DOS) must be billed on the same claim. Member must receive this service from the state contractor if this is for incontinence or urological supplies. Language Comprehension And Language Production Are Equivalent To Cognition, Thus Formal Speech Therapy Is Not Needed. This Member Has Completed Primary Intensive Services And Is Now Only Eligible For after Care/follow-up Hours. Denied due to Add Dates Not In Ascending Order Or DD/DD/DD Format. Do not insert a period in the ICD-9-CM or ICD-10-CM codes. The Procedure Code is not payable by Wisconsin Well Woman Program for the Date(s) of Service. Lenses Only Are Approved; Please Dispense A Contracted Frame. Pricing Adjustment/ Payment reduced due to the inpatient or outpatient deductible. According to the American College of Emergency Physicians, the American Heart Association and the American College of Cardiology Foundation, CT, CTA, MRA, MRI should not be performed routinely for evaluation of syncope in the absence of related neurologic signs and symptoms. This dental service limited to once per five years.Prior Authorization is needed to exceed this limit. This claim/service is pending for program review. CNAs Eligibility For Training Reimbursement Has Expired. The Member Is School-age And Services Must Be Provided In The Public Schools. Claim Denied/Cutback. Please Verify That Physician Has No DEA Number. Please show the appropriate multichanel HCPCS code rather than the individual HCPCS code. This procedure is limited to once per day. Tooth number or letter is not valid with the procedure code for the Date Of Service(DOS). Discharge Diagnosis 2 Is Not Applicable To Members Sex. CPT Or CPT/modifier Combination Is Not Valid On This Date Of Service(DOS). . One or more Diagnosis Code(s) is invalid in positions 10 through 25. Claim Paid In Accordance With Family Planning Contraceptive Services Guidelines. Service Denied. The Secondary Diagnosis Code is inappropriate for the Procedure Code. If A CNA Obtains his/her Certification After Theyve Been Hired By A NF, A NF Has A Year From Their Certification, Test, Date To Submit A Reimbursement Request To . Denied. Unable To Process Your Adjustment Request due to Member ID Not Present. You Received A PaymentThat Should Have gone To Another Provider. Claim Is For A Member With Retro Ma Eligibility. Timely Filing Request Denied. Please Refer To The Original R&S. Denied due to Claim Exceeds Detail Limit. Reimbursement limits for Community Care Services for the calendar year are close to being exceeded. Dispense Date Of Service(DOS) is required. MLN Matters Number: MM6229 Related . Please adjust quantities on the previously submitted and paid claim. The Service Requested Does Not Correspond With Age Criteria. Allowance For Coinsurance Is Limited To Allowable Amount Less Medicares Payment. 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. Please Attach Copy Of Medicare Remittance. Approved. This Is A Manual Decrease To Your Accounts Receivable Balance. Please Correct And Resubmit. The Service Requested Is Not A Covered Benefit As Determined By . Please Refer To The Original R&S. The Skills Of A Therapist Are Not Required To Maintain The Member. Indicated Diagnosis Is Not Applicable To Members Sex. FFS CLAIM PROFESSIONAL ASC X12N VERSION . Procedure not allowed for the CLIA Certification Type. Service Denied. Denied. Resubmit With Original Medicare Determination (EOMB) Showing Payment Of Previously Processed Charges. Surgical Procedure Code is not related to Principal Diagnosis Code. The Existing Appliance Has Not Been Worn For Three Years. SMV Or Prescribing Provider Description Code(s) Missing OrInvalid. Ability to proficiently use Microsoft Excel, Outlook and Word. Prior authorization requests for this drug are not accepted. Denied. Services Denied In Accordance With Hearing Aid Policies. Claim Denied. Claims For Sterilization Procedures Must Reflect ICD-9 Diagnosis Code V25.2. Because a claim can have edits and audits at both the header and detail levels, EOB codes are listed . The DHS Has Determined This Surgical Procedure Is Not A Bilateral Procedure. The From Date Of Service(DOS) for the First Occurrence Span Code is required. 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. Purchase of additional DME/DMS item exceeding life expectancy rRequires Prior Authorization. HCPCS Procedure Code is required if Condition Code A6 is present. Strong knowledge of adjustment and denial reason codes from Electronic Remittance Advices (ERA/835 files) and from paper Explanation of benefits (EOB's) / Explanation of payments (EOP's), CPT . Provider Must Have A CLIA Number To Bill Laboratory Procedures. Adjustment/reconsideration Denied, Provider Signature/date Was Not Provided OnThe Adjustment/reconsideration Request. Please Refer To Your Hearing Services Provider Handbook. Please Review Remittance AndStatus Reports For More Recent Adjustment Claim Number, Correct And Resubmit. All services should be coordinated with the Inpatient Hospital provider. Denied due to Member Not Eligibile For All/partial Dates. NFs Eligibility For Reimbursement Has Expired. Denied. The Information Provided Is Not Consistent With The Intensity Of Services Requested. Occupational Therapy Limited To 35 Treatment Days Per Spell Of Illness W/o Prior Authorization. The From Date Of Service(DOS) and To Date Of Service(DOS) must be in the same calendar month and year. Claim Is Pended For 60 Days. Out Of State Billing Provider Not Enrolled For Entire Detail DOS Span. Admit Date and From Date Of Service(DOS) must match. Type of Bill is invalid for the claim type. This Service Is Covered Only In Emergency Situations. Refer To Dental HandbookOn Billing Emergency Procedures. Charges For Anesthetics Are Included In Charge For All Surgical Procedures. SeniorCare member enrolled in Medicare Part D. Claim is excluded from Drug Rebate Invoicing. Detail To Date Of Service(DOS) is required. The Change In The Lens Formula Does Not Warrant Multiple Replacements. Quantity Billed is restricted for this Procedure Code. Supervising Nurse Name Or License Number Required. Denied due to Greater Than Four Dates Of Service Billed On One Detail. Do Not Submit Claims With Zero Or Negative Net Billed. Take care to review your EOB to ensure you understand recent charges and they all are accurate. The sum of the Accommodation Days is not equal to the sum of Covered plus Non-Covered Days. Ulcerations Of The Skin Do Not Warrant A New Spell Of Illness. Claim Denied for implementation of new Wisconsin Medicaid Interchange System.Resubmission of the claim is required due to new claim submission guidelines. Denied due to Medicare Allowed Amount Is Greater Than Total Billed Amount. This Member is enrolled in Wisconsin or BadgerCare Plus for Date(s) of Service. Contact Wisconsin s Billing And Policy Correspondence Unit. Services restricted to EPSDT clients valid only with a Full Scope, EPSDT-eligible Aid Code. Out-of-State non-emergency services require Prior Authorization. and other medical information at your current address. Provider Not Authorized To Perform Procedure. This Program Does Not Appear To Meet The Minimum Requirement For AODA Day Treatment Programming (10hrs) And Does Not Qualify For Aoda Day Treatment. Other Insurance Or Medicare Response Not Received Within 120 Days For ProviderBased Bill. A Payment For The CNAs Competency Test Has Already Been Issued. If You Have Already Obtained SSOP, Please Disregard This Message. In the above example the claim was denied with two codes, the Adjustment Reason Code of 16 and then the explanatory Remark Code of N329 (Missing/incomplete/invalid patient birth date). Superior HealthPlan News. Rebill Using Correct Procedure Code. The Surgical Procedure Code is not payable for Wisconsin Chronic Disease Program for the Date Of Service(DOS). Claim Denied For No Consent And/or PA. Reason Code 234 | Remark Codes N20. Submitted rendering provider NPI in the header is invalid. These Services Paid In Same Group on a Previous Claim. To allow for Medicare Pricing correct detail denials and resubmit. Denied/Cutback. 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. This care may be covered by another payer per coordination of benefits. Head imaging in the form of CT scans, MRI or MRA is allowed only when the service is medically reasonable and necessary. 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 National Drug Code (NDC) is not on file for the Dispense Date Of Service(DOS). Different Drug Benefit Programs. All Day Treatment Services For Members With Nursing Home Status Should Be Billed Under Procedure Code W8912(pre 10/1/03)/h2012(post 10/1/03) And Require PriorAuthorization. Reimbursement Rate Applied To Allowed Amount. Cannot bill for both Assay of Lab and other handling/conveyance of specimen. Transplants and transplant-related services are not covered under the Basic Plan. Billing Provider is not certified for the Dispense Date.

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