CO/204. More Than 5 Consecutive Calendar Days Of Continuous Care Are Not Payable. Please Disregard Additional Messages For This Claim. ACCOM REV CODE QTY BILLED NOT EQUAL TO DTL DOS. Billed Amount On Detail Paid By WWWP. Services Not Payable When Rendered To An Individual Aged 21-64 Who Is A Resident Of A Nursing Home Imd. No Financial Needs Statement On File. FFS CLAIM PROFESSIONAL ASC X12N VERSION . Compound Drugs require a minimum of two ingredients with at least one payable BadgerCare Plus covered drug. Take care to review your EOB to ensure you understand recent charges and they all are accurate. Payment Reduced Due To Patient Liability. Timely Filing Deadline Exceeded. The Medicare Claims Processing Manual and the UB-04 Data Specifications Manual outlines requirements for billing outpatient claims including that (HCPCS) codes are required on outpatient claims (UB-04) with related revenue codes. Plan options will be available in 25 states, including plans in Missouri . Member Is Eligible For Champus. 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 . A Google Certified Publishing Partner. Claim Number Given On The Adjustment/reconsideration Request Form Does Not Match Services Originally Billed. This Procedure Code Is Denied As Incidental/Integral To Another Procedure CodeBilled On This Claim. This Service Is Included In The Hospital Ancillary Reimbursement. 100 Days Supply Opportunity. Speech Therapy Limited To 45 Treatment Days Per Spell Of Illness W/o Prior Authorization. Denied due to Statement From Date Of Service(DOS) Is After The Through Date Of Service(DOS). Dental service limited to twice in a six month period. Proposed Orthodontic Service Denied; Examination/study Models Are Approved. Please Resubmit Medicares Nursing Home Coinsurance Days As A New Claim RatherThan An Adjustment/reconsideration Request. One or more From Date Of Service(DOS) (DOS) is invalid for Occurrence Span Codes in positions three through 24. 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. Has Already Issued A Payment To Your NF For This Level L Screen. To access the training video's in the portal . Once Therapy Is Prior Authorized, All Therapy Must Be Billed With A Valid Prior Authorization Number. Member has commercial dental insurance for the Date(s) of Service. Billing Provider Name Does Not Match The Billing Provider Number. Denied. Dialysis/EPO treatment is limited to 13 or 14 services per calendar month. this Procedure Code Is Denied As Mutually Exclusive To Another Code Billed On This Claim. Quantity indicated for this service exceeds the maximum quantity limit established by the National Correct Coding Initiative. Discharge Diagnosis 5 Is Not Applicable To Members Sex. Please Resubmit. The From Date Of Service(DOS) for the First Occurrence Span Code is invalid. It Corrects Claim Information Found During Research Of An OBRA Drug Rebate Dispute. NFs Eligibility For Reimbursement Has Expired. wellcare eob explanation codes. The code next to this was 264, which was described on the back of Frank's EOB as "Over What Medicare Allows" Total Patient Cost: $15.00 - Frank's office visit copayment; Amount Paid to the Provider: $50.00 - the amount of money that Frank's Medicare Advantage Plan sent to Dr. David T. Revenue code submitted with the total charge not equal to the rate times number of units. If laboratory costs exceed reimbursement, submit a claim adjustment request with lab bills for reconsideration. Denied. 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. Amount Recouped For Mother Baby Payment (newborn). Member enrolled in QMB-Only Benefit plan. Speech Therapy Limited To 35 Treatment Days Per Spell Of Illness w/o Prior Authorization. Name And Complete Address Of Destination. Disposable medical supplies are payable only once per trip, per member, per provider. Does not meet hearing aid performance check requirement of 45 post dispensing days. Due To Non-covered Services Billed, The Claim Does Not Meet The Outlier Trim Point. Denied due to Member Not Eligibile For All/partial Dates. DRG cannotbe determined. Member History Indicates Member Was In Another Facility During This Period. The Total Number Of Sessions Requested Exceeds Quarterly Guidelines. Modification Of The Request Is Necessitated By The Members Minimal Progress. Medical Need For Equipment/supply Requested Is Not Supported By Documentation Submitted. Channel: Medicare covered Codes Explanation Viewing all 30 articles Browse latest View live Explanation of Benefit. Please Resubmit A New Adjustment/reconsideration Request Form And Indicate TheMost Recent Cclaim Number Where Payment Was Made Or Allowed. This Is Not A Reimbursable Level I Screen. Day Treatment exceeding 120 hours per month is not payable regardless of PriorAuthorzation. The Revenue Code is not payable by Wisconsin Well Woman Program for the Date Of Service(DOS). Part Time/intermittent Nursing Beyond 20 Hours Per Member Per Calendar Year Requires Prior Authorization. Condition codes 71, 72, 73, 74, 75, and 76 cannot be present on the same ESRD claim at the same time. Billing Provider is not certified for the Dispense Date. Claim Corrected. Only One Outpatient Claim Per Date Of Service(DOS) Allowed. Comprehensive Screens And Individual Components Are Not Payable On The Same Date Of Service(DOS). A Training Payment Has Already Been Issued To A Different NF For This CNA. Medicare Disclaimer Code Used Inappropriately. Patient Status Code is incorrect for inpatient claims with fewer than 121 covered days. Billing provider number was used to adjudicate the service(s). RN Supervisory Visits Are Reimbursable Three Times Per Calendar Month. The Fourth Occurrence Code Date is invalid. Thank You For Your Assessment Interest Payment. Denied. Valid Numbers Are Important For DUR Purposes. Denied due to Greater Than Four Dates Of Service Billed On One Detail. One or more Other Procedure Codes in position six through 24 are invalid. The Requested Transplant Is Not Covered By . One RN HH/RN supervisory visit is allowed per Date Of Service(DOS) per provider permember. Wis Adm Code 106.04(3)(b) Requires Providers To Reimburse The Person/party (eg, County) That Previously. Partial Payment Withheld Due To Previous Overpayment. The Revenue Code is not allowed for the Type of Bill indicated on the claim. Additional services mustbe billed as treatment services and count towards the Mental Health and/or substance abuse treatment policy for prior authorization. Refer to the DME area of the Online Handbook for claims submission requirements for compression garments. Please Resubmit As A Regular Claim If Payment Desired. With Payspan's eEOB member-friendly functionality, members can log into the payer's secure portal and . Limited to once per quadrant per day. 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). Claim paid according to Medicares reimbursement methodology. Based on reimbursement guidelines it is not appropriate for providers to bill inpatient Evaluation and Management (E/M) services while the patient is in an observation status. This Diagnosis Code Has Encounter Indicator restrictions. Total billed amount is less than the sum of the detail billed amounts. Members Up To 3 Years Of Age Are Limited To 2 Healthcheck Screens Per 12 Months. Medically Needy Claim Denied. Please show the appropriate multichanel HCPCS code rather than the individual HCPCS code. This service or a related service performed on this date has already been billed by another provider and paid. Value Code 48 And 49 Must Have A Zero In The Far Right Position. Billing Provider is not certified for Substance Abuse Day Treatment for the Date(s) of Service. Submit Claim To Insurance Carrier. RN Home Health visits and Supervisory visits are not reimbursable on the same Date Of Service(DOS) for same provider. The Primary Occurrence Code Date is invalid. Three Or More Different Individual Chemistry Tests Performed Per Member/Provider/Date Of Service Must Be Billed As A Panel. All rental payments have been deducted from the purchase costsince the DME item was rented and subsequently purchased for the member. In 2015 CMS began to standardize the reason codes and statements for certain services. Claim Explanation Codes. Claim Denied. Intraoral Complete Series/comprehensive Oral Exam Limited To Once Every Three Years, Unless Prior Authorized. CNAs Eligibility For Training Reimbursement Has Expired. Denied due to Statement Covered Period Is Missing Or Invalid. Members Aged 3 Through 21 Years Old Are Limited To One Healthcheck Screening per 12 months. The CNA Is Only Eligible For Testing Reimbursement. Claim paid at program allowed rate. There is no action required. This is a same-day claim for bill types 13X, 14X, 71X, or 83X and there are multiple units or combination of chemistry/hemotology tests. Denied. Procedure code 00942 is allowed only when provided on the same date ofservice as procedure code 57520. Duplicate Item Of A Claim Being Processed. An ICD-9-CM Diagnosis Code of greater specificity must be used for the Eighth Diagnosis Code. "Laterality" (side of the body affected) is a coding convention added to relevant ICD-10 codes to increase specificity. This drug/service is included in the Nursing Facility daily rate. Valid group codes for use on Medicare remittance advice are:. Denied/Cutback. Unable To Process Your Adjustment Request due to Member ID Not Present. NDC was reimbursed at generic WAC (Wholesale Acquisition Cost) rate. Please Do Not File A Duplicate Claim. Adequate Justification For Starting Member In AODA Day Treatment Prior To Authorization being Obtained Has Not Been Provided. Consultation or surgical procedures are not reimbursable in conjuctions with Emergency Room services. PLEASE RESUBMIT CLAIM LATER. Denied. For 2020, WellCare is adding 68 new Medicare Advantage plans for a total of 261 plans with $0 or low monthly plan premiums. WWWP Does Not Process Interim Bills. Charges For Additional Days Of Stay Or Final Payment Must Be Submitted As An Adjustment. Procedimientos. Claim Reduced Due To Member/participant Spenddown. Therefore itIs Not Necessary To Wait The Full 6 Weeks After Extractions Before Taking Denture Impressions. Dosings for Narcotic Treatment Service program are limited to six per Sunday thru Saturday calendar week. The Primary Diagnosis Code is inappropriate for the Revenue Code. Principal Diagnosis 7 Not Applicable To Members Sex. Claim Submitted To Good Faith Without Proper Documentation. Claim Denied. Prescription limit of five Opioid analgesics per month. NDC was reimbursed at State Maximum Allowable Cost (SMAC) rate. This Check Automatically Increases Your 1099 Earnings. Rendering Provider is not a certified provider for Wisconsin Well Woman Program. Repackaging allowance is not allowed for unit dose NDCs. The service requested is not allowable for the Diagnosis indicated. Dispensing replacement parts and complete appliance on same Date Of Service(DOS) not Allowed. ACTION DESCRIPTION: ACTION TYPE. Modifier Invalid: Modifiers Are No Longer Allowed For Procedure Code Billed. Please Furnish A UB92 Revenue Code And Corresponding Description. Complex care of 17-plus hours and complex care of less than 17 hours are not allowed on the same Date Of Service(DOS). Combine Like Details And Resubmit. A valid procedure code is required on WWWP institutional claims. Please Furnish A Breakdown Of Your Procedure Code And Charge In Question GivenOn The Adjustment/reconsideration Request. The Dispense As Written (DAW) indicator is not allowed for the National Drug Code. Amount Recouped For Duplicate Payment on a Previous Claim. Denied due to The Members First Name Is Missing Or Incorrect. This diabetic supply has been paid under an equivalent code on this Date Of Service(DOS). You can even print your chat history to reference later! The Total Billed Amount is missing or incorrect. Denied. Prescriber ID is invalid.e. Denied/Cutback. Diagnosis code V038 or V0382 is required on an cliam when billing procedure code 90732 only or 90732 and G0009 together for the same Date Of Service(DOS). Service Denied. Claim or line denied. Pricing Adjustment/ Payment reduced due to the inpatient or outpatient deductible. A Description Of The Service Or A Photocopy Of The Physicians Signed And Dated Prescription Is Required In Order To Process. Dispensing fee denied. Services Submitted On Improper Claim Form. The Quantity Allowed Was Reduced To A Multiple Of The Products Package Size. No Reimbursement Rates on file for the Date(s) of Service. NFs Eligibility For Reimbursement Has Expired. Denied due to Per Division Review Of NDC. HCPCS Procedure Code is required if Condition Code A6 is present. Seventh Occurrence Code Date is required. FACIAL. Resubmit Claim Through Regular Claims Processing. Effective 1/1: Electronic Prescribing of Controlled Substances Required. Denied. Subsequent surgical procedures are reimbursed at reduced rate. Day Treatment Services For Members With Inpatient Status Limited To 20 Hours. Procedure Code 59420 Must Be Used For 5 Or More Prenatal Visits With One Charge. Medicare Allowed Amount Was Incorrect Or Not Provided On Crossover Claim. The Tooth Is Not Essential For Support Of A Partial Denture. The Seventh Diagnosis Code (dx) is invalid. The drug code has Family Planning restrictions. Reimbursement For This Service Has Been Approved. Member last name does not match Member ID. The Duration Of Treatment Sessions Exceed Current Guidelines. An approved PA was not found matching the provider, member, and service information on the claim. Denied. Please Provide The Type Of Drug Or Method Used To Stop Labor. Rimless Mountings Are Not Allowable Through . Units Billed Are Inconsistent With The Billed Amount. Denied. Service Denied. Use the most current year's ICD-9-CM or ICD-10-CM codes, depending on the date(s) of service. Compound Ingredient Quantity must be greater than zero. Reimbursement limit for all adjunctive emergency services is exceeded. Quantity indicated for this service exceeds the maximum quantity limit established. The Procedure Requested Is Not Allowable For The Process Type Indicated On TheRequest. The Rendering Providers taxonomy code in the header is not valid. Denied due to Member Is Eligible For Medicare. Submitted referring provider NPI in the detail is invalid. Claims adjustments. The Service Requested Is Covered By The HMO. Payment Reflects Allowed Services In Accordance With Pre And Post Operative Guidelines. Unable To Process Your Adjustment Request due to The Claim Type Of The Adjustment Does Not Match The Claim Type Of The Original Claim. A number is required in the Covered Days field. If it is medically necessary to exceed the limitation, submit an Adjustment/Reconsideration request with supporting documentation. Recoding/adjusting claim may result in a different DRG code assignmentand reimbursement. Medicare Part A Services Must Be Resubmitted. Psych Evaluation And/or Functional Assessment Ser. Billing/performing Provider Indicated On Claim Is Not Allowable. Paid In Accordance With Dental Policy Guide Determined By DHS. BMN prior authorization may be submitted for Mental Health drugs for which a Core Plan transitioned member has been previously grandfathered. Denied due to Medicare Allowed Amount Is Greater Than Total Billed Amount. Multiple Service Location Found For the Billing Provider NPI. Learns to use professional . 0300-0319 (Laboratory/Pathology). Resubmit Private Duty Nursing Services For Complex Children With Documentation Supporting The Level Of Care. Resubmit Claim With Copyof A Temporary ID Card, EVS Printed Response Or Indicate The AVR Transaction Log Number. Rinoplastia; Blefaroplastia Good Faith Claim Denied Because Of Provider Billing Error. This ProviderMay Only Bill For Coinsurance And Deductible On A Medicare Crossover Claim. Code. Policy override must be granted by the Drug Authorization and Policy Override Center to dispense less than a 100 day supply. These coding rules are published within the Medicare Claims Processing Manual, Current Procedural Terminology (CPT) by the American Medical Association (AMA) and ICD-10-CM guidelines governed by Medicare and Medicaid Services (CMS) and the National Center for Health Statistics (NCHS). Other Insurance Disclaimer Code Used Is Inappropriate For This Members Insurance Coverage. The Fifth Diagnosis Code (dx) is invalid. Home Health, Personal Care And Private Duty Nursing Services Are Subject To A Monthly Cap. 51.42 Board Stamp Required On All Outpatient Specialty Hospital Claims For Dates Of Service On Or After January 1, 1986. Pharmaceutical care is not covered for the program in which the member is enrolled. Services Requested Do Not Meet The Criteria for an Acute Episode. Unable To Process This Request Due To Either Missing, Invalid OrMismatched National Provider Identifier # (NPI)/Provider Name/POP ID. Denied due to Provider Number Missing Or Invalid. Level Of Care/accommodation Code Billed Is Not Applicable To Your Provider Specialty. Has Recouped Payment For Service(s) Per Providers Request. Two different providers cannot be reimbursed for the same procedure for the same member on the same Date Of Service(DOS). LO DENIED - RCVD MORE THAN 60 DAYS AFTER DATE ON EOB FROM OTHER MA67 2D ADJUSTMENT - DENIAL UPHELD-TIMELINESS NOT JUSTIFIED: 31 N30 34: DENIED - NOT A PLAN MEMBER,PROVIDER MUST BILL E.D.S. Unable To Process Your Adjustment Request due to A Different Adjustment Is Pending For This Claim. Information Required For Claim Processing Is Missing. Referring Provider ID is not required for this service. If correct, special billing instructions apply. Services Included In The Inpatient Hospital Rate Are Not Separately Reimbursable. Rendering Provider is not a certified provider for . One or more Diagnosis Codes are not applicable to the members gender. A Previously Submitted Adjustment Request Is Currently In Process. Annual Nursing Home Member Oral Exam Is Allowed Once Per 355 Days Per Recip Per Prov. This Surgical Code Has Encounter Indicator restrictions. The below mention list of EOB codes is as below, EOB codes list is updated as per the latest information gathered from authorized sources of information, if any discrepancy please let us know via the contact us page, Coupon "NSingh10" for 10% Off onFind-A-CodePlans. The Pharmaceutical Care Code (PCC) does not have a rate on file for the Date Of Service(DOS). This Procedure Is Limited To Once Per Day. Billed Amount Is Greater Than Reimbursement Rate. Subsequent Aide Visits Limited To 7 Hrs Per Day/per Member/per Provider. Well-baby visits are limited to 12 visits in the first year of life. Other Insurance Disclaimer Code Invalid. Detail From Date Of Service(DOS) is after the ICN Date. NDC- National Drug Code is restricted by member age. Condition code 70-76 is required on an ESRD claim when Influenza/PPV/HEP B HCPCS codes are the only codes being billed with condition code A6. Oral exams or prophylaxis is limited to once per year unless prior authorized. Denied. The Primary Diagnosis Code is inappropriate for the Procedure Code. Please Verify The Units And Dollars Billed. A Training Payment Has Already Been Issued For This Cna. A quantity dispensed is required. Please Do Not Resubmit Your Claim, And Disregard Additional Informational Messages for this claim. Denied. Denied. An ICD-9-CM Diagnosis Code of greater specificity must be used for the Second Diagnosis Code. We encourage you to take advantage of this easy-to-use feature. An amount in the Gross Amount Due field and/or Usual and Customary Charge field is required. Denied. OA 14 The date of birth follows the date of service. The Procedure Code billed not payable according to DEFRA. Correction Made Per Medical Consultant Review. Professional Service code is invalid. Language Comprehension And Language Production Are Equivalent To Cognition, Thus Formal Speech Therapy Is Not Needed. This Information Is Required For Payment Of Inhibition Of Labor. If Required Information Is not received within 60 days, the claim detail will be denied. Denied. The From Date Of Service(DOS) and To Date Of Service(DOS) must be in the same calendar month and year. The Service/procedure Proposed Is Not Supported By Submitted Documentation. Training Completion Date Must Be Within A Year Of The CNAs Certification, Test, Date. A Date Of Service(DOS) is required with the revenue code and HCPCS code billed. Reimbursement rate is not on file for members level of care. Indicator for Present on Admission (POA) is not a valid value. Timely Filing Deadline Exceeded. Home Health visits (Nursing and therapy) in excess of 30 visits per calendar year per member require Prior Authorization. Please Bill Appropriate PDP. Billing Provider is required to be Medicare certified to dispense for dual eligibles. Intermittent Peritoneal Dialysis hours must be entered for this revenue code. Members do not have to wait for the post office to deliver their EOB in a paper format. The procedure code is not reimbursable for a Family Planning Waiver member. Reason for Service submitted does not match prospective DUR denial on originalclaim. Rebill Using Correct Procedure Code. Revenue code submitted is no longer valid. Anesthesia and moderate sedation services billed with pain management services for a patient age 18 or older may deny unless a surgical procedure CPT code range 10021-69990 (other than pain management procedures) is also billed on the claim. Quantity Billed is restricted for this Procedure Code. Invalid/obsolete Procedure Code For Determination Of Refraction, Service Denied. The Member Has At Least 4 Posterior Teeth, Including Bicuspids On Each Side, which Can Be Used For Chewing. . NDC- National Drug Code is invalid for the Dispense Date Of Service(DOS). The Ninth Diagnosis Code (dx) is invalid. This Member Has Received Primary AODA Treatment In The Last Year And Is Therefore Not Eligible For Primary Intensive AODA Treatment At This Time. Member In TB Benefit Plan. Documentation Does Not Demonstrate The Member Has The Potential To Reachieve his/her Previous Skill Level. The Medical Need For This Service Is Not Supported By The Submitted Documentation. See Provider Handbook For Good Faith Billing Instructions. Pricing Adjustment/ Pharmaceutical Care dispensing fee applied. HMO Payment Equals Or Exceeds Hospital Rate Per Discharge. 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. Services Denied In Accordance With Hearing Aid Policies. Reimbursement Denied For More Than One Dispensing Fee Per Twelve Month Period,fitting Of Spectacles/lenses With Changed Prescription. The Competency Test Date On The Request Does Not Match The CNAs Test Date OnThe WI Nurse Aide Registry. Referring Provider ID is invalid. Dates Of Service Must Be Itemized. Denied/Cutback. The initial rental of a negative pressure wound therapy pump is limited to 90 days; member lifetime. Qty And/or Detail Charge Do Not Divide Out Equally For Dates Of Service and/orQty Given. Lenses Only Are Approved; Please Dispense A Contracted Frame. Third Other Surgical Code Date is invalid. Remittance Advice Remark Codes (RARCs) are used to provide additional explanation for an adjustment already described by a CARC or to convey information about remittance processing; Search for a Reason or Remark Code. Seventh Diagnosis Code (dx) is not on file. General Exercise To Promote Overall Fitness And Flexibility Are Non-covered Services. Explanation of benefits. The Services Requested Are Not Reasonable Or Appropriate For The AODA-affectedmember. Secondary Diagnosis Code (dx) is not on file. We Are Recouping The Payment. Questionable Long-term Prognosis Due To Poor Oral Hygiene. Pricing Adjustment/ Prior Authorization pricing applied. The Change In The Lens Formula Does Not Warrant Multiple Replacements. Pricing Adjustment/ Maximum Allowable Fee pricing used. Pricing Adjustment/ Medicare Pricing information. Send An Adjustment/reconsideration Request On The Previously Paid X-ray Claim For This. No Interim Billing Allowed On Or After 01-01-86. EOB Codes List|Explanation of Benefit Reason Codes (2023) February 7, 2022 by medicalbillingrcm. Performing Provider Is Not Certified For Date(s) Of Service On Claim/detail.
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