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A valid Prior Authorization is required for non-preferred drugs. This Is A Manual Increase To Your Accounts Receivable Balance. This Is A Manual Decrease To Your Accounts Receivable Balance. Referral Codes Must Be Indicated For W7001, W7002, W7003, W7006, W7008 And W7013. CO - Contractual Obligations: This group code is used when a contractual agreement between the payer and payee, or a regulatory requirement, resulted in an adjustment.These adjustments are considered a write off for the provider and are not billed to . Claim Denied/Cutback. As A Reminder, This Procedure Requires SSOP. An ICD-9-CM Diagnosis Code of greater specificity must be used for the Diagnosis Code in posistion 10 through 24. Ancillary Codes Dates Of Service And/or Quantity Billed Do Not Match Level Of Care authorized Dates. If A Reporting Form Is Not Submitted Within 60 Days, The claim detail will be denied. Claim Detail Denied Due To Required Information Missing On The Claim. Denied. Multiple Requests Received For This Ssn With The Same Screen Date. Reason Code: 234. The Reimbursement Code Assigned To This Certification Segment Does Not Authorize a NAT Payment. Valid NCPDP Other Payer Reject Code(s) required. Superior HealthPlan News. THE WELLCARE GROUP OF COMPANIES . Pharmaceutical Care Code must be billed with a payable drug detail or if a prescription was not filled, the quantity dispensed must be zero. 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. Split Decision Was Rendered On Expansion Of Units. Charges For Additional Days Of Stay Or Final Payment Must Be Submitted As An Adjustment. Supply The Place Of Service Code On The Request Form (the Place Of Service Where The Service/procedure Would Be Performed). A National Provider Identifier (NPI) is required for the Performing Provider listed in the header. NDC was reimbursed at AWP (Average Wholesale Price) (Average Wholesale Price) rate. Please Resubmit. OA 12 The diagnosis is inconsistent with the provider type. The From Date Of Service(DOS) for the Second Occurrence Span Code is required. MassHealth List of EOB Codes Appearing on the Remittance Advice. Department of Health Services (DHS) Authorized Payment Is Being Withheld Due toa Final Rate Settlement. Procedure Code Changed To Permit Appropriate Claims Processing. This Revenue Code has Encounter Indicator restrictions. Refer to the Onine Handbook. Medicare Deductible Is Paid In Full. Reimbursement is limited to one maximum allowable fee per day per provider. Medicaid Remittance Advice Remark Code:M86 MMIS EOB Code:100. 1. Claims may be denied if the only reported diagnosis is syncope and collapse when any of the listed diagnostic head, brain, carotid artery or neck imaging procedures are billed. Claim Is Being Reprocessed Through The System. Claim contains an unclassified drug HCPCS procedure code or a drug HCPCS procedure code included in the composite rate. Only One Date For EachService Must Be Used. Will Only Pay For One. Pricing Adjustment/ Spenddown deductible applied. The Tooth Is Not Essential To Maintain An Adequate Occlusion. Individual Test Paid. Denied. Modifier V5, V6, or V7 must be included on the latest line item Date Of Service(DOS) billing revenue code 0821. Individual Audiology Procedures Included In Basic Comprehensive Audiometry. Resubmit the Claim with the Appropriate Modifier for Provider Type andSpecialty. Services on this claim have been split to facilitate processing.on On Your Part Is Required. Information inadequate to establish medical necessity of procedure performed.Please resubmit with additional supporting documentation. Denied. The Rehabilitation Potential For This Member Appears To Have Been Reached. Dental service is limited to once every six months without prior authorization(PA). wellcare eob explanation codes. The Service(s) Requested Could Be Adequately Performed With Local Anesthesia In The Dental Office. Units Billed Are Inconsistent With The Billed Amount. Procedimientos. codes are provided per day by the same individual physician or other health care professional. The Service Requested Is Not A Covered Benefit Of The Program. Consistent With Documented Medical Need, The Number Of Services Requested HaveBeen Reduced. Inicio Quines somos? Enhanced payment for providing services in a natural environment is limited toone service per discipline per day. If it is medical necessary for more than 13 or 14 services per calendar month, submit an adjustment request with supporting documentation. Back-up dialysis sessions are limited to three per lifetime. Take care to review your EOB to ensure you understand recent charges and they all are accurate. This Surgical Code Has Encounter Indicator restrictions. The medical record request is coordinated with a third-party vendor. 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). Supplemental Payment Authorized By Department of Health Services (DHS) Due to an Interim Rate Settlement. Child Care Coordination services are reimbursable only if both the member and provider are located in Milwaukee County. The Third Occurrence Code Date is invalid. Submit copy of the dated and signed evaluation and indicate if this is an initial Evaluation. Denied. The National Drug Code (NDC) has a quantity restriction. You can choose to receive only your EOBs online, eliminating the paper . The detail From or To Date Of Service(DOS) is missing or incorrect. In addition, when distinct service modifier 59 or modifier XE is not appended to auditory screening services and tympanometry/impedance testing, these services may be denied. Once Therapy Is Prior Authorized, All Therapy Must Be Billed With A Valid Prior Authorization Number. No Action Required on your part. See Physicians Handbook For Details. Please Rebill Only CoveredDates. One Visit Allowed Per Day, Service Denied As Duplicate. Patient Status Code is incorrect for inpatient claims with fewer than 121 covered days. Request Denied. Denied due to Provider Signature Date Is Missing Or Invalid. Request was not submitted Within A Year Of The CNAs Hire Date. Discharge Diagnosis 2 Is Not Applicable To Members Sex. Invalid Provider Type To Claim Type/Electronic Transaction. Denied. Documentation You Have Submitted Does Not Meet The Requirements Of HSS 107.09(4)(k). Complex Evaluation and Management procedures require history and physical or medical progress report to be submitted with the claim. Other Insurance Or Medicare Response Not Received Within 120 Days For ProviderBased Bill. This National Drug Code Has Diagnosis Restrictions. Follow specific Core Plan policy for PA submission. Basic knowledge of CPT and ICD-codes. The Other Payer ID qualifier is invalid for . Authorizations. Denied/Cutback. NDC was reimbursed at Employer Medical Assistance Contribution (EMAC) rate. RN Home Health visits and Supervisory visits are not reimbursable on the same Date Of Service(DOS) for same provider. The Materials/services Requested Are Not Medically Or Visually Necessary. Note: The Group, Reason and Remark Codes are HIPAA EOB codes and are cross-walked to L&I's EOB codes. Date Of Service Must Fall Between The Prior Authorization Grant Date And Expiration Date. Claim cannot contain both Condition Codes A5 and X0 on the same claim. The To Date Of Service(DOS) for the First Occurrence Span Code is invalid. Pricing Adjustment/ Prior Authorization pricing applied. Please Correct And Resubmit. The To Date Of Service(DOS) for the Second Occurrence Span Code is invalid. Insufficient Info On Unlisted Med Proc; Submit Claim Or Attachment With A Complete Description Of The Procedure As Described In History and Physical Exam Report, Med Progress, anesthesia or Op Report. In the above example the claim was denied with two codes, the Adjustment Reason Code of 16 and then the explanatory Remark Code of N329 (Missing/incomplete/invalid patient birth date). Detail From Date Of Service(DOS) is after the ICN Date. The topic of Requirements for Compression Garments can be found in the Claims Section, Submission Chapter. The Reimbursement Code Assigned To This CNA Does Not Authorize A NAT Payment. Reimbursement limit for all adjunctive emergency services is exceeded. Pricing Adjustment/ Payment reduced due to benefit plan limitations. Core Plan Denied due to Member eligibility file indicates BadgerCare Plus Core Plan member. Denied due to Provider Is Not Certified To Bill WCDP Claims. The Member Appears To Be At A Maximum Level For Age, Diagnosis, And Living Arrangement. Please Furnish An ICD-9 Surgical Code And Corresponding Description. The service was previously paid for this Date Of Service(DOS). The sum of the Accommodation Days is not equal to the sum of Covered plus Non-Covered Days, or the From and To Dates of Service cannot be the same. Either The Date Was Not In MM/DD/CCYY Format Or Its AFuture Date. Quick Tip: In Microsoft Excel, use the " Ctrl + F " search function to look up specific denial codes. 2004-79 For Instructions. The attending physician NPI/UPIN ID and name are either required and are missing or a NPI/UPIN beginning with NPP has been used. The Total Number Of Sessions Requested Exceeds Quarterly Guidelines. This drug has been paid under an equivalent code within seven days of this Date Of Service(DOS). Service Denied. The Header and Detail Date(s) of Service conflict. Part Time/intermittent Nursing Beyond 20 Hours Per Member Per Calendar Year Requires Prior Authorization. Benefit code These codes are submitted by the provider to identify state programs. OA 13 The date of death precedes the date of service. A traditional dispensing fee may be allowed for this claim. The Functional Assessment And/or Progress Status Report Does Not Indicate Any Change, and/or Positive Rehabilitation Potential. Providers will find a list of all EOB codes used with the corresponding description on the last page of the Remittance Advice. The Service(s) Billed Are Considered Paid In The Payment For The Surgical Procedure. Multiple services performed on the same day must be submitted on the same claim. Denied due to NDC Is Not Allowable Or NDC Is Not On File. Quantity submitted matches original claim. Incidental modifier is required for secondary Procedure Code. You can view these EOBs online by following these steps: Log in to your bcbsm.com account to view your prescriptions coverage. Claim Detail Denied As Duplicate. PleaseResubmit Charges For Each Condition Code On A Separate Claim. Prescribing Provider UPIN Or Provider Number Missing. All services should be coordinated with the Inpatient Hospital provider. The changes in the brain that happen during a migraine cannot be seen by the imaging studies since a migraine is caused by a complicated interaction between the brain and the blood vessels in the face and head. The Total Billed Amount is missing or incorrect. Denied due to Claim Contains Future Dates Of Service. As a result, providers experience more continuity and claim denials are easier to understand. ACTION DESCRIPTION: ACTION TYPE. Denied. Payment may be reduced due to submitted Present on Admission (POA) indicator. Claim Paid Under DRG Reimbursement, Except For Transplants Billed Using Suffixes 05 Through 09. Indicator for Present on Admission (POA) is not a valid value. This procedure is limited to once per day. Duplicate Item Of A Claim Being Processed. One or more Diagnosis Codes has a gender restriction. Surgical Procedure Code is not related to Principal Diagnosis Code. Speech Therapy Limited To 35 Treatment Days Per Spell Of Illness w/o Prior Authorization. Ability to proficiently use Microsoft Excel, Outlook and Word. Complex care of 17-plus hours and complex care of less than 17 hours are not allowed on the same Date Of Service(DOS). A SeniorCare drug rebate agreement is not on file for this drug for the Date Of Service(DOS). Pricing Adjustment/ The submitted charge exceeds the allowed charge. Review Patient Liability/paid Other Insurance, Medicare Paid. Providers should submit adequate medical record documentation that supports the claim (services) billed. This National Drug Code (NDC) has been terminated by CMS for the Date Of Service(DOS). This Member Is Receiving Concurrent AODA/Psychotherapy Services And Is Therefore Only Eligible For Maintenance Hours. Service Must Be Billed On Drug Claim Form Utilizing NDC Codes. This Payment Is To Satisfy The Amount Owed For OBRA Level 1. Professional Components Are Not Payable On A Ub-92 Claim Form. Please adjust quantities on the previously submitted and paid claim. The Service Requested Is Inappropriate For The Members Diagnosis. Unable To Process Your Adjustment Request due to. The Primary Diagnosis Code is inappropriate for the Procedure Code. Procedue Code is allowed once per member per calendar year. Submitted rendering provider NPI in the detail is invalid. Value code 48 exceeds 13.0 or value code 49 exceeds 39.0 and HCPCS codes Q4081or J0882 are present but either modifer ED or EE are not present. Admit Date and From Date Of Service(DOS) must match. . Avoiding denial reason code CO 22 FAQ Q: We received a denial with claim adjustment reason code (CARC) CO 22. The Information Provided Indicates Regression Of The Member. The Primary Occurrence Code Date is invalid. The Related Surgical Procedure is not a covered service under Wisconsin Medicaid or BadgerCare Plus. The Secondary Diagnosis Code is inappropriate for the Procedure Code. Denied/Cutback. Resubmit Private Duty Nursing Services For Complex Children With Documentation Supporting The Level Of Care. Review Billing Instructions. Header To Date Of Service(DOS) is required. Claim Denied The Combined Medicare And Private Insurance Payments Equal Or Exceed The Lesser Of The And Medicare Allowable Amounts. Disposable medical supplies are payable only once per trip, per member, per provider. Duplicate/second Procedure Deemed Medically Necessary And Payable. Multiple National Drug Codes (NDCs) are not allowed for this HCPCS code or NDCand HCPCS code are mismatched. Please Supply NDC Code, Name, Strength & Metric Quantity. HTTP Status Code Connect Time (ms) Result; 2023-03-01 04:10:52: 200: 255: Page Active: Claim Denied For Future Date Of Service(DOS). We have redesigned our website to help you find the information you need more easily. No Action On Your Part Required. A Version Of Software (PES) Was In Error. The Service Requested Does Not Correspond With Age Criteria. Claim Denied for implementation of new Wisconsin Medicaid Interchange System.Resubmission of the claim is required due to new claim submission guidelines. Secondary Diagnosis Code (dx) is not on file. Repackaged National Drug Codes (NDCs) are not covered. A valid Prior Authorization is required for Brand Medically Necessary Drugs. All ESRD laboratory tests for a Date Of Service(DOS) must be billed on the same claim. Revenue code submitted with the total charge not equal to the rate times number of units. CPT/HCPCS codes are not reimbursable on this type of bill. The National Drug Code (NDC) submitted with this HCPCS code is CMS terminated or not covered by the program. An ICD-9-CM Diagnosis Code of greater specificity must be used for the Ninth Diagnosis Code. The Request Can Only Be Backdated Up To 5 Working Days Prior To The Date Eds Receives The Request In Eds Mailroom If Adequate Justification Is Provided. This drug is limited to a quantity for 100 days or less. Third Other Surgical Code Date is required. With Payspan's eEOB member-friendly functionality, members can log into the payer's secure portal and . 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. Other Amount Submitted Not Reimburseable. The Evaluation Was Received By Fiscal Agent More Than Two Weeks After The Evaluation Date. These codes provide additional explanation for an adjustment already described by a Claim Adjustment Reason Code (CARC) or convey information about remittance processing. Prescription Date is after Dispense Date Of Service(DOS). Service Billed Limited To Three Per Pregnancy Per Guidelines. Claim Detail Denied. Please Resubmit. Admission Date is on or after date of receipt of claim. $150.00 Reimbursement Limit Has Been Reached For Individual And Group Pncc Health Education/nutritional Counseling. 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. Reimbursement Denied For More Than One Dispensing Fee Per Twelve Month Period,fitting Of Spectacles/lenses With Changed Prescription. Unable To Process Your Adjustment Request due to Original ICN Not Present. This Is A Duplicate Request. Claim Denied. The Service Billed Does Not Match The Prior Authorized Service. Claim Generated An Informational ProDUR Alert, Drug-Drug Interaction prospective DUR alert, Drug-Disease (reported) prospective DUR alert, Drug-Disease (inferred) prospective DUR alert, Therapeutic Duplication prospective DUR alert, Suboptimal Regiment prospective DUR alert, Insufficient Quantity prospective DUR alert. Submit Claim To Other Insurance Carrier. Requested Documentation Has Not Been Submitted. Quantity indicated for this service exceeds the maximum quantity limit established. Verify billed amount and quantity billed. This procedure is age restricted. Revenue Codes 0110 (N6) And 0946 (N7) Are Not Payable When Billed On The Same Dateof Service As Bedhold Days. The Timeframe Between Certification, Test, Date And Hire Date Exceeds A Year. Please Furnish A Breakdown Of Your Procedure Code And Charge In Question GivenOn The Adjustment/reconsideration Request. Header Billing Provider used as Detail Performing Provider, Header Performing Provider used as Detail Performing Provider. Denied due to Procedure Billed Not A Covered Service For Dates Indicated. 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.