Tooth surface is invalid or not indicated. DME rental is limited to 90 days without Prior Authorization. Procedure Code is not covered for members with a Nursing Home Authorization onthe Date(s) of Service. Name And Complete Address Of Destination. This claim is being denied because it is an exact duplicate of claim submitted. CPT Code And Service Date For Member Is Identical To Another Claim Detail On File For Provider On Claim. Denied. Adjustments To Correct Copayment Deductions On date Ranged Claims Are Not Payable. For additional information on HIPAA EOB codes, visit the Code List section of the WPC website at www.wpc-edi.com. NFs Eligibility For Reimbursement Has Expired. First modifier code is invalid for Date Of Service(DOS). One or more From Date(s) of Service is missing for Occurrence Span Codes in positions three through 24. Crossover Claims/adjustments Must Be Received Within 180 Days Of The Medicare Paid Date. Please Correct And Resubmit. Principal Diagnosis 7 Not Applicable To Members Sex. The Non-contracted Frame Is Not Medically Justified. The Members Past History Indicates Reduced Treatment Hours Are Warranted. For over 40 years, Washington Publishing Company (WPC) has specialized in managing and distributing data integration information through publications, training, and consulting services. When the nerve conduction study or the needle EMG is performed on its own, the results can be misleading and important diagnoses may be missed. The Surgical Procedure Code is restricted. Timely Filing Deadline Exceeded. The Other Payer ID qualifier is invalid for . Claim Denied. The National Drug Code (NDC) has an age restriction. Service Denied. All services should be coordinated with the Hospice provider. Value codes 48 Homoglobin Reading and 49 Hematocrit Reading, must have a zero in the far right position. Claim paid at the program allowed amount. Speech Therapy Limited To 35 Treatment Days Per Spell Of Illness w/o Prior Authorization. We thank you for your continued partnership in servicing the Wellcare By Fidelis Care membership. Per Information From Insurer, Requested Information Was Not Supplied By The Provider. DRG cannotbe determined. Service Denied. PDF Explanation of Benefit Codes (EOBs) - Province of Manitoba An ICD-9-CM Diagnosis Code of greater specificity must be used for the Third Diagnosis Code. Professional Components Are Not Payable On A Ub-92 Claim Form. Anesthesia Modifying Services Must Be Billed Separately From The Charge For Anesthesia Base And Time Units. It Must Be In MM/DD/YY FormatAnd Can Not Be A Future Date. The Second Other Provider ID is missing or invalid. Level, Intensity Or Extent Of Service(s) Requested Has Been Modified Consistent With Medical Need As Defined In The Plan Of Care. Continuous home care must be billed in an hourly quantity equal to or greater than eight hours, up to and including 24 hours. 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. Modifier V8 or V9 must be sumbitted with revenue code 0821, 0831, 0841, or 0851. Principal Diagnosis 8 Not Applicable To Members Sex. The Diagnosis Code Is Not Valid On This Date Of Service(DOS). Mail-to name and address - We mail the TRICARE EOB directly to. Services Billed Denied As Being Covered In The Payment For Day Rx Per Medical Day Treatment Guidelines. Explanation . Inpatient psychiatric services are not reimbursable for members age 21 65 (age 22 if receiving services prior to 21st birthday). PDN Codes W9045/w9046 Are Not Payable On The Same Date As PDN Codes W9030/W9031 For The Same Provider And Member. Denied. is unable to is process this claim at this time. Member eligibility file indicates that BadgerCare Plus Benchmark, CorePlan or Basic Plan member. Men. Please Review Remittance And Status Report. An ICD-9-CM Diagnosis Code of greater specificity must be used for the Second Diagnosis Code. Please Reference Payment Report Mailed Separately. Claim Denied For No Client Enrollment Form On File. Claim Is For A Member With Retro Ma Eligibility. If The Proc Code Does Not Require A Modifier, Please Remove The Modifier. Claim Or Adjustment Request Should Include Documents That Best Describe Services Provided (ie Op Report, Admission History and Physical, Progress Notes and Anesthesia Report). Early Refill Alert. Only One Federally Required Annual Therapy Evaluation Per Calendar Year, Per Member, Per Provider. Documentation Does Not Justify Reconsideration For Payment. Reimbursement limits for Community Care Services for the calendar year are close to being exceeded. A valid header Medicare Paid Date is required. Medicare Copayment Out Of Balance. Submitted referring provider NPI in the detail is invalid. Request For Training Reimbursement Denied. Effective 1/1: Electronic Prescribing of Controlled Substances Required. Procedure Not Payable for the Wisconsin Well Woman Program. Recoding/adjusting claim may result in a different DRG code assignmentand reimbursement. Supplemental tests billed on the same Date Of Service(DOS) as vision examination are not payable. This National Drug Code Has Diagnosis Restrictions. Denied. 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. Pricing Adjustment/ Traditional dispensing fee applied. X-rays and some lab tests are not billable on a 72X claim. The Resident Or CNAs Name Is Missing. The topic of Requirements for Compression Garments can be found in the Claims Section, Submission Chapter. Pricing Adjustment/ Long Term Care pricing applied. Because a claim can have edits and audits at both the header and detail levels, EOB codes are listed . The Total Billed Amount is missing or incorrect. By continuing to use our site, you agree to our Privacy Policy and Terms of Use. Dispensing Two Lens Replacements On Same Date Of Service(DOS) Not Allowed. Additional information is needed for unclassified drug HCPCS procedure codes. Please Submit On The Cms 1500 Using The Correct Hcpcs Code. Claim contains duplicate segments for Present on Admission (POA) indicator. Procedure Code Changed To Permit Appropriate Claims Processing. Transplants and transplant-related services are not covered under the Basic Plan. Reimbursement For This Service Is Included In The Transportation Base Rate. Repackaged National Drug Codes (NDCs) are not covered. A code with no Trip Modifier billed on same day as a code with Modifier U1 are considered the same trip. The Rendering Providers taxonomy code in the detail is not valid. Complete Refusal Detail Is Not Payable Without Referral/treatment Details. There are many different remittance adjustment reason codes (RARCs) established for Medicare and we understand their explanations may be "generic" and confusing, so we have provided a listing in the table below of the most commonly used denial messages and RARCs utilized by Medical Review Part B during medical record review. An xray or diagnostic urinalysis is reimbursable only when performed on the same Date Of Service(DOS) and billed on the same claim as the initial office visit. Claim Submitted To Good Faith Without Proper Documentation. Pricing Adjustment/ Payment amount increased based on hospital access paymentpolicies. Urinalysis And X-rays Are Reimbursed Only When Performed In Conjunction With An Initial Office Visit On Same Date Of Service(DOS). Claim date(s) of service modified to adhere to Policy. Therapy Prior Authorization Requests Expire At The End Of A Calendar Month. Effective 5/31/2019, we will introduce new Coding Integrity Reimbursement Guidelines. Procedure Code is restricted by member age. This claim has been adjusted due to Medicare Part D coverage. This Member Appears To Continue To Abuse Alcohol And/or Other Drugs And Is Therefore Not Eligible For Day Treatment. -OR- The claim contains value code 49but does not contain revenue code 0636 and HCPCS Q4054. Denied due to Per Division Review Of NDC. Denied due to Detail Billed Amount Missing Or Zero. The Reimbursement Code Assigned To This Certification Segment Does Not Authorize a NAT Payment. Please familiarize yourself with these new explanation codes and update your accounts receivable as indicated. Handwritten Changes/corrections On The Medicare EOMB Are Not Acceptable. Please Indicate Mileage Traveled. Medicaid Claim Adjustment Reason Code:B13 - thePracticeBridge Use Of Therapy Equipment Alone Is Not Sufficient To Justify Maintenance Therapy. Additional Psychotherapy Is Not Considered Appropriate Or Inline With More Effective, Available Services. Procedure Code is not allowed on the claim form/transaction submitted. Non-covered Charges Are Missing Or Incorrect. Explanaton of Benefits Code Crosswalk - Wisconsin Header From Date Of Service(DOS) is after the date of receipt of the claim. Therapy visits in excess of one per day per discipline per member are not reimbursable. A WCDP drug rebate agreement for this drug is not on file for the Date Of Service(DOS). WCDP member enrolled in Medicare Part D. Claim is excluded from Drug Rebate Invoicing. The Medicare Paid Amount is missing or incorrect. The detail From Date Of Service(DOS) is after the detail To Date Of Service(DOS). Billing Provider ID is missing or unidentifiable. The relationship between the Billed and Allowed Amounts exceeds a variance threshold. qatar to toronto flight status. DN017 Medicare EOB Denials BH N/A 10/15/2017 9/26/2017 6815, 321095 CE034 99213 99214 in Place of Service 52 Physical Therapy Limited To 45 Treatment Days Per Spell Of Illness W/o Prior Authorization. The service requested is not allowable for the Diagnosis indicated. 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. Denied. Fourth Other Surgical Code Date 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. The Service Billed Does Not Match The Prior Authorized Service. Please Itemize Services Including Date And Charges For Each Procedure Performed. Only Medicare Crossover claims are reimbursed for coinsurance, copayment, and deductible. Supplemental Payment Authorized By Department of Health Services (DHS) Due to aAudit. A federal drug rebate agreement for this drug is not on file for the Date Of Service(DOS)(DOS). Please adjust quantities on the previously submitted and paid claim. You Received A PaymentThat Should Have gone To Another Provider. 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. Payment may be reduced due to submitted Present on Admission (POA) indicator. Service Billed Limited To Three Per Pregnancy Per Guidelines. Additional Encounter Service(s) Denied. Claim or Adjustment received beyond 365-day filing deadline. Medicare denial codes, reason, action and Medical billing appeal EOB Codes List|Explanation of Benefit Reason Codes (2023) February 7, 2022 by medicalbillingrcm. The Comprehensive Community Support Program reimbursement limitations have been exceeded. Nursing Home Visits Limited To One Per Calendar Month Per Provider. Extended Care Is Limited To 20 Hrs Per Day. Denied due to Detail Dates Are Not Within Statement Covered Period. Claim Is Being Reprocessed, No Action On Your Part Required. Quantity indicated for this service exceeds the maximum quantity limit established by the National Correct Coding Initiative. Voided Claim Has Been Credited To Your 1099 Liability. Pregnancy Indicator must be "Y" for this aid code. Claim count of Present on Admission (POA) indicators does not match count of non-admitting and non-emergency diagnosis codes. 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. Modifiers are required for reimbursement of these services. First Other Surgical Code Date is invalid. 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. This Service Is A Resubmission Of A Service Previously Denied For Prior Authorization. Surgical Procedure Code billed is not appropriate for members gender. Reduction To Maintenance Hours. Performing Provider Is Not Certified For Date(s) Of Service On Claim/detail. The Service Performed Was Not The Same As That Authorized By . Training CompletionDate Exceeds The Current Eligibility Timeline. This Claim HasBeen Manually Priced Using The Medicare Coinsurance, Deductible, And Psyche RedUction Amounts As Basis For Reimbursement. The detail From Date Of Service(DOS) is invalid. Prescriptions Or Services Must Be Billed As ASeparate Claim. This revenue code requires value code 68 to be present on the claim. Prescriber ID and Prescriber ID Qualifier do not match. This Member Has Completed Intensive AODA Treatment Within The Past 12 Months and Documentation Provided Is Not Adequate To Justify Intensive Treatment at this time. Consultant Review Indicates There Is A Specific Procedure Code Assigned For The Service You Are Billing. Pricing Adjustment/ Prior Authorization pricing applied. This obstetrical service was previously paid for this Date Of Service(DOS) for thismember. Day Treatment Services For Members With Inpatient Status Limited To 20 Hours. Claimchecks Editing And Your Supporting Documentation Was Reviewed By The DHS Medical Consultant. Denied. Please Supply Modifier Code(s) Corresponding To The Procedure Code Description. Service Denied. 100 Days Supply Opportunity. Condition codes 71, 72, 73, 74, 75, and 76 cannot be present on the same ESRD claim at the same time. BMN prior authorization may be submitted for Mental Health drugs for which a Core Plan transitioned member has been previously grandfathered. Dispensing fee denied. Please Submit A Separate New Day Claim For Copayment Exempt Days/services. Detail To Date Of Service(DOS) is required. Denied. Prior authorization is required for Advair or Symbicort if no other Glucocorticoid Inhaled product has been reimbursed within 90 days. Prior Authorization is required for manipulations/adjustments exceeding 20 perspell of illness. Denied due to Provider Signature Date Is Missing Or Invalid. Claims may deny for a CT head or brain, CTA head, MRA head, MRI brain or CT follow-up when the only diagnosis on the claim is a migraine. The initial rental of a negative pressure wound therapy pump is limited to 90 days; member lifetime. 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. Prescription Date is after Dispense Date Of Service(DOS). PleaseResubmit Charges For Each Condition Code On A Separate Claim. Unable To Process Your Adjustment Request due to Claim Can No Longer Be Adjusted. 2434. OA 11 The diagnosis is inconsistent with the procedure. Medicare Part A Or B Charges Are Missing Or Incorrect. Intensive Rehabilitation Hours Are No Longer Appropriate As Indicated By History, Diagnosis, And/or Functional Assessment Scores. Language Comprehension And Language Production Are Equivalent To Cognition, Thus Formal Speech Therapy Is Not Needed. EPSDT/healthcheck Indicator Submitted Is Incorrect. THE WELLCARE GROUP OF COMPANIES . Effective 04/01/09, the BadgerCare Plus Core Plan will limit coverage for Brochodilators-Beta Agonists to Proventil HFA and Serevent. 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. Has Recouped Payment For Service(s) Per Providers Request. Denied. Member is not enrolled in /BadgerCare Plus for the Date(s) of Service. Preventive Medicine Code Billed Is Allowed For Health Check Agencies Only With The Appropriate Healthcheck Modifier. Denial Codes - RCM Revenue Cycle Management - Healthcare Guide Denied. The Member Does Not Meet The Criteria For Binaural Amplification; One Hearing Aid Is Authorized. The Diagnosis Is Not Covered By WWWP. Reimbursement For Training Is One Time Only. According to the American College of Radiology and the American Academy of Neurology, a CT of the head or brain, CTA of the head, MRA of the head or MRI of the brain should not be performed routinely for patients with a migraine in the absence of related neurologic signs and symptoms. The medical record request is coordinated with a third-party vendor. Supplemental Payment Authorized By Department of Health Services (DHS) Due to an Interim Rate Settlement. Accident Related Service(s) Are Not Covered By WCDP. Claims may deny when reported with mutually exclusive code combinations according to the ICD-10-CM Excludes 1 Notes guideline policy. This Is A Duplicate Request. Please Clarify. A Third Occurrence Code Date is required. Denied. Other Medicare Part B Response not received within 120 days for provider basedbill. Quantity Would Always Be 00010 If Number Of Pounds Not Indicated. Pricing Adjustment/ Paid according to program policy. Patient Status Code is incorrect for Long Term Care claims. Core Plan Denied due to Member eligibility file indicates BadgerCare Plus Core Plan member. This drug/service is included in the Nursing Facility daily rate. Claims For Sterilization Procedures Must Reflect ICD-9 Diagnosis Code V25.2. The Related Surgical Procedure is not a covered service under Wisconsin Medicaid or BadgerCare Plus. An Explanation of Benefits (EOB) code corresponds to a printed message about the status or action taken on a claim. Adequate Justification For Starting Member In AODA Day Treatment Prior To Authorization being Obtained Has Not Been Provided. Only One Date For EachService Must Be Used. Will Only Pay For One. Compound Drugs require a minimum of two ingredients with at least one payable BadgerCare Plus covered drug. Claims may deny when a procedure defined as requiring an anatomical modifier is billed without an associated anatomical modifier. Multiple Unloaded Trips For Same Day/same Recip. The Primary Diagnosis Code is inappropriate for the Procedure Code. Claim paid at program allowed rate. The Billing Providers taxonomy code is invalid. Please Do Not Resubmit Your Claim, And Disregard Additional Informational Messages for this claim. A valid procedure code is required on WWWP institutional claims. Single Bitewing X-rays Limited To Once Per Day And No More Than Two InA Six Month Period. Denied. Program guidelines or coverage were exceeded. Pricing Adjustment/ Payment reduced due to the inpatient or outpatient deductible. Submit copy of the dated and signed evaluation and indicate if this is an initial Evaluation. The National Drug Code (NDC) is not on file for the Dispense Date Of Service(DOS). The Clinical Profile/Diagnosis Makes This Member Ineligible For AODA Services. A Less Than 6 Week Healing Period Has Been Specified For This PA. Claim Denied Due To Invalid Occurrence Code(s). This procedure is duplicative of a service already billed for same Date Of Service(DOS). Intensive Multiple Modality Treatment Is Not Consistent With The Information Provided. Unable To Process Your Adjustment Request due to Original Claim ICN Not Found. Backdating Allowed Only In Cases Of Retroactive Member/provider Eligibility. Ninth Diagnosis Code (dx) is not on file. Reason/Remark Code Lookup Diagnosis Codes Assigned Must Be At The Greatest Specificity Available. Plan options will be available in 25 states, including plans in Missouri . 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. Please Correct And Resubmit. Dispense Date Of Service(DOS) is required. Claim Detail Denied As Duplicate. The Surgical Procedure Code is not payable for /BadgerCare Plus for the Date Of Service(DOS). CPT Or CPT/modifier Combination Is Not Valid On This Date Of Service(DOS). This Dms Item Is Limited To 12 Per 30 Days, Per Provider, Without Prior Authorization. Denied. Senior Reimbursement Specialist - Medical Claims Remittance Advice Remark Codes | X12 Established in 1975 and incorporated in 1987, WPC is widely recognized as a leading expert in supporting the development, publishing, and licensing of complex . Please Correct And Resubmit. Header Bill Date is before the Header From Date Of Service(DOS). Pricing Adjustment/ Claim has pricing cutback amount applied. Please Resubmit Using Newborns Name And Number. Invalid Procedure Code For Dx Indicated. Claim Denied. This Claim Is A Reissue of a Previous Claim. A Photocopy Of The PA Request Form Has Been Mailed Separately Identifying the Reimbursement Rate For The Procedure Codes Authorized. Services Are Covered For Medically Needy Members Only When Healthcheck Referral is Indicated On Claim. This Incidental/integral Procedure Code Remains Denied. Duplicate Item Of A Claim Being Processed. This procedure is not paid separately. Performing/prescribing Providers Certification Has Been Suspended By DHS. An Approved AODA Day Treatment Program Cannot Exceed A 6 Week Period. Denied. Submitted referring provider NPI in the header is invalid. Referring Provider is not currently certified. This Member Is Receiving Concurrent AODA/Psychotherapy Services And Is Therefore Only Eligible For Maintenance Hours. Out of State Billing Provider not certified on the Dispense Date. The Maximum limitation for dosages of EPO is 500,000 UIs (value code 68) per month and the maximum limitation for dosages of ARANESP is 1500 MCG (1 unit=1 MCG) per month. Dispense as Written indicator is not accepted by . Requires A Unique Modifier. Abortion Dx Code Inappropriate To This Procedure. No Supporting Documentation. Documentation Does Not Justify Medically Needy Override. Procedure Code or Drug Code not a benefit on Date Of Service(DOS). We Have Determined There Were (are) Several Home Health Agencies Willing To Provide Medically Necessary Skilled Nursing Services To This Member.
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