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. Please submit future claims with the appropriate NPI, taxonomy and/or Zip +4 Code. One or more Surgical Code Date(s) is invalid in positions seven through 24. Please Submit A Separate New Day Claim For Copayment Exempt Days/services. 1. Therapy visits in excess of one per day per discipline per member are not reimbursable. Services Cutback/denied, Charges Greater Than Patient Liability, Not Responsible For Noncovered Services In Excess Of Patient Liability. Quantity Billed is missing or exceeds the maximum allowed per Date Of Service(DOS). Please Resubmit. Denied. Benefit Payment Determined By Fiscal Agent Review. If not, the procedure code is not reimbursable. The Diagnosis Code is not payable for the member. Pricing Adjustment/ Paid according to program policy. If you are having difficulties registering please . Please Complete Information. This list was formerly published as Part 6 of the administrative and billing instructions in Subchapter 5 of your MassHealth provider manual. An Alert willbe posted to the portal on how to resubmit. Claim Generated An Informational ProDUR Alert, Drug-Drug Interaction prospective DUR alert, Drug-Disease (reported) prospective DUR alert, Drug-Disease (inferred) prospective DUR alert, Therapeutic Duplication prospective DUR alert, Suboptimal Regiment prospective DUR alert, Insufficient Quantity prospective DUR alert. Denied. Header Rendering Provider number is not found. In 2015 CMS began to standardize the reason codes and statements for certain services. CO - Contractual Obligations: This group code is used when a contractual agreement between the payer and payee, or a regulatory requirement, resulted in an adjustment.These adjustments are considered a write off for the provider and are not billed to . Third Diagnosis Code (dx) (dx) is not on file. 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. Denied/Cutback. In addition, duplex scan of extracranial arteries, computed tomographic angiography (CTA) of the neck and magnetic resonance angiography (MRA) of the neck are not medically necessary for evaluation of syncope in patients with no suggestion of seizure and no report of other neurologic symptoms or signs. Lab Procedures Billed In Conjunction With Family Planning Pharmacy Visit Denied as not a Benefit. Refer to the DME area of the Online Handbook for claims submission requirements for compression garments. A dispense as written indicator is not allowed for this generic drug. The Service Requested Is Considered To Be Professionally Unacceptable, Unproven and/or Experimental. Medicare Id Number Missing Or Incorrect. Pharmacy Clm Submitted Exceeds The Number Of Clms Allowed Per Cal. Denied. Claim Submitted To Good Faith Without Proper Documentation. Alternatively, the provider has billed a prior inpatient E&M visit, without an inpatient discharge service (CPT 99238-99239) in the interim. Denied. The Service Requested Is Included In The Nursing Home Rate Structure. flora funeral home rocky mount va. Jun 5th, 2022 . Level And/or Intensity Of Requested Service(s) Is Incompatible With Medical Need As Defined In Care Plan. According to the AMA CPT Manual and our policy, an initial inpatient admission (CPT 99221-99223) is allowed once every seven days. No Reimbursement Rates on file for the Date(s) of Service. Lenses Only Are Approved; Please Dispense A Contracted Frame. Rebill Using Correct Claim Form As Instructed In Your Handbook. Other Coverage Code is missing or invalid. Type of Bill indicates services not reimbursable or frequency indicated is notvalid for the claim type. Please Review Remittance AndStatus Reports For More Recent Adjustment Claim Number, Correct And Resubmit. Well-baby visits are limited to 12 visits in the first year of life. Remark Codes: N20. A Training Payment Has Already Been Issued For This Cna. Service (Procedure Code/Modifier Combination) is not reimbursable for Date Of Service(DOS). Result of Service submitted indicates the prescription was not filled. This National Drug Code is not covered under the Core Plan or Basic Plan for the diagnosis submitted. Your latest EOB will be under Claims on the top menu. If You Have Already Obtained SSOP, Please Disregard This Message. Denied. Denied. The Number Of Weeks Has Been Reduced Consistent With Goals And Progress Documented. Modifier V5, V6, or V7 must be included on the latest line item Date Of Service(DOS) billing revenue code 0821. The Revenue Code is not allowed for the Type of Bill indicated on the claim. A SeniorCare drug rebate agreement is not on file for this drug for the Date Of Service(DOS). Procedure Code or Drug Code not a benefit on Date Of Service(DOS). Request Denied Due To Late Billing. Claim Reduced Due To Member/participant Spenddown. Fifth Diagnosis Code (dx) is not on file. A Less Than 6 Week Healing Period Has Been Specified For This PA. Reason Code 234 | Remark Codes N20. One or more Condition Code(s) is invalid in positions eight through 24. Only one antipsychotic drug is allowed without an Attestation to Prescribe More Than One Antipsychotic Drug for a Member 16 Years of Age or Younger. Denied due to Some Charges Billed Are Non-covered. A six week healing period is required after last extraction, prior to obtaining impressions for denture. The Duration Of Treatment Sessions Exceed Current Guidelines. Denied due to Provider Is Not Certified To Bill WCDP Claims. Provider Is Responsible For Averaging Costs During Cal Year Not To Exceed YrlyTotal (12 x $2325.00). Level Of Care/accommodation Code Billed Is Not Applicable To Your Provider Specialty. Pricing Adjustment/ Reimbursement reduced by the members copayment amount. This Member Has Completed Primary Intensive Services And Is Now Only Eligible For after Care/follow-up Hours. Previously Paid Individual Test May Be Adjusted Under a Panel Code. Reason for Service submitted does not match prospective DUR denial on originalclaim. Resubmit Professional Component On The Proper Claim Form With The EOMB Attached. This Report Was Mailed To You Separately. Complex care of 17-plus hours and complex care of less than 17 hours are not allowed on the same Date Of Service(DOS). All services should be coordinated with the Inpatient Hospital provider. Wellcare uses cookies. An explanation of benefits is a document from your insurance company outlining the services you received and how much they cost. You should receive it within 30 to 60 days of services provided, but it's not an official bill. This ProviderMay Only Bill For Coinsurance And Deductible On A Medicare Crossover Claim. The Second Other Provider ID is missing or invalid. Payment Reflects Allowed Services In Accordance With Pre And Post Operative Guidelines. An ICD-9-CM Diagnosis Code of greater specificity must be used for the Fourth Diagnosis Code. The Service Requested Is Covered By The HMO. The Documentation Submitted Does Not Indicate Medically Oriented Tasks Are Medically Necessary, Therefore Personal Care Services Have Been Approved. A Procedure Code without a modifier billed on the same day as a Procedure Codewith modifier 11 are viewed as the same trip. Activities To Promote Diversion Or General Motivation Are Non-covered Services. The Quantity Allowed Was Reduced To A Multiple Of The Products Package Size. Procedure Code is not allowed on the claim form/transaction submitted. A more specific Diagnosis Code(s) is required. Payment Recovered For Claim Previously Processed Under Wrong Member ID Number. Acute Care General And Specialty Hospitals Are Subject To Pre-admission Requirements Or The Pre-admission Review Number Indicated Is Invalid. If A Reporting Form Is Not Submitted Within 60 Days, The claim detail will be denied. Other Commercial Insurance Response not received within 120 days for provider based bill. The Performing Or Billing Provider On The Claim Does Not Match The Billing Provider On Theprior Authorization File. Denied due to Detail Billed Amount Missing Or Zero. Please verify the accuracy of the procedure code and the presence of the appropriate procedure code modifier before cont acting ACS for assistance. WellCare Known Issues List Please be advised: Claims that have either rejected or denied . HMO Capitation Claim Greater Than 120 Days. Service Denied. Claims may deny when reported with incompatible ICD-10-CM Laterality policy for Diagnosis-to-Modifier comparison. Please familiarize yourself with these new explanation codes and update your accounts receivable as indicated. The Maximum Allowable Was Previously Approved/authorized. BMN prior authorization may be submitted for Mental Health drugs for which a Core Plan transitioned member has been previously grandfathered. PDN Codes W9045/w9046 Are Not Payable On The Same Date As PDN Codes W9030/W9031 For The Same Provider And Member. The Reimbursement Code Assigned To This CNA Does Not Authorize A NAT Payment. Medicare Coinsurance Amount Was Not Provided On Crossover Claim. Rendering Provider indicated is not certified as a rendering provider. Denied due to The Members First Name Is Missing Or Incorrect. Pricing Adjustment/ Provider Level of Care (LOC) pricing applied. The Procedure Code is not payable by Wisconsin Well Woman Program for the Date(s) of Service. Prior Authorization (PA) required for payment of this service. The first occurrence span from Date Of Service(DOS) is after the to Date Of Service(DOS). The Services Requested Do Not Meet Criteria For An Acute Episode. Procedure Denied Per DHS Medical Consultant Review. Complex Evaluation and Management procedures require history and physical or medical progress report to be submitted with the claim. Services Can Only Be Authorized Through One Year From The Prescription Date. Total Rental Payments For This Item Have Exceeded The Maximum Allowable Forthe Purchase Of This Item. Denied. The diagnosis codes must be coded to the highest level of specificity. Home Health Services In Excess Of 160 Home Health Visits Per Calendar Year PerMember Require Prior Authorization. Only Medicare Crossover claims are reimbursed for coinsurance, copayment, and deductible. Seventh Occurrence Code Date is required. The From Date Of Service(DOS) for the First Occurrence Span Code is invalid. Denied. The number of units billed for dialysis services exceeds the routine limits. Members File Shows Other Insurance. Cannot Be Reprocessed Unless There Is Change In Eligibility Status. DME rental is limited to 90 days without Prior Authorization. Billing Provider ID is missing or unidentifiable. Detail To Date Of Service(DOS) is required. FACIAL. Denied due to Medicare Allowed Amount Is Greater Than Total Billed Amount. Request Denied Because The Screen Date Is After The Admission Date. Claim Detail from Date Of Service(DOS) And to Date Of Service(DOS) Are Required And Must Be Within The Same Calendar Month. NFs Eligibility For Reimbursement Has Expired. Denied. The Revenue Code is not reimbursable for the Date Of Service(DOS). Allowance For Coinsurance Is Limited To Allowable Amount Less Medicares Payment. Routine foot care is limited to no more than once every 61days per member. If the KT/V reading was not performed, then the value code D5 with 9.99 must be present without the occurrence code 51. Thank You For The Payment On Your Account. The Sixth Diagnosis Code (dx) is invalid. Pharmacuetical care limitation exceeded. Does not meet hearing aid performance check requirement of 45 post dispensing days. Please Review All Provider Handbook For Allowable Exception. Assessment Is Not A Covered Service Unless All Four Components Of Skilled Nursing Are Present: Assessment, Planning, Intervention And Evaluation. This Is An Adjustment of a Previous Claim. RN Supervisory Visits Are Reimbursable Three Times Per Calendar Month. Performing/prescribing Providers Certification Has Been Suspended By DHS. Rn Visit Every Other Week Is Sufficient For Med Set-up. Provider signature and/or date is required. This Is A Manual Increase To Your Accounts Receivable Balance. Additional Reimbursement Is Denied. DX Of Aphakia Is Required For Payment Of This Service. SMV Mileage Exceeding 40 Miles In Urban Counties Or 70 Miles In Rural CountiesRequires Prior Authorization. Endurance Activities Do Not Require The Skills Of A Therapist. Default Prescribing Physician Number XX9999991 Was Indicated. CO/96/N216. CPT is registered trademark of American Medical Association. CPT Code And Service Date For Member Is Identical To Another Claim Detail On File For Provider On Claim. Member eligibility file indicates that BadgerCare Plus Benchmark, CorePlan or Basic Plan member. When a provider submits an E&M level of service that exceeds the maximum level of E&M service level based on the diagnosis submitted, the E&M code is recoded (and allowed to pay) to match the maximum level of E&M service allowed based on the severity of the medical diagnosis submitted. Your 1099 Liability Has Been Credited. Procedure Code is allowed once per member per lifetime. Denied/Cutback. Members Are Limited To 45 Dates Of Service Per Therapy/spell Of Illness without Prior Authorization. An Explanation of Benefits (EOB) code corresponds to a printed message about the status or action taken on a claim. Pricing Adjustment/ Third party liability deducible amount applied. Denied. Modification Of The Request Is Necessitated By The Members Minimal Progress. Attachment was not received within 35 days of a claim receipt. Secondary Diagnosis Code(s) in positions 2-9 cannot duplicate the Primary Discharge Diagnosis. The From Date Of Service(DOS) and To Date Of Service(DOS) must be in the same calendar month and year. NDC was reimbursed at Employer Medical Assistance Contribution (EMAC) rate. Denied/Cuback. This Procedure Code Is Not Valid In The Pharmacy Pos System. Documentation Does Not Justify Medically Needy Override. Fourth Diagnosis Code (dx) is not on file. Other Insurance Disclaimer Code Used Is Inappropriate For This Members Insurance Coverage. Denied. Diagnosis Code indicated is not valid as a primary diagnosis. This National Drug Code (NDC) has diagnosis restrictions. subsequent hospital care (CPT 99231-99233) or inpatient consultations (CPT 99251-99255) in the previous week. The Tooth Is Not Essential For Support Of A Partial Denture. Money Will Be Recouped From Your Account. Individual Test Paid. Please verify billing. Explanation of Benefit Codes (EOBs) Mar 14, 2022 1 EOB EOB DESCRIPTION. The Timeframe Between Certification, Test, Date And Hire Date Exceeds A Year. The total of amounts billed for the DOS on the claim exceeds the allowed dailylimit for PDN services. It Must Be In MM/DD/YY FormatAnd Can Not Be A Future Date. Members Aged 3 Through 21 Years Old Are Limited To One Healthcheck Screening per 12 months. For Newly Certified CNAs, Date Of Inclusion Is T heir Test Date. Please Correct And Re-bill. Inpatient Respite Care Is Not Covered For Hospice Members Residing In Nursing Homes. Service(s) Must Be Submitted On Paper Claim Form Along With Preoperative History And Physical Report And Operation Report. For Revenue Code 0820, 0821, 0825 or 0829, HCPCS Code 90999 or Modifier G1-G6 must be present. The To Date Of Service(DOS) for the Second Occurrence Span Code is invalid. Second And Subsequent Cerebral Evoked Response Tests Paid At A Reduced Rate Per Guidelines. The information on the claim isinvalid or not specific enough to assign a DRG. The Seventh Diagnosis Code (dx) is invalid. Referring Provider ID is not required for this service. Member is assigned to a Hospice provider. Training Completion Date Must Be Prior To And Within A Year Of The CNAs Certification Date. The Related Surgical Procedure is not a covered service under Wisconsin Medicaid or BadgerCare Plus. Claim or adjustment/reconsideration request must have both a Revenue Code and either a HCPCS Code or CPT Code. Unable To Process Your Adjustment Request due to Claim ICN Not Found. Service(s) Denied By DHS Transportation Consultant. Please watch for periodic updates. Dialysis/EPO treatment is limited to 13 or 14 services per calendar month. Staywell is committed to continually improving its claims review and payment processes. Multiple Service Location Found For the Billing Provider NPI. Occupational therapy limited to 35 treatment days per lifetime without prior authorization. Prescription Date is after Dispense Date Of Service(DOS). 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. Amount Recouped For Duplicate Payment on a Previous Claim. Denied. This Unbundled Procedure Code Remains Denied. The detail From or To Date Of Service(DOS) is missing or incorrect. You can choose to receive only your EOBs online, eliminating the paper . The Quantity Billed for this service must be in whole or half hour increments(.5) Increments. Header From Date Of Service(DOS) is after the date of receipt of the claim. Bilateral Procedures Must Be Billed On One Detail With Modifier 50, Quantity Of 1.detail With Modifier 50 May Be Adjusted If Necessary. Live-agent chat is the easiest and fastest way to get real-time support for an array of topics, including: Member Eligibility. Header From Date Of Service(DOS) is after the header To Date Of Service(DOS). The diagnosis code on the claim requires Condition code A6 be present on the Type of Bill. Claim count of Present on Admission (POA) indicators does not match count of non-admitting and non-emergency diagnosis codes. Procedure Not Payable for the Wisconsin Well Woman Program. Denied/Cutback. Services Not Provided Under Primary Provider Program. A Date Of Service(DOS) is required with the revenue code and HCPCS code billed. Resubmit Complete And/or Second Page Of Medicares EOMB Showing All Total And Payments. Records Indicate This Tooth Has Previously Been Extracted. Please note that the submission of medical records is not a guarantee of payment. Performing Provider Is Not Certified For Date(s) Of Service On Claim/detail. Documentation You Have Submitted Does Not Meet The Requirements Of HSS 107.09(4)(k). Condition codes 71, 72, 73, 74, 75, and 76 cannot be present on the same ESRD claim at the same time. CPT Code 88305 (Level IV Surgical pathology, gross and microscopic examination) includes different types of biopsies. Procedure not payable for Place of Service. Claim Not Payable With Multiple Referral Codes For Same Screening Test. Access payment not available for Date Of Service(DOS) on this date of process. Claims may deny when a nerve conduction study is billed without a needle EMG, or a needle EMG is billed without a Nerve conduction study, and the only diagnosis is radiculopathy (ICD-10 codes M50.1-M50.23, M51.1-M51.27, M51.9, M53.80, M54.10-M54.18, M54.30-M54.42, and M79.2). This drug is limited to a quantity for 100 days or less. The Existing Appliance Has Not Been Worn For Three Years. Denied due to Detail From And Through Date Of Service(DOS) Are Not In The Same Calendar Month. A claim cannot contain only Not Otherwise Specified (NOS) Surgical Procedure Codes. Discharge Date is before the Admission Date. The Competency Test Date On The Request Does Not Match The CNAs Test Date OnThe WI Nurse Aide Registry. Only one initial visit of each discipline (Nursing) is allowedper day per member. Resubmit Using Valid Rn/lpn Procedure Codes And A Valid PA Number. Medicare Paid The Total Allowable For The Service. Reimbursement determination has been made under DRG 981, 982, or 983. Claim Paid Under DRG Reimbursement, Except For Transplants Billed Using Suffixes 05 Through 09. What steps can we take to avoid this denial? Revenue Code 082X is present on an ESRD claim which also contains revenue codes 083X, 084X, or 085X. Purchase Only Allowed; Medical Need For Rental Has Not Been Documented. Services have been determined by DHCAA to be non-emergency. Diag Restriction On ICD9 Coverage Rule edit. Claim Corrected. Denied/Cutback. The procedure code has Family Planning restrictions. Service Denied/cutback. Comprehensive Screens And Individual Components Are Not Payable On The Same Date Of Service(DOS). Separate reimbursement for drugs included in the composite rate is not allowed. Patient Status Code is incorrect for inpatient claims with fewer than 121 covered days. Please Resubmit A New Adjustment/reconsideration Request Form And Indicate TheMost Recent Cclaim Number Where Payment Was Made Or Allowed. All ESRD clinical diagnostic laboratory tests must be billed individually to ensure that automated multi-chanel chemistry tests are paid in accordance with the Medicare Provider Reimbursement Manual (PRM) 2711. Per Information From Insurer, Claims(s) Was (were) Paid. Denied. This claim is a duplicate of a claim currently in process. Newborn Care Must Be Billed Under Newborn Name And Number; Occurrence Codes 50& 51 Cannotbe Present if Billing Under Newborn Name. Amount Paid Reduced By Amount Of Other Insurance Payment. Verify billed amount and quantity billed. 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. 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. 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. Adjustment Denied For Insufficient Information. Claim Denied. This Adjustment/reconsideration Request Was Initiated By . A valid Prior Authorization is required for non-preferred drugs. Request was not submitted Within A Year Of The CNAs Hire Date. Dispensing fee denied. Health (3 days ago) Webwellcare explanation of payment codes and comments. Contact. Denied due to Claim Exceeds Detail Limit. Medicaid Remittance Advice Remark Code:M86 MMIS EOB Code:100. This Mutually Exclusive Procedure Code Remains Denied. Training CompletionDate Exceeds The Current Eligibility Timeline. To access the training video's in the portal . Reimbursement Rate Applied To Allowed Amount. One or more To Date(s) of Service is missing for Occurrence Span Codes in positions three through 24. . The Members Clinical Profile/diagnosis Is Not Within Diagnostic Limitations for Psychotherapy Services. Diagnosis 635-635.92 May Only Be Used When Billing For Abortion Procedures. The Performing Provider Id, Member Id, And Date Of Service(DOS) Must Match The Completion Certificate Received From Ddes. First modifier code is invalid for Date Of Service(DOS). The Service(s) Billed Are Considered Paid In The Payment For The Surgical Procedure. Resubmit Claim Once Election Form Requirements Are Met Per The Hospice Provider Handbook. The Comprehensive Community Support Program reimbursement limitations have been exceeded. Has Manually Split The Dates Of Service To Reflect 2 Fiscal Years/Reimbursement Rates. Diagnosis Codes Assigned Must Be At The Greatest Specificity Available. Continuous home care must be billed in an hourly quantity equal to or greater than eight hours, up to and including 24 hours. 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. Pricing Adjustment/ Payment amount increased based on hospital access paymentpolicies. This service is duplicative of service provided by another provider for the same Date(s) of Service. Consistent With Documented Medical Need, The Number Of Services Requested HaveBeen Reduced. Valid NCPDP Other Payer Reject Code(s) required. Ongoing assessment is not reimbursable when skilled nursing visits have been performed within the past sixty days. Billing Provider is not certified for the detail From Date Of Service(DOS). FL 44 HCPCS/Rates/HIPPS Rate Codes Required. The Clinical Profile, Narrative History, And Treatment History Indicate The Recipient Is Only Eligible For Maintenance Hours. 51.42 Board Directors Or Designees Statement & Signature Required OnThe Claim Form For Payment Of Functional Assessment. Our Records Indicate This Tooth Previously Extracted. The Surgical Procedure Code of greatest specificity must be used.
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