12/06/2022 . Do Not Bill Intraoral Complete Series Components Separately. Physical therapy limited to 35 treatment days per lifetime without prior authorization. This Request Can Only Be Backdated To The Date EDS First Receives The Request In The Mailroom. The Service Requested Does Not Correspond With Age Criteria. If correct, special billing instructions apply. Payment Reduced Due To Patient Liability. Cannot bill for both Assay of Lab and other handling/conveyance of specimen. Denied by Claimcheck based on program policies. A discrepancy exists between the Other Coverage Indicator and the Other Paid Amount. The detail From Date Of Service(DOS) is invalid. Claim count of Present on Admission (POA) indicators does not match count of non-admitting and non-emergency diagnosis codes. Training Completion Date Must Be Prior To And Within A Year Of The CNAs Certification Date. ACode With No Modifier Billed On The Same Day As A Code With Modifier 11 Are Viewed as the same trip. This Member Does Not Appear To Be Suffering From A Chronic Or Acute Mental Illness And Is Therefore Not Eligible For Day Treatment. Please Do Not File A Duplicate Claim. CPT Or CPT/modifier Combination Is Not Valid On This Date Of Service(DOS). Claim Denied. Correct Claim Or Submi Paper Claim Noting That Verification Has Occurred. -OR- The claim contains value code 48, 49, or 68 but does not contain revenue codes 0634 or 0635. Diagnosis Indicated Is Not Allowable For Procedures Designated As Mycotic Procedures. Claim Denied. Allowed Amount On Detail Paid By WWWP. Lab Procedures Billed In Conjunction With Family Planning Pharmacy Visit Denied as not a Benefit. Discharge Diagnosis 4 Is Not Applicable To Members Sex. BY . Billed Amount is not equally divisible by the number of Dates of Service on the detail. Individual Vaccines And Combination Vaccine Code May Not Be Billed For The Same Dates Of ervice. Denied/Cutback. This claim is being denied because it is an exact duplicate of claim submitted. Department of Health Services (DHS) Authorized Payment Is Being Withheld Due toan Interim Rate Settlement. Pricing Adjustment/ Traditional dispensing fee applied. Denied. A HCPCS code is required when condition code A6 is included on the claim. As a provider, you have access to a portal that streamlines your work, keeps you up-to-date more than ever before and provides critical information. A valid Prior Authorization is required. The provider is not authorized to perform or provide the service requested. The Non-contracted Frame Is Not Medically Justified. Department of Health Services (DHS) Authorized Payment Is Being Withheld Due toa Department Of Justice Settlement. Medicare Coinsurance Amount Was Not Provided On Crossover Claim. Ability to proficiently use Microsoft Excel, Outlook and Word. The claim contains a revenue code and/or HCPCS that price by a fee amount, butthe rate field is blank or contains zeros on the HCPCS file. The Fourth Occurrence Code Date is invalid. NDC was reimbursed at AWP (Average Wholesale Price) (Average Wholesale Price) rate. One or more Occurrence Span Code(s) is invalid in positions three through 24. A covered DRG cannot be assigned to the claim. Claim Number Given On The Adjustment/reconsideration Request Form Does Not Match Services Originally Billed. This change to be effective 4/1/2008: Submission/billing error(s). Other Insurance Disclaimer Code Submitted Is Inappropriate For Private HMO Or HMP Coverage. Transplant services not payable without a transplant aquisition revenue code. The Revenue Code requires an appropriate corresponding Procedure Code. The Tooth Is Not Essential For Support Of A Partial Denture. Billed Amount Is Greater Than Reimbursement Rate. Please Review Remittance AndStatus Reports For More Recent Adjustment Claim Number, Correct And Resubmit. If you are still unable to resolve the login problem, read the troubleshooting steps or report your issue. This Modifier has been discontinued by CMS or AMA for the Date Of Service(DOS)(s). WellCare Known Issues List EOP Denial Code or Rejection Reason Code Issue Description Impacted Provider Specialty . Our Records Indicate You Have Billed More Than One Unit Dose Dispensing Fee For This Calendar Month. PDN services billed on this claim exceed 12 hours/day per nurse, PDN services billed on this claim exceed 60 hours/week per nurse, PDN services billed on this claim exceed 24 hours/day per member. Dosings for Narcotic Treatment Service program are limited to six per Sunday thru Saturday calendar week. Rendering Provider is not a certified provider for . Denied due to The Member WCDP Id Number Is Incorrect Or Not On Our Current Eligibility File. The Member Is Also Involved In A Structured Living And/or Working Arrangement.A Reduction In Day Treatment Hours Is Indicated. Care Does Not Meet Criteria For Complex Case Reimbursement. This HMO Capitation Payment Is Being Recouped It Was Inappropriately Paid During The Inital February HMO Capitation Cycle. Compound drugs require a minimum of two components with at least one payable FowardHealth covered drug. The Functional Assessment And/or Progress Status Report Does Not Indicate Any Change, and/or Positive Rehabilitation Potential. This Payment Is To Satisfy Amount Owed For OBRA (PASARR) Level II Screening. Claim Denied. codes are provided per day by the same individual physician or other health care professional. This Service Is Included In The Hospital Ancillary Reimbursement. Normal delivery reimbursement includes anesthesia services. If A CNA Obtains his/her Certification After Theyve Been Hired By A NF, A NF Has A Year From Their Certification, Test, Date To Submit A Reimbursement Request To . OA 14 The date of birth follows the date of service. Check Your Current/previous Payment Reports forPayment. Denied. The Diagnosis Code Is Not Valid On This Date Of Service(DOS). Refer To Your Pharmacy Handbook For Policy Limitations. Member Name Missing. THE WELLCARE GROUP OF COMPANIES . If required information is not received within 60 days, the claim will be. Documentation You Have Submitted Does Not Meet The Requirements Of HSS 107.09(4)(k). This Is A Duplicate Request. The Total Number Of Sessions Requested Exceeds Quarterly Guidelines. Reimbursement rate is not on file for members level of care. Discharge Diagnosis 5 Is Not Applicable To Members Sex. Denied. Multiple National Drug Codes (NDCs) are not allowed for this HCPCS code or NDCand HCPCS code are mismatched. Valid Numbers Are Important For DUR Purposes. Denied. Reimbursement Is Limited To The Average Monthly Nursing Home Cost And Services Above That Amount Are Considered Non-covered Services. Assessment Is Not A Covered Service Unless All Four Components Of Skilled Nursing Are Present: Assessment, Planning, Intervention And Evaluation. Claims may deny when reported and not meeting the ICD-10-CM Laterality policy for Diagnosis-to-Diagnosis comparison. Procedure Not Payable for the Wisconsin Well Woman Program. NDC- National Drug Code is not allowed for the member on the Date Of Service(DOS). Earn Money by doing small online tasks and surveys, What is Denials Management in Medical Billing? . Purchase of a blood glucose monitor includes the first 30 days of supplies for the monitor. Because a claim can have edits and audits at both the header and detail levels, EOB codes are listed . Please Rebill Only CoveredDates. Personal Care Services Exceeding 30 Hours Per 12 Month Period Per Member Require Prior Authorization. Department of Health Services (DHS) Authorized Payment Is Being Withheld Due toan Audit. These materials include the HPMS memorandum titled, "Updates Regarding Final Part C EOB Model Templates and Implementation of the Part C EOB," the final templates and instructions, and Frequently Asked Questions regarding the Part C EOB requirements for Medicare Advantage . Do Not Submit Claims With Zero Or Negative Net Billed. All three DUR fields must indicate a valid value for prospective DUR. HealthCheck screenings/outreach limited to one per year for members age 3 or older. Occupational Therapy Limited To 35 Treatment Days Per Spell Of Illness W/o Prior Authorization. Pricing Adjustment/ Level of effort dispensing fee applied. A Pharmaceutical Care Code (PCC) must include a valid diagnosis code. Member is enrolled in Medicare Part D for the Dispense Date Of Service(DOS). Please Furnish A Breakdown Of Your Procedure Code And Charge In Question GivenOn The Adjustment/reconsideration Request. Provider Not Eligible For Outlier Payment. Abortion Dx Code Inappropriate To This Procedure. Resubmit the Claim with the Appropriate Modifier for Provider Type andSpecialty. Please Select A Procedure Code In The 58980-58988 Range That Best Describes The Procedure Being Performed. Other Payer Coverage Type is missing or invalid. Claim Is Pended For 60 Days. Personal Care In Excess Of 250 Hrs Per Calendar Year Requires Prior Authorization. Reimbursement determination has been made under DRG 981, 982, or 983. Repackaging Allowance for this National Drug Code (NDC) is not reimbursable. Members do not have to wait for the post office to deliver their EOB in a paper format. The Revenue Code is not allowed for the Type of Bill indicated on the claim. Level Of Care/accommodation Code Billed Is Not Applicable To Your Provider Specialty. Independent Laboratory Provider Number Required. The following are the most common reasons HCFA/CMS-1500 and UB/CMS-1450 paper claims for Veteran care are rejected: Requires the 17 alpha-numeric internal control number (ICN) [format: 10 digits + "V" + 6 digits] or 9-digit social security number (SSN) with no special characters. To allow for Medicare Pricing correct detail denials and resubmit. This service was previously paid under an equivalent Procedure Code. Please Disregard Additional Informational Messages For This Claim. A Primary Occurrence Code Date is required. The Number Of Weeks Has Been Reduced Consistent With Goals And Progress Documented. The National Drug Code (NDC) was reimbursed at a generic rate. Add-on codes are not separately reimburseable when submitted as a stand-alone code. Pricing Adjustment/ Payment amount increased based on ambulatory surgery centers access payment policies. Service Denied. Requests For Training Reimbursement Denied Due To Late Billing. Pharmacuetical care limitation exceeded. Diag Restriction On ICD9 Coverage Rule edit. Mail-to name and address - We mail the TRICARE EOB directly to. Please Supply Modifier Code(s) Corresponding To The Procedure Code Description. Member enrolled in Tuberculosis-Related Services Only Benefit Plan. Non-covered Charges Are Missing Or Incorrect. The detail From Date Of Service(DOS) is required. Other Medicare Part B Response not received within 120 days for provider basedbill. Denied. Voided Claim Has Been Credited To Your 1099 Liability. The procedure code has Family Planning restrictions. All Outpatient Services/or Accommodations And Ancillaries Are Denied, Therefore The Total Charge Is Denied. The Surgical Procedure Code is not payable for /BadgerCare Plus for the Date Of Service(DOS). Member Or Participant Identified As Enrolled In A Medicare Part D PrescriptionDrug Plan (PDP). Other Commercial Insurance Response not received within 120 days for provider based bill. This Claim Has Been Denied Due To A POS Reversal Transaction. flora funeral home rocky mount va. Jun 5th, 2022 . The Services Requested Do Not Meet Criteria For An Acute Episode. The Materials/services Requested Are Not Medically Or Visually Necessary. 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. Reimbursement For This Certification, Test, Segment Has Already Been Issued ToYour NF. Please Do Not Resubmit Your Claim, And Disregard Additional Informational Messages for this claim. We update the Code List to conform to the most recent publications of CPT and HCPCS . The Ninth Diagnosis Code (dx) is invalid. Request Denied Because The Screen Was Done More Than 90 Days Prior To The Admission Date. The Member Was Not Eligible For On The Date Received the Request. Denied. Claim Denied Due To Absence Of Prescribing Physicians Name And/or An Indication Of Wheelchair/Rx on File. This Member Is Receiving Concurrent AODA/Psychotherapy Services And Is Therefore Only Eligible For Maintenance Hours. Gastrointestinal Surgery For The Purpose Of Weight Control Is Covered Only As An Emergency Procedure. 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. Prospective DUR denial on original claim can not be overridden. Supplemental Payment Authorized By Department of Health Services (DHS) Due to an Interim Rate Settlement. Denied. Denied. WWWP Does Not Process Interim Bills. Pricing Adjustment/ Prescription reduction applied. For example, F80.2 (Mixed receptive-expressive language disorder) cannot be billed on the same claim as F84.0 (Autism Disorder) since ICD-10's Coding Manual views them as mutually exclusive dx codes. 690 Canon Eb R-FRAME-EB The Primary Occurrence Code Date is invalid. Inpatient psychiatric services are not reimbursable for members age 21 65 (age 22 if receiving services prior to 21st birthday). The Hearing Aid Recommended Is Not Necessary; The Member Could Be Adequately Fitted With A Conventional Aid. The Procedure Code Indicated Is For Informational Purposes Only. Good Faith Claim Denied Because Of Provider Billing Error. Denied due to Claim Exceeds Detail Limit. WCDP is the payer of last resort. The revenue code has Family Planning restrictions. Member last name does not match Member ID. By continuing to use our site, you agree to our Privacy Policy and Terms of Use. Quantity Billed is restricted for this Procedure Code. The billing provider number is not on file. Six hour limitation on evaluation/assessment services in a 2 year period has been exceeded. Lenses Only Are Approved; Please Dispense A Contracted Frame. One or more Diagnosis Code(s) is invalid for the Date(s) of Service. Explanation of Benefit Codes (EOBs) Mar 14, 2022 4. 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. Good Faith Claim Has Previously Been Denied By Certifying Agency. Procedure not payable for Place of Service. Accident Related Service(s) Are Not Covered By WCDP. Payment(s) For Capital Or Medical Education Are Generated By EDS And May Not Be Billed By The Provider. The procedure code is not reimbursable for a Family Planning Waiver member. Claim Denied Due To Incorrect Billed Amount. Note: The Group, Reason and Remark Codes are HIPAA EOB codes and are cross-walked to L&I's EOB codes. Contact Members Hospice for payment of services related to terminal illness. If laboratory costs exceed reimbursement, submit a claim adjustment request with lab bills for reconsideration. Members age does not fall within the approved age range. Paid In Accordance With Dental Policy Guide Determined By DHS. Billing Provider does not have required Certification Addendum on file. Denied due to Procedure Is Not Allowable For Diagnosis Indicated. A traditional dispensing fee may be allowed for this claim. Compound Ingredient Quantity must be greater than zero. Services have been determined by DHCAA to be non-emergency. Copyright 2023 Wellcare Health Plans, Inc. New Coding Integrity Reimbursement Guidelines. Attachment was not received within 35 days of a claim receipt. All services should be coordinated with the Hospice provider. Primary Tooth Restorations Limited To Once Per Year Unless Claim Narrative Documents Medical Necessity. The Services Requested Are Not Reasonable Or Appropriate For The AODA-affectedmember. The Dispense As Written (DAW) indicator is not allowed for the National Drug Code. The detail From or To Date Of Service(DOS) is missing or incorrect. This National Drug Code (NDC) has Encounter Indicator restrictions. The From Date Of Service(DOS) for the Second Occurrence Span Code is invalid. Medical Necessity For Food Supplements Has Not Been Documented. OA 11 The diagnosis is inconsistent with the procedure. Please Verify That Physician Has No DEA Number. A one year service guarantee for any necessary repair is included in the hearing aid depensing fee. Pricing Adjustment. Denied/Cuback. Please verify the accuracy of the procedure code and the presence of the appropriate procedure code modifier before cont acting ACS for assistance. Member first name does not match Member ID. that provide either supplemental explanation for a monetary adjustment or policy information are required in the remittance advice transaction.
