Gastrointestinal Surgery For The Purpose Of Weight Control Is Covered Only As An Emergency Procedure. Denied. The CNA Is Only Eligible For Testing Reimbursement. Pricing Adjustment/ Payment reduced due to the inpatient or outpatient deductible. Header Rendering Provider number is not found. One or more Diagnosis Code(s) in positions 10 through 25 is not on file. Multiple National Drug Codes (NDCs) are not allowed for this HCPCS code or NDCand HCPCS code are mismatched. Six Week Healing Time Is Required Between Endentulation And Final Impressions.Payment For Dentures Will Be Denied Or Recouped If Healing Period Is Not Observed. Payment Recovered For Claim Previously Processed Under Wrong Member ID Number. paul pion cantor net worth. Valid Numbers AreImportant For DUR Purposes. Does not reimburse both the global service and the individual component parts of the service for the same Date Of Service(DOS). A covered DRG cannot be assigned to the claim. Member ID has changed. Member is in a divestment penalty period. This claim/service is pending for program review. The Revenue code on the claim requires Condition code 70 to be present for this Type of Bill. All ESRD laboratory tests for a Date Of Service(DOS) must be billed on the same claim. Please Resubmit using A Approved CPT Or HCPCS Procedure Code. Reason Code Remark Code(s) Denial Denial Description; 16: M51 | N56: Your Adjustment/reconsideration Request For Additional Payment Has Been Denied, Request Was Received Beyond The 90 Day Requirement For Payment Reconsideration. NFs Eligibility For Reimbursement Has Expired. Revenue code billed with modifier GL must contain non-covered charges. Other Insurance/TPL Indicator On Claim Was Incorrect. These Supplies/items Are Included In The Purchase Of The Dme Item Billed On The Same Date Of Service(DOS). Independent Laboratory Provider Number Required. A NAT Reimbursement Request Must Be Submitted To WI Within A Year Of The CNAs Hire Date. Revenue Codes 0110 (N6) And 0946 (N7) Are Not Payable When Billed On The Same Dateof Service As Bedhold Days. Member is not enrolled in /BadgerCare Plus for the Date(s) of Service. Pricing Adjustment/ Level of effort dispensing fee applied. Claim Is For A Member With Retro Ma Eligibility. THE WELLCARE GROUP OF COMPANIES . Dental X-rays Indicate A Dental Cleaning, Followed By Good Dental Care At Home, Would Be Sufficient To Maintain Healthy Gums. Member has Medicare Managed Care for the Date(s) of Service. Claim date(s) of service modified to adhere to Policy. If you are having difficulties registering please . The Documentation Submitted Indicates The Tasks Specified Can Be Completed During The Visits Approved. DME rental beyond the initial 30 day period is not payable without prior authorization. Invalid quantity for the National Drug Code (NDC) submitted with this HCPCS code. 12/06/2022 . A WCDP drug rebate agreement for this drug is not on file for the Date Of Service(DOS). RN Home Health visits and Supervisory visits are not reimbursable on the same Date Of Service(DOS) for same provider. 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. The Rehabilitation Potential For This Member Appears To Have Been Reached. One or more Surgical Code(s) is invalid in positions six through 23. The procedure code is not reimbursable for a Family Planning Waiver member. Dispensing Two Lens Replacements On Same Date Of Service(DOS) Not Allowed. No Complete Program Enrollment Form Is On File For This Client Or The Client Is Not Eligible For The Date Of Service(DOS) On The Clai im. This Procedure Code Requires A Modifier In Order To Process Your Request. SeniorCare member enrolled in Medicare Part D. Claim is excluded from Drug Rebate Invoicing. This Is Not A Good Faith Claim. If you are still unable to resolve the login problem, read the troubleshooting steps or report your issue. Physical Therapy Limited To 45 Treatment Days Per Spell Of Illness W/o Prior Authorization. This diabetic supply has been paid under an equivalent code on this Date Of Service(DOS). Pricing Adjustment/ Prior Authorization pricing applied. Timely Filing Deadline Exceeded. Details Include Revenue/surgical/HCPCS/CPT Codes. Calls are recorded to improve customer satisfaction. Header Bill Date is before the Header From Date Of Service(DOS). Home Health Services In Excess Of 60 Visits Per Calendar Month Per Member Required Prior Authorization. Purchase Of A DME/DMS Item Exceeding One Per Month Requires Prior Authorization. Denied. No Complete WWWP Participation Agreement Is On File For This Provider. The provider enters the appropriate revenue codes to identify specific accommodation and/or ancillary charges. For Review, Forward Additional Information With R&S To WCDP. Individual Replacements Reimbursed As Dispensing A Complete Appliance. Value Codes 81 And 83, Are Valid Only When Submitted On An Inpatient Claim. Occupational Therapy Limited To 35 Treatment Days Per Spell Of Illness W/o Prior Authorization. Dates of Service reflected by the Quantity Billed for dialysis exceeds the Statement Covers Period. Please Furnish A UB92 Revenue Code And Corresponding Description. Training Completion Date Must Be Prior To And Within A Year Of The CNAs Certification Date. To better assist you, please first select your state. Multiple Screens Performed Within A Fifteen Day Time Frame For This SSN. These Urinalysis Procedures Reimbursed Collectively At The Maximum For Routine Urinalysis With Microscopy. Pricing Adjustment/ Maximum Flat Fee Level 2 pricing applied. Denied. The From Date Of Service(DOS) for the First Occurrence Span Code is invalid. Prior authorization is required for Maxalt when Maxalt or sumatriptan productshave not been reimbursed within 365 days. Nine Digit DEA Number Is Missing Or Incorrect. One or more Diagnosis Codes has a gender restriction. Unable To Process Your Adjustment Request due to. This Member, As Indicated By Narrative History, Does Not Agree To Abstinence from Alcohol Or Other Drugs And Is Ineligible For AODA Treatment. Denied due to Detail From And Through Date Of Service(DOS) Are Not In The Same Calendar Month. Reason Code 234 | Remark Codes N20. Recd Beyond 90 Days Special Filing Deadline FOr System Generated Adjmts/Medicare X-overs/Other Insurance Reconsideration/Cou rt Order/Fair Hearing. Admit Diagnosis Code is invalid for the Date(s) of Service. Payment Is Limited To One Unit Dose Service Per Calendar Month, Per Legend Drug, Per Member. Inpatient Respite Care Is Not Covered For Hospice Members Residing In Nursing Homes. No Extractions Performed. 51.42 Board Directors Or Designees Statement & Signature Required OnThe Claim Form For Payment Of Functional Assessment. Providers May Only Bill For Assessments And Care Plans Twice Per Calendar Year. Payment For Immunotherapy Service Included In Reimbursement For Allergy Extract Injection. NDC is obsolete for Date Of Service(DOS). Claim Denied/Cutback. There are approximately 20 Medicaid Explanation Codes which map to Denial Code 16. Information Required For Claim Processing Is Missing. If it is medically necessary to exceed the limitation, submit an Adjustment/Reconsideration request with supporting documentation. Whenever claim denied with CO 197 denial code, we need to follow the steps to resolve and reimburse the claim from insurance company: First step is to verify the denial reason and get the denial date. The Existing Appliance Has Not Been Worn For Three Years. An ICD-9-CM Diagnosis Code of greater specificity must be used for the Eighth Diagnosis Code. Resubmit charges for covered service(s) denied by Medicare on a claim. Name And Complete Address Of Destination. Please Review All Provider Handbook For Allowable Exception. Pricing Adjustment/ Ambulatory Payment Classification (APC) pricing applied. Quantity submitted matches original claim. Service Paid At The Maximum Amount Allowed By ReimbursementPolicies. Please Add The Coinsurance Amount And Resubmit. 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 . Rendering Provider is not a certified provider for Wisconsin Well Woman Program. Service Denied. We encourage you to take advantage of this easy-to-use feature. CORE Plan Members are limited to 25 non-emergency outpatient hospital visits per enrollment year. Additional Psychotherapy Is Not Considered Appropriate Or Inline With More Effective, Available Services. A Qualified Provider Application Is Being Mailed To You. Explanation of Benefits (EOB) The four-digit explanation of benefits (EOB) codes and the corresponding narratives indicate that the submitted claim paid as billed or describe the reason the claim suspended, was denied, or did not pay in full. We Are Recouping The Payment. For example, a claim from a physician provider with place of service 11 (Office) would be considered incorrectly coded when a claim from an outpatient facility (e.g. Claim Denied For No Provider Agreement On File Or Not Certified For Date Of Service(DOS). An Approved AODA Day Treatment Program Cannot Exceed A 6 Week Period. This Payment Is A Refund For An Overpayment Of A Provider Assessment, Thank You For Your Assessment Payment By Check, In Accordance With Your Request, EDS Has Deducted Your Assessment From This Payment. One BMI Incentive payment is allowed per member, per renderingprovider, per calendar year. Claim paid at the program allowed amount. The Primary Occurrence Code Date is invalid. For Newly Certified CNAs, Date Of Inclusion Is T heir Test Date. Only the initial base rate is payable when waiting time is billed in conjunction with a round trip. A Primary Occurrence Code Date is required. Provider Reminders: Claims Definitions. Claim Denied. 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. To access the training video's in the portal, please register for an account and request access to your contract or medical group. Other Payer Date can not be after claim receipt date. WellCare_Consult_ManagedProcedureCodeList_2023_20221222 Page 2 of 7 Remote afterloading high dose rate radionuclide interstitial or intracavitary brachytherapy, includes An ICD-9-CM Diagnosis Code of greater specificity must be used for the Fourth Diagnosis Code. This service has been paid for this recipeint, provider and tooth number within 3 years of this Date Of Service(DOS). PLEASE RESUBMIT CLAIM LATER. As A Reminder, This Procedure Requires SSOP. Claim Detail Is Pended For 60 Days. Staywell is committed to continually improving its claims review and payment processes. Denied due to NDC Is Not Allowable Or NDC Is Not On File. Time Spent In AODA Day Treatment By Affected Family Members Is Not Covered. Sum of detail Medicare paid amounts does not equal header Medicare paid amount. CNAs Eligibility For Nat Reimbursement Has Expired. This Claim Is Being Reprocessed As An Adjustment On This R&s Report. Rendering Provider is not a certified provider for . The Surgical Procedure Code of greatest specificity must be used. Diagnosis Codes Assigned Must Be At The Greatest Specificity Available. Do not resubmit. A Valid Level Of Effort Is Required For Billing Compound Drugs Or Pharmaceutical Care. CO/96/N216. These Individual Vaccines Must Be Billed Under The Appropriate Combination Injection Code. This Service Is Included In The Hospital Ancillary Reimbursement. One or more Diagnosis Code(s) is invalid in positions 10 through 25. Denied. Reimbursement limit for all adjunctive emergency services is exceeded. Documentation Indicates That Client Is Able To Direct Cares And Can Safely Direct A PCW. Diagnosis Code is restricted by member age. The Screen Date Must Be In MM/DD/CCYY Format. Member has Medicare Supplemental coverage for the Date(s) of Service. The total of amounts billed for the DOS on the claim exceeds the allowed dailylimit for PDN services. Plan options will be available in 25 states, including plans in Missouri . Individual Audiology Procedures Included In Basic Comprehensive Audiometry. FL 44 HCPCS/Rates/HIPPS Rate Codes Required. Ongoing assessment is not reimbursable when skilled nursing visits have been performed within the past sixty days. Payment Reduced Due To Patient Liability. Rn Visit Every Other Week Is Sufficient For Med Set-up. Prior Authorization Is Required For Payment Of Hospital Exceptional Claims. Admission Date does not match the Header From Date Of Service(DOS). The Revenue Code is not reimbursable for the Date Of Service(DOS). Resubmit Claim With Corrected Tooth Number/letter Or With X-ray Documenting Tooth Placement. Incorrect Or Invalid National Drug Code Billed. Condition code 80 is present without condition code 74. Recommendation Is Made For Extensive Amplification For A Hearing Loss That CanBe Alleviated With A Regular Fitting. Intermittent Peritoneal Dialysis hours must be entered for this revenue code. Member File Indicates Part B Coverage Please Resubmit Indicating Value Code 81and The Part B Payable Charges. Tooth number or letter is not valid with the procedure code for the Date Of Service(DOS). The service requested is not allowable for the Diagnosis indicated. Watch FutureRemittance And Status Reports For Its Finalization Before Resubmitting. Service(s) paid in accordance with program policy limitation. Claims may deny when reported and not meeting the ICD-10-CM Laterality policy for Diagnosis-to-Diagnosis comparison. Either The Date Was Not In MM/DD/CCYY Format Or Its AFuture Date. The topic of Requirements for Compression Garments can be found in the Claims Section, Submission Chapter. Type of Bill is invalid for the claim type. The Diagnosis Code is not payable for the member. HMO Extraordinary Claim Denied. Medically Unbelievable Error. Revenue code 0850 thru 0859 is not allowed when billed with revenue codes 0820thru 0829, 0830 thru 0839, or 0840 thru 0849. No More Than 2 Medication Check Services (30 Minutes) Are Payable Per Date Of Service(DOS). Pricing Adjustment/ Prescription reduction applied. Member Name Missing. FFS CLAIM PROFESSIONAL ASC X12N VERSION . Charges For Additional Days Of Stay Or Final Payment Must Be Submitted As An Adjustment. Please Clarify. Type of Bill indicates services not reimbursable or frequency indicated is notvalid for the claim type. OA 11 The diagnosis is inconsistent with the procedure. An ICD-9-CM Diagnosis Code of greater specificity must be used for the Second Diagnosis Code. No Action Required on your part. The Service Requested Is Covered By The HMO. The Medical Need For Some Requested Services Is Not Supported By Documentation. Please Clarify Services Rendered/provide A Complete Description Of Service. The Ninth Diagnosis Code (dx) is invalid. Denied/Cutback. Denied. Default Prescribing Physician Number XX5555555 Was Indicated. The Service Requested Is Inappropriate For The Members Diagnosis. The Reimbursement Code Assigned To This Certification Segment Does Not Authorize a Training Payment. Diagnosis of malignancies and inflammatory conditions frequently requires numerous biopsies of a particular organ or suspicious site. Please Correct And Resubmit. From Date Of Service(DOS) is before Admission Date. The three key components when selecting the appropriate level of E&M services provided are history, examination, and medical decision-making. Home Health, Personal Care And Private Duty Nursing Services Are Subject To A Monthly Cap. All services should be coordinated with the Inpatient Hospital provider. Only Healthcheck Modifiers Can Be Billed With Healthcheck Services. Non-covered Charges Are Missing Or Incorrect. Transplants and transplant-related services are not covered under the Basic Plan. This Claim Is Being Returned. One or more Condition Code(s) is invalid in positions eight through 24. Submitclaim to the appropriate Medicare Part D plan. Denied. Received Beyond Special Filing Deadline For ThisType Of Claim Or Adjustment/reconsideration. Timely Filing Deadline Exceeded. An antipsychotic drug has recently been dispensed for this member. The Timeframe Between Certification, Test, Date And Hire Date Exceeds A Year. A Reimbursement Request For A Level I Screen Must Be Received At Within A Year Of The Screen Date. Serviced Denied. Part A Reason Codes are maintained by the Part A processing system. Multiple Providers Of Treatment Are Not Indicated For This Member. Services Beyond The Six Week Postpartum Period Are Not Covered, Per DHS. Prospective DUR denial on original claim can not be overridden. When diagnoses 800.00 through 999.9 are present, an etiology (E-code) diagnosis must be submitted in the E-code field. Fifth Diagnosis Code (dx) is not on file. Resubmit Claim With Copyof A Temporary ID Card, EVS Printed Response Or Indicate The AVR Transaction Log Number. When coding HCPCS for outpatient services, the provider enters the HCPCS code describing the procedure. 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. This Claim Has Been Manually Priced Based On Family Deductible. All services should be coordinated with the Hospice provider. Billing Provider is not certified for the Date(s) of Service. More Than 5 Consecutive Calendar Days Of Continuous Care Are Not Payable. Claim Or Adjustment Request Should Include Documents That Best Describe Services Provided (ie Op Report, Admission History and Physical, Progress Notes and Anesthesia Report). 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. . An ICD-9-CM Diagnosis Code of greater specificity must be used for the Diagnosis Code in posistion 10 through 24. Denied. Unable To Process Your Adjustment Request due to A Different Adjustment Is Pending For This Claim. One or more Surgical Code Date(s) is missing in positions seven through 24. Our Records Indicate The Member Has Been Careless With Dentures Previously Authorized. The Revenue Code is not payable by Wisconsin Chronic Disease Program for the Date(s) of Service. Reimbursement Rate Applied To Allowed Amount. Explanation of benefits. Payment(s) For Capital Or Medical Education Are Generated By EDS And May Not Be Billed By The Provider. 1 PC Dispensing Fee Allowed Per Date Of Service(DOS). The Narrative History Does Not Indicate the Members Functioning is Impaired due To AODA Usage. Election Form Is Not On File For This Member. Please Select A Procedure Code In The 58980-58988 Range That Best Describes The Procedure Being Performed. Dollar Amount Of Claim Was Adjusted To Correct Mathematical Error. The drug code has Family Planning restrictions. Complete Refusal Detail Is Not Payable Without Referral/treatment Details. Ancillary Billing Not Authorized By State. Denied. Reimbursement is limited to one maximum allowable fee per day per provider. Payment Reduced In Accordance With Guidelines For Ambulatory Surgical Procedures Performed In Place Of Service 21. 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. NDC- National Drug Code is invalid for the Dispense Date Of Service(DOS). The diagnosis code on the claim requires Condition code A6 be present on the Type of Bill. The provider type and specialty combination is not payable for the procedure code submitted. Service not covered as determined by a medical consultant. Admission Denied In Accordance With Pre-admission Review Criteria. The Member Was Not Eligible For On The Date Received the Request. Member eligibility file indicates that BadgerCare Plus Benchmark, CorePlan or Basic Plan member. Reimbursement For This Certification, Test, Segment Has Already Been Issued ToYour NF. The Other Payer Amount Paid qualifier is invalid for . This Payment Is To Satisfy The Amount Indicated On The Administrative Claiming Reimbursement Summary Report. Use This Claim Number If You Resubmit. Newsroom. Auditory Screening with Preventive Medicine Visits. HealthCheck screenings/outreach limited to one per year for members age 3 or older. Missing or invalid level of effort submitted and/or reason for service, professional service, or result of service code billed in error. TPA Certification Required For Reimbursement For This Procedure. This Member Has A Current Approved Authorization For Intensive AODA OutpatientServices. The Medical Need For This Service Is Not Supported By The Submitted Documentation. Pricing Adjustment/ Ambulatory Surgery pricing applied. Billed Amount Is Greater Than Reimbursement Rate. Procedue Code is allowed once per member per calendar year. Policy override must be granted by the Drug Authorization and Policy Override Center to dispense less than a 100 day supply. Condition Code 73 for self care cannot exceed a quantity of 15. Medicare Copayment Out Of Balance. Denied. The Tooth Is Not Essential For Support Of A Partial Denture. The Second Other Provider ID is missing or invalid. Excessive height and/or weight reported on claim. Denied. Revenue Code 0001 Can Only Be Indicated Once. 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. 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. . The detail From Date Of Service(DOS) is invalid.