wellcare eob explanation codes

Revenue code submitted is no longer valid. Denied due to Diagnosis Code Is Not Allowable. Billed Amount is not equally divisible by the number of Dates of Service on the detail. This Incidental/integral Procedure Code Remains Denied. Was Unable To Process This Request Due To Illegible Information. The Sixth Diagnosis Code (dx) is invalid. The detail From or To Date Of Service(DOS) is missing or incorrect. Amount Recouped For Mother Baby Payment (newborn). This Member, As Indicated By Narrative History, Does Not Agree To Abstinence from Alcohol Or Other Drugs And Is Ineligible For AODA Treatment. Please Contact The Surgeon Prior To Resubmitting this Claim. Use the most current year's ICD-9-CM or ICD-10-CM codes, depending on the date(s) of service. Claim Detail Is Pended For 60 Days. Admission Date is on or after date of receipt of claim. Payspan's Core Payment Network comes with a feature that allows payers to send members an electronic version of their Explanation of Benefits (eEOB). Allowed Amount On Detail Paid By WWWP. Billing Provider indicated is not certified as a billing provider. Service not allowed, benefits exhausted occurrence code billed. Effective 5/31/2019, we will introduce new Coding Integrity Reimbursement Guidelines. Provider Is Responsible For Averaging Costs During Cal Year Not To Exceed YrlyTotal (12 x $2325.00). Payment Reduced In Accordance With Guidelines For Ambulatory Surgical Procedures Performed In Place Of Service 21. Claim Reduced Due To Member/participant Spenddown. 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. Prior Authorization (PA) is required for this service. Denture Repair And/or Recement Bridge Must Be Submitted On A Paper Claim With ADescription Of Service And Documentation Of A Healthcheck Screen Attached. This Payment Is To Satisfy The Amount Owed For OBRA Nurse Aid Training. The detail From Date Of Service(DOS) is invalid. Service Denied. NDC is obsolete for Date Of Service(DOS). Service Denied. Pricing Adjustment/ Maximum allowable fee pricing applied. Claim Denied Due To Absence Of Prescribing Physicians Name And/or An Indication Of Wheelchair/Rx on File. Denied. From Date Of Service(DOS) is before Admission Date. Hospital discharge must be within 30 days of from Date Of Service(DOS). NDC- National Drug Code is restricted by member age. Second Surgical Opinion Guidelines Not Met. CPT Code 88305 (Level IV Surgical pathology, gross and microscopic examination) includes different types of biopsies. This Adjustment/reconsideration Request Was Initiated By . The relationship between the Billed and Allowed Amounts exceeds a variance threshold. Adjustment Requested Member ID Change. Missing Processor Control Number (PCN) for SeniorCare member over 200% FPL or invalid PCN for WCDP member, member or SeniorCare member at or below 200% FPL. Denied. Incorrect Liability Start/end DatesOr Dollar Amounts Must Be Corrected Through County Social Services Agency. This service is not payable for the same Date Of Service(DOS) as another service included on the same claim, according to the National Correct Coding Initiative. There are approximately 20 Medicaid Explanation Codes which map to Denial Code 16. Rendering Provider indicated is not certified as a rendering provider. Head imaging in the form of CT scans, MRI or MRA is allowed only when the service is medically reasonable and necessary. Third Other Surgical Code Date is invalid. Procedure code 00942 is allowed only when provided on the same date ofservice as procedure code 57520. Denied. Contact Wisconsin s Billing And Policy Correspondence Unit. Backdating Allowed Only In Cases Of Retroactive Member/provider Eligibility. Comprehension And Language Production Are Age-appropriate. The following table outlines the new coding guidelines. Explanation of Benefit codes (EOBs) Explanation of Benefit (EOB) codes are reported on your remittance statement. Repackaging allowance is not allowed for unit dose NDCs. All Outpatient Services/or Accommodations And Ancillaries Are Denied, Therefore The Total Charge Is Denied. Submitted referring provider NPI in the detail is invalid. This claim is eligible for electronic submission. This claim is a duplicate of a claim currently in process. Ancillary Billing Not Authorized By State. The Member Is Also Involved In A Structured Living And/or Working Arrangement.A Reduction In Day Treatment Hours Is Indicated. Service Fails To Meet Program Requirements. Header Billing Provider used as Detail Performing Provider, Header Performing Provider used as Detail Performing Provider. The Performing Provider Id, Member Id, And Date Of Service(DOS) Must Match The Completion Certificate Received From Ddes. 0; The Member Information Provided By Medicare Does Not Match The Information On Files. Pricing Adjustment/ Usual & Customary Charge (UCC) rate pricing applied. An xray or diagnostic urinalysis is reimbursable only when performed on the same Date Of Service(DOS) and billed on the same claim as the initial office visit. Prescriber Number Supplied Is Not On Current Provider File. Calls are recorded to improve customer satisfaction. Review Billing Instructions. Service not payable with other service rendered on the same date. Physical Therapy, Occupational Therapy Or Speech Therapy Limited To 90 Min PerDay. Revenue code 082X is present on an ESRD claim which also contains revenue code088X (X frequency non equal to 9). The medical record request is coordinated with a third-party vendor. Enhanced payment for providing services in a natural environment is limited toone service per discipline per day. Procedimientos. Resubmit the Claim with the Appropriate Modifier for Provider Type andSpecialty. Has Already Issued A Payment To Your NF For This Level L Screen. BY . Adjustments To Correct Copayment Deductions On date Ranged Claims Are Not Payable. Discharge Diagnosis 3 Is Not Applicable To Members Sex. A new set of Generic Reason codes and statements for Part A, Part B and DME have been added and approved for use across all Prior Authorization (PA), Claim reviews . Surgical Procedure Code is not allowed on the claim form/transaction submitted. This Adjustment Was Initiated By . 1 PC Dispensing Fee Allowed Per Date Of Service(DOS). Unable To Process Your Adjustment Request due to This Claim Is In Post Pay Billing For Third Party Liability Payment. Customer Service Agents are available to answer questions at this toll-free number: Phone: 800-688-6696. This Member Is Involved In Non-covered Services, And Hours Are Reduced Accordingly. To access the training video's in the portal . Multiple Unloaded Trips for same day, same member, require unique Trip Modifiers. LTC hospital bedhold quantity must be equal to or less than occurrence code 75span date range(s). The Total Billed Amount is missing or incorrect. 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 Pregnancy Indicator must be "Y" for this aid code. This National Drug Code Has Diagnosis Restrictions. 51.42 Board Stamp Required On All Outpatient Specialty Hospital Claims For Dates Of Service On Or After January 1, 1986. Dental X-rays Indicate A Dental Cleaning, Followed By Good Dental Care At Home, Would Be Sufficient To Maintain Healthy Gums. You can view these EOBs online by following these steps: Log in to your bcbsm.com account to view your prescriptions coverage. We Have Determined There Were (are) Several Home Health Agencies Willing To Provide Medically Necessary Skilled Nursing Services To This Member. Therapy visits in excess of one per day per discipline per member are not reimbursable. Denied. Denied due to Member Not Eligibile For All/partial Dates. The Rendering Providers taxonomy code is missing in the detail. Denied. Assessment Is Not A Covered Service Unless All Four Components Of Skilled Nursing Are Present: Assessment, Planning, Intervention And Evaluation. Recasing Or Replacement Of Hearing Aid Case Is Limited To Once Per 2 Year Period Per Member Per Provider. Permanent Tooth Restoration/sealant, Limited To Once Every 3 Years Unless Narrative Documents Medical Necessity. This Claim Is Being Returned. Claim Denied. Therefore itIs Not Necessary To Wait The Full 6 Weeks After Extractions Before Taking Denture Impressions. Endurance Activities Do Not Require The Skills Of A Therapist. Value Code 48 And 49 Must Have A Zero In The Far Right Position. Denied. Quantity Would Always Be 00010 If Number Of Pounds Not Indicated. Please Review The Cover Letter Attached To Your Claim, Any Informational Messages, And Provide The Requested Information BeforeResubmitting the Claim. This member is eligible for Medication Therapy Management services. If this is your first visit, be sure to check out the FAQ & read the forum rules.To view all forums, post or create a new thread, you must be an AAPC Member.If you are a member and have already registered for member area and forum access, you can log in by clicking here.If you've forgotten your username or password use our . Condition Code 73 for self care cannot exceed a quantity of 15. Home Health services for CORE plan members are covered only following an inpatient hospital stay. Pricing Adjustment/ Provider Level of Care (LOC) pricing applied. Billing Provider Type and Specialty is not allowable for the Place of Service. Denied. Unable To Process Your Adjustment Request due to Member ID Number On The Claim And On The Adjustment Request Do Not Match. Unable To Process Your Adjustment Request due to Member ID Not Present. Department of Health Services (DHS) Authorized Payment Is Being Withheld Due toa Final Rate Settlement. Member last name does not match Member ID. Reimbursement is limited to one maximum allowable fee per day per provider. WI Can Not Issue A NAT Payment Without A Valid Hire Date. Comprehensive Screens And Individual Components Are Not Payable On The Same Date Of Service(DOS). Restorative Nursing Can Provide Follow-through, Based On Diagnosis Of Long-standing Nature, And The Amount Of Therapy. Part C Explanation of Benefits (EOB) Materials. Claim Paid In Accordance With Family Planning Contraceptive Services Guidelines. and other medical information at your current address. Requires A Unique Modifier. 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 Member is enrolled in Wisconsin or BadgerCare Plus for Date(s) of Service. WellCare 2016 NA_11_16 NA6PROGDE80121E_1116 . A Total Charge Was Added To Your Claim. Service(s) paid at the maximum daily amount per provider per member. First Other Surgical Code Date is invalid. Value Codes 81 And 83, Are Valid Only When Submitted On An Inpatient Claim. Limited to once per quadrant per day. Service Denied. Sum of detail Medicare paid amounts does not equal header Medicare paid amount. Pricing Adjustment/ Ambulatory Surgery pricing applied. Rendering Provider is not a certified provider for Wisconsin Chronic Disease Program. Reimbursement For This Service Is Included In The Transportation Base Rate. Authorizations. Dates of Service reflected by the Quantity Billed for dialysis exceeds the Statement Covers Period. The Service Requested Does Not Correspond With Age Criteria. Adjustment Denied For Insufficient Information. Second Other Surgical Code Date is required. To access the training video's in the portal, please register for an account and request access to your contract or medical group. Birth to 3 enhancement is not reimbursable for place of service billed. Please Bill Appropriate PDP. Service Allowed Once Per Lifetime, Per Tooth. Requested Documentation Has Not Been Submitted. Medicare Disclaimer Code invalid. Claim Is Pended For 60 Days. A more specific Diagnosis Code(s) is required. 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. Emergency Services Indicator must be "Y" or Pregnancy Indicator must be "Y" for this aid code. According To Our Records, The Hospital Has Not Received Prior Authorization For This Surgery. Men. Home Health, Personal Care And Private Duty Nursing Services Are Subject To A Monthly Cap. Multiple Service Location Found For the Billing Provider NPI. Please Contact The Hospital Prior Resubmitting This Claim. This procedure is duplicative of a service already billed for same Date Of Service(DOS). Good Faith Claim Correctly Denied. According to the American Society of Anesthesiologists and the International Spine Intervention Society, minor pain procedures such as epidural steroid injections, epidural blood patch, trigger point injections, sacroiliac joint injection, bursal injections, occipital nerve block and facet injections under most routine circumstances, require only local anesthesia. This Member Is Receiving Concurrent AODA/Psychotherapy Services And Is Therefore Only Eligible For Maintenance Hours. Denied. Please Correct And Resubmit. Referral/treatment Procedures Are Not Payable When Billed With A Complete Refusal Detail. Goals Are Not Realistic To The Members Way Of Life Or Home Situation, And Serve No Functional Or Maintenance Service. HMO Payment Equals Or Exceeds Hospital Rate Per Discharge. Supplemental Payment Authorized By Department of Health Services (DHS) Due to a Department Of Justice Settlement. Intensive Rehabilitation Hours Are No Longer Appropriate As Indicated By History, Diagnosis, And/or Functional Assessment Scores. Providers should submit adequate medical record documentation that supports the claim (services) billed. Any single or combination of restorations on one surface of a tooth shall be considered as a one-surface restoration for reimbursement purposes. This HMO Capitation Payment Is Being Recouped It Was Inappropriately Paid During The Inital February HMO Capitation Cycle. Laboratory Is Not Certified To Perform The Procedure Billed. This level not only validates the code sets , but also ensures the usage is appropriate for any This CNAs Social Security Number, SSN, Is Not On The EDS Nurse Aide Registry File. Always bill the correct place of service. Denied due to Detail Dates Are Not Within Statement Covered Period. Denied. Your Adjustment/reconsideration Request For Additional Payment Has Been Denied, Request Was Received Beyond The 90 Day Requirement For Payment Reconsideration. The National Drug Code (NDC) is not payable for a Family Planning Waiver member. This Check Automatically Increases Your 1099 Earnings. One or more Surgical Code Date(s) is invalid in positions seven through 24. Timely Filing Deadline Exceeded. Other Insurance Disclaimer Code Invalid. Good Faith Claim Denied For Timely Filing. Claim cannot contain both Condition Codes A5 and X0 on the same claim. Reason Code 159: State-mandated Requirement for Property and Casualty, see Claim Payment Remarks Code for specific explanation. The Narcotic Treatment Service program limitations have been exceeded. Good Faith Claim Denied Because Of Provider Billing Error. Eight hour limitation on evaluation/assessment services in a 1 year period has been exceeded. RN Home Health visits and Supervisory visits are not reimbursable on the same Date Of Service(DOS) for same provider. The To Date Of Service(DOS) for the First Occurrence Span Code is required. Capitation Payment Recouped Due To Member Disenrollment. Dosings for Narcotic Treatment Service program are limited to six per Sunday thru Saturday calendar week. 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. A six week healing period is required after last extraction, prior to obtaining impressions for denture. Referring Provider ID is not required for this service. Effective 04/01/09, the BadgerCare Plus Core Plan will limit coverage for Brochodilators-Beta Agonists to Proventil HFA and Serevent. The respiratory care services billed on this claim exceed the limit. Please Refer To The PDL For Preferred Drugs In This Therapeutic Class. Submit Claim To For Reimbursement. Denied. ACTION DESCRIPTION: ACTION TYPE. The Timeframe Between Certification, Test, Date And Hire Date Exceeds A Year. Claim Denied For Invalid Diagnosis Code Or Diagnosis Code/CPT Combination. Reimbursement of this service is included in the reimbursement of the most complex/complete procedure performed. Homecare Services W/o PA Are Not Payable When Prior Authorized Homecare Services have Been Provided To The Same Member. Abortion Dx Code Inappropriate To This Procedure. Please Re-submit This Claim With The Insurance EOB Showing A Denial OrPartial Payment. 1. Please Furnish A Breakdown Of Your Procedure Code And Charge In Question GivenOn The Adjustment/reconsideration Request. A valid Prior Authorization is required. Personal Care Services Exceeding 30 Hours Per 12 Month Period Per Member Require Prior Authorization. Benefit Payment Determined By Fiscal Agent Review. Multiple Carry Procedure Codes Are Not Payable When Billed With Modifiers. Edentulous Alveoloplasty Requires Prior Authotization. Denied. For Revenue Code 0820, 0821, 0825 or 0829, HCPCS Code 90999 or Modifier G1-G6 must be present. Modifier Invalid: Modifiers Are No Longer Allowed For Procedure Code Billed. Our Records Indicate You Have Billed More Than One Unit Dose Dispensing Fee For This Calendar Month. Certifying Agency Did Not Verify Member Eligibility within 70 Day Period. Reimbursement For IUD Insertion Includes The Office Visit. Invalid modifier removed from primary procedure code billed. This service is payable at a frequency of once per 12-month period, per provider, per hearing aid. Reimbursement Based On Members County Of Residence. Inpatient psychiatric services are not reimbursable for members age 21 65 (age 22 if receiving services prior to 21st birthday). Claim Reduced Due To Member/participant Deductible. The Related Surgical Procedure is not a covered service under Wisconsin Medicaid or BadgerCare Plus. Claimchecks Editing And Your Supporting Documentation Was Reviewed By The DHS Medical Consultant. Correct Claim Or Resubmit With X-ray. Continue ToUse Appropriate Codes On Billing Claim(s). The Processor Control Number (PCN) for SeniorCare member over 200% FPL is missing, or the PCN is invalid for a WCDP member, member or SeniorCare member at or below 200% FPL. Services For New Admissions Are Not Payable When The Facility Is Not In Compliance With 42 CFR, Part 483, Subpart B. Number On Claim Does Not Match Number On Prior Authorization Request. Pharmaceutical care code must be billed with a valid Level of Effort. The Information Provided Is Not Consistent With The Intensity Of Services Requested. Please show the appropriate multichanel HCPCS code rather than the individual HCPCS code. Day Treatment Services For Members With Inpatient Status Limited To 20 Hours. This Program Does Not Appear To Meet The Minimum Requirement For AODA Day Treatment Programming (10hrs) And Does Not Qualify For Aoda Day Treatment. This Claim Has Been Excluded From Home Care Cap To Allow For Acute Episode. Timely Filing Deadline Exceeded. Do Not Indicate NS On The Claim When The NDC Billed Is For A Generic Drug. Denied. This Claim Is Being Reprocessed As An Adjustment On This R&s Report. Submitted rendering provider NPI in the detail is invalid. Out-of-State non-emergency services require Prior Authorization. The Procedure Code has Diagnosis restrictions. A Previously Submitted Adjustment Request Is Currently In Process. Only One Panel Code Within Same Category (CBC Or Chemistry) Maybe Performed Per Member/Provider/Date Of Service. Payment Recouped. A Payment For The CNAs Competency Test Has Already Been Issued. is unable to is process this claim at this time. Modifiers are required for reimbursement of these services. The Service(s) Requested Could Be Adequately Performed With Local Anesthesia In The Dental Office. Service(s) paid in accordance with program policy limitation. Denied. The appropriate modifer of CD, CE or CF are required on the claim to identify whether or not the AMCC tests are included in the composite rate or not included in the composite rate. The Rendering Providers taxonomy code in the detail is not valid. Header Rendering Provider number is not found. If Required Information Is not received within 60 days, the claim detail will be denied. Dispense as Written indicator is not accepted by . Member is not enrolled for the detail Date(s) of Service. A dispense as written indicator is not allowed for this generic drug. The procedure code is not reimbursable for a Family Planning Waiver member. The Information Provided Indicates Regression Of The Member. CO/204/N30. Policy override must be granted by the Drug Authorization and Policy Override Center to dispense less than a 100 day supply. Rqst For An Acute Episode Is Denied. Member is assigned to a Lock-in primary provider. Please Verify That Physician Has No DEA Number. One or more Date(s) of Service is missing for Occurrence Span Codes in positions 9 through 24. Panel And Individual Test Not Payable For Same Member/Provider/ Date Of Service(DOS). Claim Explanation Codes. Use Of Therapy Equipment Alone Is Not Sufficient To Justify Maintenance Therapy. No Complete WWWP Participation Agreement Is On File For This Provider.

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