A Third Occurrence Code Date is required. Please Correct And Re-bill. The Total Number Of Sessions Requested Exceeds Quarterly Guidelines. No Separate Payment For IUD. Hospital discharge must be within 30 days of from Date Of Service(DOS). Was Unable To Process This Request. Edentulous Alveoloplasty Requires Prior Authotization. Service(s) Approved By DHS Transportation Consultant. Claims may deny when reported and not meeting the ICD-10-CM Laterality policy for Diagnosis-to-Diagnosis comparison. Denied/cutback. Resubmit Claim With Corrected Tooth Number/letter Or With X-ray Documenting Tooth Placement. Ninth Diagnosis Code (dx) is not on file. Immunization Questions A And B Are Required For Federal Reporting. This Member Has Already Received Intensive Day Treatment In The Past Year and is Only Eligible For Reduced Hours At This Time. Part C Explanation of Benefits (EOB) Materials. Denied. A National Provider Identifier (NPI) is required for the Billing Provider. Rn Visit Every Other Week Is Sufficient For Med Set-up. This National Drug Code (NDC) requires a whole number for the Quantity Billed. This claim did not include the Plan ID, therefore we assigned TXIX as the Plan ID for this claim. Please Resubmit Corr. . Additional Reimbursement Is Denied. Referring Provider is not currently certified. Claim Denied. Please Verify The Units And Dollars Billed. Resubmit Your Services Using The Appropriate Modifier After YouReceive A Update Providing Additional Billing Information. The Service Requested Is Included In The Nursing Home Rate Structure. This Claim Is A Reissue of a Previous Claim. Denied. A Second Surgical Opinion Is Required For This Service. Service Denied/cutback. Drugs Prescribed and Filled on the Same Day, Cannot have a Refill Greater thanZero. Denied. This limitation may only exceeded for x-rays when an emergency is indicated. The likelihood of a central nervous system (CNS) cause of the event is extremely low, and patient outcomes are not improved with brain imaging studies. 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 Is For A Member With Retro Ma Eligibility. Please Re-submit This Claim With The Insurance EOB Showing A Denial OrPartial Payment. Denied due to The Members First Name Is Missing Or Incorrect. Other Therapies Currently Provide Sufficient Services To Meet The Members Needs. 1. Adjustment Denied For Insufficient Information. All Requests Must Have A 9 Digit Social Security Number. Dates Of Service Must Be Itemized. Denied. Only Medicare Crossover claims are reimbursed for coinsurance, copayment, and deductible. Qty And/or Detail Charge Do Not Divide Out Equally For Dates Of Service and/orQty Given. Pricing Adjustment/ Maximum Flat Fee pricing applied. Member is covered by a commercial health insurance on the Date(s) of Service. Please Do Not Resubmit Your Claim, And Disregard Additional Informational Messages for this claim. This service is not covered under the ESRD benefit. The content shared in this website is for education and training purpose only. The Second Occurrence Code Date is invalid. Mail-to name and address - We mail the TRICARE EOB directly to. AODA Day Treatment Is Not A Covered Service For Members Who Are Residents Of Nursing Homes or Who Are Hospital Inpatients. These Supplies/items Are Included In The Purchase Of The Dme Item Billed On The Same Date Of Service(DOS). Please Indicate Computation For Unloaded Mileage. Billing Provider is restricted from submitting electronic claims. For 2020, WellCare is adding 68 new Medicare Advantage plans for a total of 261 plans with $0 or low monthly plan premiums. The Procedure Requested Is Not Allowable For The Process Type Indicated On TheRequest. Revenue Code 0001 Can Only Be Indicated Once. Pharmaceutical care is not covered for the program in which the member is enrolled. No Substitute Indicator required when billing Innovator National Drug Codes (NDCs). CO/204/N182 . Revenue code submitted is no longer valid. This National Drug Code Has Diagnosis Restrictions. EOB EOB DESCRIPTION. Permanent Tooth Restoration/sealant, Limited To Once Every 3 Years Unless Narrative Documents Medical Necessity. Third Diagnosis Code (dx) (dx) is not on file. Denied. The Members Gait Is Not Functional And Cannot Be Carried Over To Nursing. Member eligibility file indicates that BadgerCare Plus Benchmark, CorePlan or Basic Plan member. Do not insert a period in the ICD-9-CM or ICD-10-CM codes. Submit copy of the dated and signed evaluation and indicate if this is an initial Evaluation. Service Not Covered For Members Medical Status Code. Payment reduced. To Continue Treatment With Two Anti-ulcer Drugs Beyond Authorized Limit Please Submit Request On Paper With Clinical Documentation Clearly Indicating medical necessity. Also, to ensure claims process and pay accurately, Staywell may deny a claim and ask for pertinent medical documentation from the provider or supplier who submitted the claim. that provide either supplemental explanation for a monetary adjustment or policy information are required in the remittance advice transaction. An NCCI-associated modifier was appended to one or both procedure codes. Service(s) Denied/cutback. Please Refer To The Original R&S. Denied due to Procedure Is Not Allowable For Diagnosis Indicated. To bill any code, the services furnished must meet the definition of the code. Please Clarify Services Rendered/provide A Complete Description Of Service. Check Your Current/previous Payment Reports forPayment. Medicare Id Number Missing Or Incorrect. Inicio Quines somos? Pricing Adjustment/ Medicare benefits are exhausted. Claim Denied For Invalid Diagnosis Code Or Diagnosis Code/CPT Combination. Participant Is Enrolled In Medicare Part D. Beginning 09/01/06, Providers AreRequired To Bill Part D And Other Payers Prior To Seniorcare Or Seniorcare WillDeny The Claim. Denied. Valid Numbers Are Important For DUR Purposes. This Is Not A Reimbursable Level I Screen. The training Completion Date On This Request Is After The CNAs CertificationTest Date. The total of amounts billed for the DOS on the claim exceeds the allowed dailylimit for PDN services. 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). Denied due to Add Dates Not In Ascending Order Or DD/DD/DD Format. 51.42 Board Stamp Required On All Outpatient Specialty Hospital Claims For Dates Of Service On Or After January 1, 1986. Denied. The following table outlines the new coding guidelines. Denied. Do Not Bill Intraoral Complete Series Components Separately. Revenue code 082X is present on an ESRD claim which also contains revenue code088X (X frequency non equal to 9). The Request Does Not Meet Generally Accepted Conditions Requiring Fluoride Treatments. Claim Number Given On The Adjustment/reconsideration Request Form Does Not Match Services Originally Billed. Prescribing Provider UPIN Or Provider Number Missing From Claim And Attachment. List of Explanation of Benefit Codes Appearing on the Remittance Advice Services Requested Do Not Meet The Criteria for an Acute Episode. A number is required in the Covered Days field. Service Denied. Occupational Therapy Limited To 35 Treatment Days Per Spell Of Illness W/o Prior Authorization. View the Part C EOB materials in the Downloads section below. Claim Detail Pended As Suspect Duplicate. This Procedure Is Limited To Once Per Day. Reason Code 234 | Remark Codes N20 - JD DME - Noridian This Request Can Only Be Backdated To The Date EDS First Receives The Request In The Mailroom. The Member Does Not Meet The Criteria For Binaural Amplification; One Hearing Aid Is Authorized. Explanation of benefits. Procedure Code 59420 Must Be Used For 5 Or More Prenatal Visits With One Charge. Denied. Discharge Date is before the Admission Date. If laboratory costs exceed reimbursement, submit a claim adjustment request with lab bills for reconsideration. Service Denied. The Billing Providers taxonomy code is missing. A discrepancy exists between the Other Coverage Indicator and the Other Paid Amount. Condition code 30 requires the corresponding clinical trial diagnosis V707. Rebill On Pharmacy Claim Form. Either The Date Was Not In MM/DD/CCYY Format Or Its AFuture Date. Referral/treatment Procedures Are Not Payable When Billed With A Complete Refusal Detail. Timely Filing Request Denied. Member has Medicare Managed Care for the Date(s) of Service. Cannot Be Reprocessed Unless There Is Change In Eligibility Status. Procedure code 00942 is allowed only when provided on the same date ofservice as procedure code 57520. Reimbursement For This Certification, Test, Segment Has Been Issued To AnotherNF. 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. The From Date Of Service(DOS) for the Second Occurrence Span Code is invalid. 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. Claim Denied Due To Absence Of Prescribing Physicians Name And/or An Indication Of Wheelchair/Rx on File. Service Denied. The drug code has Family Planning restrictions. The relationship between the Billed and Allowed Amounts exceeds a variance threshold. The Performing Or Billing Provider On The Claim Does Not Match The Billing Provider On Theprior Authorization File. Denied. 2. Rendering Provider is not certified for the From Date Of Service(DOS). Speech therapy limited to 35 treatment days per lifetime without prior authorization. Inpatient Respite Care Is Not Covered For Hospice Members Residing In Nursing Homes. Up Cannot bill for both Assay of Lab and other handling/conveyance of specimen. Reason Code 161: Attachment referenced on the claim was not received in a timely fashion. No Action On Your Part Required. No matching Reporting Form on file for the detail Date Of Service(DOS). Timeframe Between The CNAs Training Date And Test Date Exceeds 365 Days. Member is enrolled in Medicare Part A on the Date(s) of Service. The header total billed amount is required and must be greater than zero. Pricing Adjustment/ Ambulatory Surgery pricing applied. Members age does not fall within the approved age range. Please Resubmit. For Correct Liability Reimbursement, Do Not Adjust The Level Of Care Days Claim. . The Evaluation Was Received By Fiscal Agent More Than Two Weeks After The Evaluation Date. A Reimbursement Request For A Level I Screen Must Be Received At Within A Year Of The Screen Date. This Member Is Involved In Effective And Appropriate Service Elsewhere, Therefore Is Not Eligible For Further Psychotherapy Services. The detail From or To Date Of Service(DOS) is missing or incorrect. A Qualified Provider Application Is Being Mailed To You. Handwritten Changes/corrections On The Medicare EOMB Are Not Acceptable. According to CMS policy and the American College of Radiology, a chest X-ray (CPT codes 71045, 71046) should not be performed for screening purposes in the absence of pertinent signs, symptoms or diseases. Refer To Your Pharmacy Handbook For Policy Limitations. WellCare Known Issues List Please be advised: Claims that have either rejected or denied . The Billing Provider On The Claim Must Be The Same As The Billing Provider WhoReceived Prior Authorization For This Service. Your latest EOB will be under Claims on the top menu. Claim Explanation Codes. NDC was reimbursed at generic WAC (Wholesale Acquisition Cost) rate. Admit Diagnosis Code is invalid for the Date(s) of Service. X-rays and some lab tests are not billable on a 72X claim. This Dental Service Limited To Once Every Six Months, Unless Prior Authorized. Prescription Date is after Dispense Date Of Service(DOS). Medical explanation of benefits. Denied. 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). In 2015 CMS began to standardize the reason codes and statements for certain services. Department of Health Services (DHS) Authorized Payment Is Being Withheld Due toa Final Rate Settlement. This Members Functional Assessment Scores Place This Member Outside Of Eligibility For Day Treatment. This procedure is age restricted. 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 Has Been Manually Priced Based On Family Deductible. Pricing Adjustment/ Provider Level of Care (LOC) pricing applied. According to the AMA CPT Manual and our policy, an initial inpatient admission (CPT 99221-99223) is allowed once every seven days. Please Refer To The Original R&S. An ICD-9-CM Diagnosis Code of greater specificity must be used for the Fifth Diagnosis Code. Effective July 15, 2021 through December 31, 2021: Temporary Relaxation of Prior Authorization . Please Resubmit Your Non-healthcheck Services Using The Appropriate Claim SortIndicator Or Electronic Format. The To Date Of Service(DOS) for the Second Occurrence Span Code is invalid. Pricing Adjustment/ Repackaging dispensing fee applied. The Travel component for this service must be billed on the same claim as the associated service. 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. Transplant services not payable without a transplant aquisition revenue code. NDC was reimbursed at Employer Medical Assistance Contribution (EMAC) rate. Alternatively, CPT XXXXX has been billed in the previous 10 days for a CPT code with a 10-day post-operative period, or in the previous 90 days for a code with a 90-day post-operative period by the same provider. Goals Are Not Realistic To The Members Way Of Life Or Home Situation, And Serve No Functional Or Maintenance Service. Condition Code 73 for self care cannot exceed a quantity of 15. One or more To Date(s) of Service is missing for Occurrence Span Codes in positions three through 24. This Program Does Not Appear To Meet The Minimum Requirement For AODA Day Treatment Programming (10hrs) And Does Not Qualify For Aoda Day Treatment. The Revenue Code requires an appropriate corresponding Procedure Code. Denied due to Medicare Allowed, Deductible, Coinsurance And Paid Amounts Do Not Balance. Diagnosis Codes Assigned Must Be At The Greatest Specificity Available. Seventh Occurrence Code Date is required. Member is enrolled in Medicare Part B on the Date(s) of Service. Denial Codes - RCM Revenue Cycle Management - Healthcare Guide Admission Date does not match the Header From Date Of Service(DOS). All Outpatient Services/or Accommodations And Ancillaries Are Denied, Therefore The Total Charge Is Denied. Claim Denied In Order To Reprocess WithNew ID. A valid Level of Effort is also required for pharmacuetical care reimbursement. Please File With Champus Carrier. Denied. Good Faith Claim Has Previously Been Denied By Certifying Agency. The Functional Assessment Indicates This Member Has Less Than A 50% Likelihoodof Benefit, Therefore Day Treatment Is Not Appropriate. 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. First Other Surgical Code Date is required. MassHealth List of EOB Codes Appearing on the Remittance Advice. Third modifier code is invalid for Date Of Service(DOS). The Sixth Diagnosis Code (dx) is invalid. Please Correct And Resubmit. Occupational therapy limited to 35 treatment days per lifetime without prior authorization. Second modifier code is invalid for Date Of Service(DOS) (DOS). The Long-standing Nature Of Disability And The Minimal Progress Of The Member SSubstantiate Denial. The Diagnosis Code Is Not Valid On This Date Of Service(DOS). Rejected Claims-Explanation of Codes - Community Care - Veterans Affairs No Extractions Performed. It Must Be In MM/DD/YY Format AndCan Not Be A Future Date. Fifth Other Surgical Code Date is invalid. Submitted referring provider NPI in the header is invalid. Member has commercial dental insurance for the Date(s) of Service. Program guidelines or coverage were exceeded. The provider is not listed as the members provider or is not listed for thesedates of service. Canon R-FRAME-EB 84 Eb Has Recouped Payment For Service(s) Per Providers Request. Please Provide The Type Of Drug Or Method Used To Stop Labor. Services Denied In Accordance With Hearing Aid Policies. Claim or Adjustment received beyond 365-day filing deadline. Service Denied. THE WELLCARE GROUP OF COMPANIES . ICD-9-CM Diagnosis code in diagnosis code field(s) 1 through 9 is missing or incorrect. Multiple Screens Performed Within A Fifteen Day Time Frame For This SSN. Home Health, Personal Care And Private Duty Nursing Services Are Subject To A Monthly Cap. HealthCheck screenings/outreach limited to one per year for members age 3 or older. Denied. Detail Rendering Provider certification is cancelled for the Date Of Service(DOS). Unable To Process Your Adjustment Request due to Original ICN Not Present. Please Refer To Update No. Combine Like Details And Resubmit. Denied due to Detail Billed Amount Missing Or Zero. Certifying Agency Did Not Verify Member Eligibility within 70 Day Period. These Individual Vaccines Must Be Billed Under The Appropriate Combination Injection Code. This National Drug Code (NDC) has diagnosis restrictions. Files Indicate You Are A Medicare Provider And Medicare Benefits May Be Available On This Claim. This change to be effective 4/1/2008: Submission/billing error(s). Billing or Rendering Provider certification is cancelled for the From Date Of Service(DOS). CPT Code And Service Date For Memberis Identical To Another Claim Detail On File For Another WWWP Provider. This Service Is A Resubmission Of A Service Previously Denied For Prior Authorization. Repackaging allowance is not allowed for unit dose NDCs. Only Four Dates Of Service Are Allowed Per Line Item (detail) For Each Procedure. Header Rendering Provider number is not found. Unable To Process Your Adjustment Request due to Provider Not Found. Reason Code 162: Referral absent or exceeded. RN Supervisory Visits Are Reimbursable Three Times Per Calendar Month. Pricing Adjustment/ Prescription reduction applied. Consultation or surgical procedures are not reimbursable in conjuctions with Emergency Room services. DME rental is limited to 90 days without Prior Authorization. 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. The Dispense As Written (DAW) indicator is not allowed for the National Drug Code. Please Request Prior Authorization For Additional Days. Department of Health Services (DHS) Authorized Payment Is Being Withheld Due toan Audit. Header To Date Of Service(DOS) is required. The Hearing Aid Recommended Is Not Necessary; The Member Could Be Adequately Fitted With A Conventional Aid. This HMO Capitation Payment Is Being Recouped It Was Inappropriately Paid During The Inital February HMO Capitation Cycle. When diagnoses 800.00 through 999.9 are present, an etiology (E-code) diagnosis must be submitted in the E-code field. Provider signature and/or date is required. Services Not Provided Under Primary Provider Program. PDF WellCare Procedure Codes - HealthHelp Please Correct and Resubmit. Review Of Adjustment/reconsideration Request Shows Original Claim Payment Was Max Allowed For Medical Service/Item/NDC. Traditional dispensing fee may be allowed. Submitted referring provider NPI in the detail is invalid. Timely Filing Deadline Exceeded. Supplemental Payment Authorized By Department of Health Services (DHS) Due to a Department Of Justice Settlement. 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. Hearing aid repairs are limited to once per six months, per provider, per hearing aid. The Information Provided Indicates Regression Of The Member. The Service(s) Requested Could Be Adequately Performed With Local Anesthesia In The Dental Office. Services Can Only Be Authorized Through One Year From The Prescription Date. Critical care performed in air ambulance requires medical necessity documentation with the claim. The Procedure Code has Encounter Indicator restrictions. Information Required For Claim Processing Is Missing. is unable to is process this claim at this time. Allowed Amount On Detail Paid By WWWP. This Service Is Covered Only In Emergency Situations. Denied due to Claim Contains Future Dates Of Service. NDC is obsolete for Date Of Service(DOS). Principle Surgical Procedure Code Date is missing. Payment has been reduced or denied because the maximum allowance of this ESRD service has been reached. The Member Has Shown No Ability Within 6 Months To Carry Over Abilities GainedFrom Treatment In A Facility To The Members Place Of Residence. Diag Restriction On ICD9 Coverage Rule edit. EOB for services that should be paid as primary by the Health Plan EPSDT: claims billed with EP modifier 3/28/2022 03/09/2022 2636 In Process DN018 . Documentation Does Not Justify Fee For ServiceProcessing . Adjustment and original claim do not have the same finanical payer, 6355 replacing 635R diagnosis (For use of Category of Service only), 6360 replacing 635S diagnosis (For use of Category of Service only), 6365 replacing 635T diagnosis (For use of Category of Service only). Please Furnish A UB92 Revenue Code And Corresponding Description. Denied. Claim Is Being Special Handled, No Action On Your Part Required. Services Not Allowed For Your Provider T. The Procedure Code has Place of Service restrictions. The Service/procedure Proposed Is Not Supported By Submitted Documentation. Preventive Medicine Code Billed Is Allowed For Health Check Agencies Only With The Appropriate Healthcheck Modifier. The Procedure Requested Is Not Appropriate To The Members Sex. Multiple Requests Received For This Ssn With The Same Screen Date. No payment allowed for Incidental Surgical Procedure(s). Effective September 1, 2021: Benefit Changes to Total Disc Arthroplasty for Medicaid and CHIP. A Primary Occurrence Code Date is required. FACIAL. Please Resubmit Medicares Nursing Home Coinsurance Days As A New Claim RatherThan An Adjustment/reconsideration Request. One or more Diagnosis Code(s) is not payable for the Date Of Service(DOS). Denied. All rental payments have been deducted from the purchase costsince the DME item was rented and subsequently purchased for the member. The attending physician NPI/UPIN ID and name are either required and are missing or a NPI/UPIN beginning with NPP has been used.

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