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Services Not Provided Under Primary Provider Program. CNAs Eligibility For Training Reimbursement Has Expired. The From Date Of Service(DOS) for the Second Occurrence Span Code is invalid. Valid group codes for use on Medicare remittance advice are:. 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. Requires A Unique Modifier. This Member Has Received Primary AODA Treatment In The Last Year And Is Therefore Not Eligible For Primary Intensive AODA Treatment At This Time. The Hearing Aid Recommended Is Not Necessary; The Member Could Be Adequately Fitted With A Conventional Aid. The submitted claim contains value code 68 and 48 or 49 but does not contain revenue code 0634 or 0635 and HCPCS Q4055. You can even print your chat history to reference later! Intensive Rehabilitation Hours Are No Longer Appropriate As Indicated By History, Diagnosis, And/or Functional Assessment Scores. Claims may deny when tympanometry/impedance testing (CPT 92567) is billed with a preventive medicine service (CPT 99381-99397) or wellness visit (CPT G0438-G0439) without appropriate modifier appended to the E&M service to identify a separately identifiable procedure; tympanometry/impedance testing will be considered part of the office visit. Certifying Agency Did Not Verify Member Eligibility within 70 Day Period. The training Completion Date On This Request Is After The CNAs CertificationTest Date. These Individual Vaccines Must Be Billed Under The Appropriate Combination Injection Code. Service Must Be Billed On Drug Claim Form Utilizing NDC Codes. An explanation of benefits is a document from your insurance company outlining the services you received and how much they cost. Do Not Use Informational Code(s) When Submitting Billing Claim(s). Denied. OA 11 The diagnosis is inconsistent with the procedure. Effective 04/01/09, the BadgerCare Plus Core Plan will limit coverage for Hypoglycemics-Insulin to Humalog and Lantus. Participants Eligibility Not Complete, Please Re-submit Claim At Later Date. The detail From Date Of Service(DOS) is invalid. Unable To Process Your Adjustment Request due to Provider ID Number On The Claim And On The Adjustment Request Do Not Match. 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. This Adjustment/reconsideration Request Was Initiated By . Paid In Accordance With Dental Policy Guide Determined By DHS. These Services Paid In Same Group on a Previous Claim. This drug is limited to a quantity for 100 days or less. EOB. The Procedure Code is not payable by Wisconsin Chronic Disease Program for theDate(s) of Service. Please Indicate The Dollar Amount Requested For The Service(s) Requested. NDC- National Drug Code billed is not appropriate for members gender. Unable To Process Your Adjustment Request due to Member Not Found. If You Have Already Obtained SSOP, Please Disregard This Message. Private Duty Nursing Beyond 30 Hrs /Member Calendar Year Requires Prior Authorization. This obstetrical service was previously paid for this Date Of Service(DOS) for thismember. Reimbursement Is At The Unilateral Rate. Thank You For Your Assessment Interest Payment. The Performing Provider Id, Member Id, And Date Of Service(DOS) Must Match The Completion Certificate Received From Ddes. Request was not submitted Within A Year Of The CNAs Hire Date. Service(s) paid in accordance with program policy limitation. Claim contains an unclassified drug HCPCS procedure code or a drug HCPCS procedure code included in the composite rate. A Trading Partner Agreement/profile Form(s) Authorizing Electronic Claims Submission Is Required. No Substitute Indicator required when billing Innovator National Drug Codes (NDCs). The detail From or To Date Of Service(DOS) is missing or incorrect. Records Indicate This Tooth Has Previously Been Extracted. Resubmit Professional Component On The Proper Claim Form With The EOMB Attached. Compound Drug Service Denied. Policy override must be granted by the Drug Authorizationand Policy Override Center to dispense early. Claim/adjustment Received Beyond The 455 Day Resubmission Deadline. Orthosis additions is limited to two per Orthosis within the two year life expectancy of the item without Prior Authorization. The quantity billed of the NDC is not equally divisible by the NDC package size. Please Correct And Resubmit. The Lens Formula Does Not Justify Replacement. DX Of Aphakia Is Required For Payment Of This Service. Ability to proficiently use Microsoft Excel, Outlook and Word. The Members Gait Is Not Functional And Cannot Be Carried Over To Nursing. Payment For Immunotherapy Service Included In Reimbursement For Allergy Extract Injection. The Service Requested Is Not A Covered Benefit As Determined By . It Must Be In MM/DD/YY Format AndCan Not Be A Future Date. Effective 04/01/09, the BadgerCare Plus Core Plan will limit coverage for Brochodilators-Beta Agonists to Proventil HFA and Serevent. The statement coverage FROM date on a hemodialysis ESRD claim (revenue code 0821, 0880, or 0881) was greater than the hemodialysis termination date in the provider file. Claim Denied Due To Incorrect Billed Amount. Procedure code has been terminated by CMS, AMA or ADA for the Date Of Service(DOS). The Medical Need For This Service Is Not Supported By The Submitted Documentation. Service Denied, refer to Medicares Billing and/or Policy Guidelines. Denied/Cutback. You Must Either Be The Designated Provider Or Have A Refer. EDI TRANSACTION SET 837P X12 HEALTH CARE . Use The New Prior Authorization Number When Submitting Billing Claim. . This drug is limited to a quantity for 34 days or less. Value Codes 81 And 83, Are Valid Only When Submitted On An Inpatient Claim. The first position of the attending UPIN must be alphabetic. Home Health, Personal Care And Private Duty Nursing Services Are Subject To A Monthly Cap. Denied due to Provider Is Not Certified To Bill WCDP Claims. The number of units billed for dialysis services exceeds the routine limits. The total billed amount is missing or is less than the sum of the detail billed amounts. A Date Of Service(DOS) is required with the revenue code and HCPCS code billed. No Functional Regression Has Occurred To Warrant A Spell Of Illness; Submit AsA Prior Authorization Request. Speech Therapy Limited To 45 Treatment Days Per Spell Of Illness W/o Prior Authorization. Homecare Services W/o PA Are Not Payable When Prior Authorized Homecare Services have Been Provided To The Same Member. Vision Diagnostic Services Limited To 1 Of These: Vision Exam, Diagnostic Review, Supplemental Test Or Contact Lens Therapy. Please Correct And Resubmit. Referring Provider ID is not required for this service. Claimchecks Editing And Your Supporting Documentation Was Reviewed By The DHS Medical Consultant. This service or a related service performed on this date has already been billed by another provider and paid. Traditional dispensing fee may be allowed. Inicio Quines somos? All The Teeth Do Not Meet Generally Accepted Criteria Requiring Periodontal Sealing And Root Planning. Complete Refusal Detail Is Not Payable Without Referral/treatment Details. Rendering Provider may not submit claims for reimbursement as both the Surgeonand Assistant Surgeon For The Same Member On The Same DOS. The Member Is Only Eligible For Maintenance Hours. A Separate Notification Letter Is Being Sent. Service Denied. Header From Date Of Service(DOS) is required. Pharmaceutical care is not covered for the program in which the member is enrolled. Denied. Unable To Process Your Adjustment Request due to This Claim Is In Post Pay Billing For Third Party Liability Payment. No Action On Your Part Required. One or more To Date(s) of Service is missing for Occurrence Span Codes in positions three through 24. CO/204/N30. Date of service is on or after July 1, 2010 and TOB is 72X, value code D5 mustbe present. Dialysis/EPO treatment is limited to 13 or 14 services per calendar month. Please Add The Coinsurance Amount And Resubmit. The Third Occurrence Code Date is invalid. Annual Physical Exam Limited To Once Per Year By The Same Provider. Partial Payment Withheld Due To Previous Overpayment. Service Fails To Meet Program Requirements. Non-scheduled drugs are limited to the original dispensing plus 11 refills or 12 months. First Other Surgical Code Date is required. SeniorCare member enrolled in Medicare Part D. Claim is excluded from Drug Rebate Invoicing. Recoding/adjusting claim may result in a different DRG code assignmentand reimbursement. Pricing Adjustment/ SeniorCare claim cutback because of Patient Liability and/or other insurace paid amounts. The Medicare Paid Amount is missing or incorrect. Documentation Does Not Justify Reconsideration For Payment. Restorative Nursing Can Provide Follow-through, Based On Diagnosis Of Long-standing Nature, And The Amount Of Therapy. Please Request Prior Authorization For Additional Days. Back-up dialysis sessions are limited to three per lifetime. Language Comprehension And Language Production Are Equivalent To Cognition, Thus Formal Speech Therapy Is Not Needed. Explanation of Benefit codes (EOBs) Explanation of Benefit (EOB) codes are reported on your remittance statement. Denied. Physical Therapy, Occupational Therapy Or Speech Therapy Limited To 90 Min PerDay. Critical care performed in air ambulance requires medical necessity documentation with the claim. A dispense as written indicator is not allowed for this generic drug. Referring Provider is not currently certified. Unable To Process This Request Because The Competency Test Date And TrainingCompletion Date Fields Are Blank. RN Home Health visits and Supervisory visits are not reimbursable on the same Date Of Service(DOS) for same provider. Formal Speech Therapy Is Not Needed. The Timeframe Between Certification, Test, Date And Hire Date Exceeds A Year. Member is enrolled in a commercial health insurance on the Dispense Date Of Service(DOS). Pharmaceutical Care Code must be billed with a payable drug detail or if a prescription was not filled, the quantity dispensed must be zero. Based on these reimbursement guidelines, claims may deny when the following revenue codes are billed without the appropriate HCPCS code: Pricing Adjustment/ Ambulatory Payment Classification (APC) pricing applied. Please Provide Copy Of Medicare Explanation Of Benefits/medicare Remittance Advice Attached To Claim. Reduction To Maintenance Hours. One or more Diagnosis Code(s) is not payable for the Date Of Service(DOS). Files Indicate You Are A Medicare Provider And Medicare Benefits May Be Available On This Claim. Please Re-submit This Claim With The Insurance EOB Showing A Denial OrPartial Payment. Unable To Process Your Adjustment Request due to Original Claim ICN Not Found. The National Drug Code (NDC) submitted with this HCPCS code is CMS terminated or not covered by the program. Claim Denied. A covered DRG cannot be assigned to the claim. The Service Requested Is Not A Covered Benefit Of The Program. The Revenue Code is not payable for the Date(s) of Service. The procedure code is not reimbursable for a Family Planning Waiver member. Purchase of a blood glucose monitor includes the first 30 days of supplies for the monitor. We maintain and annually update a List of Current Procedural Terminology (CPT)/Healthcare Common Procedure Coding System (HCPCS) Codes (the Code List), which identifies all the items and services included within certain designated health services (DHS) categories or that may qualify for certain exceptions. Dates Of Service For Purchased Items Cannot Be Ranged. A code with no Trip Modifier billed on same day as a code with Modifier U1 are considered the same trip. Provider is not eligible for reimbursement for this service. 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 Procedure Code billed not payable according to DEFRA. Reimbursement determination has been made under DRG 981, 982, or 983. A Pharmaceutical Care Code (PCC) must include a valid diagnosis code. Third Other Surgical Code Date is required. 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. Providers must ensure that the E&M CPT codes selected reflect the services furnished. Covered By An HMO As A Private Insurance Plan. Denied due to Diagnosis Not Allowable For Claim Type. DME rental is limited to 90 days without Prior Authorization. NDC- National Drug Code is invalid for the Dispense Date Of Service(DOS). Denied/Cuback. Denied due to Provider Signature Is Missing. Admission Date is on or after date of receipt of claim. This claim has been adjusted due to a change in the members enrollment. 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. NFs Eligibility For Reimbursement Has Expired. Reference: Transmittal 477, change request 3720 issued February 18, 2005. Good Faith Claim Denied For Timely Filing. Denied. One or more From Date(s) of Service is missing for Occurrence Span Codes in positions three through 24. Timely Filing Deadline Exceeded. Resubmit Claim With Corrected Tooth Number/letter Or With X-ray Documenting Tooth Placement. This Adjustment Was Initiated By . Subsequent surgical procedures are reimbursed at reduced rate. Claim or line denied. Therefore, physician provider claim would deny. Submitted rendering provider NPI in the header is invalid. 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. Reimbursement Rate Applied To Allowed Amount. Do Not Bill Intraoral Complete Series Components Separately. This Claim Is A Reissue of a Previous Claim. Find top links about Wellcare Cvs Caremark Login along with social links, FAQs, and more. EPSDT/healthcheck Indicator Submitted Is Incorrect. This National Drug Code (NDC) has been terminated by CMS for the Date Of Service(DOS). 10 Important Billing Tips for FQHC and RHC Providers. No Complete WWWP Participation Agreement Is On File For This Provider. Claim Denied. Timely Filing Request Denied. Surgical Procedure Code billed is not appropriate for members gender. FACIAL. The Treatment Request Is Not Consistent With The Members Diagnosis. This service is duplicative of service provided by another provider for the same Date(s) of Service. Denied. The Surgical Procedure Code is not payable for /BadgerCare Plus for the Date Of Service(DOS). Invalid/obsolete Procedure Code For Determination Of Refraction, Service Denied. Treatment With More Than One Drug Per Class Of Ulcer Treatment Drug At The Same Time Is Not Allowed Through Stat PA. Denied. Value codes 48 Homoglobin Reading and 49 Hematocrit Reading, must have a zero in the far right position. The Members Reported Diagnosis Is Not Considered Appropriate For AODA Day Treatment. If Required Information Is not received within 60 days, the claim detail will be denied. Child Care Coordination services are reimbursable only if both the member and provider are located in Milwaukee County. Denied due to Provider Signature Date Is Missing Or Invalid. Refer To Provider Handbook. Denied. Member Is Eligible For Champus. Billing Provider is not certified for the Date(s) of Service. Header Rendering Provider number is not found. Please Correct And Resubmit. Contingency Plan for CORE and HIRSP Kids Suspend all non-pharmacy claims. The Documentation Submitted Indicates The Tasks Specified Can Be Completed During The Visits Approved. Denied. Please verify the accuracy of the procedure code and the presence of the appropriate procedure code modifier before cont acting ACS for assistance. This claim is a duplicate of a claim currently in process. wellcare eob explanation codes. Charges For Anesthetics Are Included In Charge For All Surgical Procedures. Denied. Watch FutureRemittance And Status Reports For Its Finalization Before Resubmitting. Multiple Prescriptions For Same Drug/ Same Fill Date, Not Allowed. Therefore itIs Not Necessary To Wait The Full 6 Weeks After Extractions Before Taking Denture Impressions. Denied/Cutback. Bilateral Procedures Must Be Billed On One Detail With Modifier 50, Quantity Of 1.detail With Modifier 50 May Be Adjusted If Necessary. Documentation Does Not Justify Medically Needy Override. Medicare accepts any National Uniform Billing Committee (NUBC) approved revenue codes. Resubmit The Original Medicare Determination (EOMB) Along With Medicares Reconsideration. Members I.d. 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. Out of State Billing Provider not certified on the Dispense Date. Please Refer To The Original R&S. Medical Need For Equipment/supply Requested Is Not Supported By Documentation Submitted. Do not leave blank fields between the multiple occurance codes. Please Correct And Resubmit. Professional Components Are Not Payable On A Ub-92 Claim Form. Staywell is committed to continually improving its claims review and payment processes. Because a claim can have edits and audits at both the header and detail levels, EOB codes are listed . Assessment Is Not A Covered Service Unless All Four Components Of Skilled Nursing Are Present: Assessment, Planning, Intervention And Evaluation. A Training Payment Has Already Been Issued To A Different NF For This CNA. One Visit Allowed Per Day, Service Denied As Duplicate. The Reimbursement Code Assigned To This Certification Segment Does Not Authorize a Training Payment. Denied due to Claim Exceeds Detail Limit. The maximum number of details is exceeded. 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. 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). Our Records Indicate This Tooth Previously Extracted. Please Disregard Additional Information Messages For This Claim. This drug has been paid under an equivalent code within seven days of this Date Of Service(DOS). Services Can Only Be Authorized Through One Year From The Prescription Date. Please Submit Charges Minus Credit/discount. Fourth Other Surgical Code Date is invalid. Denied. Principal Diagnosis 8 Not Applicable To Members Sex. The To Date Of Service(DOS) for the Second Occurrence Span Code is required. The Procedure Code/Modifier combination is not payable for the Date Of Service(DOS). The Quantity Allowed Was Reduced To A Multiple Of The Products Package Size. The Seventh Diagnosis Code (dx) is invalid. (National Drug Code). Services have been determined by DHCAA to be non-emergency. Claim reimbursement has been cutback to reimbursement limits for denture repairs performed within 6 months. 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 and ICD10 codes; Excellent interpersonal and communication skills with professional demeanor and positive attitude In general, the more complex the visit, the higher the E&M level of code you may bill within the appropriate category. Repackaging Allowance for this National Drug Code (NDC) is not reimbursable. Denied due to Take Home Drugs Not Billable On UB92 Claim Form. Name And Complete Address Of Destination. CO/204. A Total Charge Was Added To Your Claim. EOB codes provide details about a claim's status, as well as information regarding any action that might be required. Authorization For Surgery Requiring Second Opinion Valid For 6Months After Date Approved. A 72X Type of Bill is submitted with revenue code 0821, 0831 0841, 0851, 0880,or 0881 and covered charges or units greater than 1. -OR- The claim contains value code 48, 49, or 68 but does not contain revenue codes 0634 or 0635. The Clinical Status Of The Member Does Not Meet Standards Accepted By The Department Of Health And Family Services For Transplant. Competency Test Date Is Not A Valid Date. 51.42 Board Directors Or Designees Statement & Signature Required OnThe Claim Form For Payment Of Functional Assessment. Timely Filing Deadline Exceeded. Procedure Code Changed To Permit Appropriate Claims Processing. Review Patient Liability/paid Other Insurance, Medicare Paid. Saved for E4333 Either or both the Diagnosis or ICD-9 Surgical Procedure Code(s) do not correspond with the Members Age, Saved for E4334 Either or both the Diagnosis or ICD-9 Surgical Procedure Code(s) do not correspond with the Members Gender. This claim must contain at least one specified Surgical Procedure Code. Real time pharmacy claims require the use of the NCPDP Plan ID. This Member Is Involved In Intensive Day Treatment, Which Is To Include Psychotherapy Services. Speech Therapy Is Not Warranted. Services Not Allowed For Your Provider T. The Procedure Code has Place of Service restrictions. Rendering Provider is not a certified provider for Wisconsin Chronic Disease Program. The following table outlines the new coding guidelines. Claim Reduced Due To Member Income Available Toward Cost Of Care (Nursing Home Liability). Requested Documentation Has Not Been Submitted. Acknowledgement Of Receipt Of Hysterectomy Info Form Is Missing, Incomplete, Or Contains Invalid Information. Pricing Adjustment/ Third party liability amount applied is greater than the amount paid by the program. For Revenue Code 0820, 0821, 0825 or 0829, HCPCS Code 90999 or Modifier G1-G6 must be present. Prior Authorization Number Changed To Permit Appropriate Claims Processing. 0; Check Your Current/previous Payment Reports forPayment. BY . A National Drug Code (NDC) is required for this HCPCS code. Condition Code 73 for self care cannot exceed a quantity of 15. A Training Payment Has Already Been Issued To Your NF For This CNA. Reason Code 161: Attachment referenced on the claim was not received in a timely fashion. Second modifier code is invalid for Date Of Service(DOS) (DOS). The provider enters the appropriate revenue codes to identify specific accommodation and/or ancillary charges.