Please Indicate The Revenue Code/procedure Code/NDC Code For Which The Credit is To Be Applied. Service (Procedure Code/Modifier Combination) is not reimbursable for Date Of Service(DOS). To Continue Treatment With Two Anti-ulcer Drugs Beyond Authorized Limit Please Submit Request On Paper With Clinical Documentation Clearly Indicating medical necessity. Scope Aid Code and an EPSDT Aid Code. Has Recouped Payment For Service(s) Per Providers Request. Members Are Limited To 45 Dates Of Service Per Therapy/spell Of Illness without Prior Authorization. Resubmit Using Valid Rn/lpn Procedure Codes And A Valid PA Number. Unable To Process Your Adjustment Request due to Member ID Not Present. Effective 04/01/09, the BadgerCare Plus Core Plan will limit coverage for Hypoglycemics-Insulin to Humalog and Lantus. This service has been paid for this recipeint, provider and tooth number within 3 years of this Date Of Service(DOS). Oral exams or prophylaxis is limited to once per year unless prior authorized. Contact. 0001 01/01/1900 NOT USED - MEMBER'S DMAP I.D. CO 197 Denial Code - Authorization or Pre-Certification missing Wellcare By Fidelis Care - New Explanation Codes on Dual Access Please Correct And Resubmit. Billing Provider is not certified for the Dispense Date. Reason Code: 234. Rejected Claims-Explanation of Codes - Community Care - Veterans Affairs 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 Total Number Of Sessions Requested Exceeds Quarterly Guidelines. A discrepancy exists between the Other Coverage Indicator and the Other Paid Amount. HMO Payment Equals Or Exceeds Hospital Rate Per Discharge. Documentation Does Not Justify Medically Needy Override. Secondary Diagnosis Code (dx) is not on file. Reimbursement For This Service Has Been Approved. Procedure Code Used Is Not Applicable To Your Provider Type. Date Of Service Must Fall Between The Prior Authorization Grant Date And Expiration Date. This limitation may only exceeded for x-rays when an emergency is indicated. An NCCI-associated modifier was appended to one or both procedure codes. No action required. Different Drug Benefit Programs. Please correct and resubmit. This National Drug Code (NDC) is only payable as part of a compound drug. This care may be covered by another payer per coordination of benefits. No matching Reporting Form on file for the detail Date Of Service(DOS). MCR - 835 Denial Code List | Medicare Payment, Reimbursement, CPT code Denied. Adjustments To Correct Copayment Deductions On date Ranged Claims Are Not Payable. Occupational therapy limited to 35 treatment days per lifetime without prior authorization. Discharge Diagnosis 2 Is Not Applicable To Members Sex. Condition code 70-76 is required on an ESRD claim when Influenza/PPV/HEP B HCPCS codes are the only codes being billed with condition code A6. An ICD-9-CM Diagnosis Code of greater specificity must be used for the Second Diagnosis Code. Members age does not fall within the approved age range. Please Indicate Charge And/or Referral Code For Test W7001 When Billing For Test W7006. Home Health visits (Nursing and therapy) in excess of 30 visits per calendar year per member require Prior Authorization. Reconsideration With Documentation Warranting More X-rays. Multiple Requests Received For This Ssn With The Same Screen Date. The Total Number Of Hours Per Day Requested For AODA Day Treatment Exceeds Guidelines And The Request Has Been Adjusted Accordingly. Billing Provider is not certified for Substance Abuse Day Treatment for the Date(s) of Service. Procedure Code is allowed once per member per lifetime. The Service Requested Is Considered To Be Professionally Unacceptable, Unproven and/or Experimental. Pricing Adjustment/ Long Term Care pricing applied. A Previously Submitted Adjustment Request Is Currently In Process. Denied due to The Member WCDP Id Number Is Incorrect Or Not On Our Current Eligibility File. The submitted claim contains value code 68 and 48 or 49 but does not contain revenue code 0634 or 0635 and HCPCS Q4055. Denied. Pap Smears, Hematocrit, Urinalysis Are Not Reimbursable Separately In Conjunction With Family Planning Medical Visits. Member is in a divestment penalty period. Explanation of Benefits Messages - Wisconsin Procedure Code Modifier(s) Invalid For Date Of Service(DOS) Or For Prior Authorization Date Of Receipt. Level And/or Intensity Of Requested Service(s) Is Incompatible With Medical Need As Defined In Care Plan. The Billing Providers taxonomy code in the header is invalid. The amount in the Other Insurance field is invalid. Please watch future remittance advice. Denied. Definitions and text of all the Claim Adjustment Reason Codes and the Remittance Advice Remark Codes used on the claim will be printed on the last page of the RA. 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. SeniorCare member enrolled in Medicare Part D. Claim is excluded from Drug Rebate Invoicing. The Surgical Procedure Code is not payable for the Date Of Service(DOS). Referring Provider ID is not required for this service. Denied. Claims With Dollar Amounts Greater Than 9 Digits. Admission Date does not match the Header From Date Of Service(DOS). Each month you fill a prescription, your Medicare Prescription Drug Plan mails you an "Explanation of Benefits" (EOB). For over 40 years, Washington Publishing Company (WPC) has specialized in managing and distributing data integration information through publications, training, and consulting services. Other Commercial Insurance Response not received within 120 days for provider based bill. Ulcerations Of The Skin Do Not Warrant A New Spell Of Illness. Claim reduced to fifteen Hospital Bedhold Days for stays exceeding fifteen days. If The Proc Code Does Not Require A Modifier, Please Remove The Modifier. Election Form Is Not On File For This Member. The Medical Necessity For Psychotherapy Services Has Not Been Documented, ThusMaking This Member Ineligible For The Requested Service. Please Refer To The PDL For Preferred Drugs In This Therapeutic Class. A Less Than 6 Week Healing Period Has Been Specified For This PA. These case coordination services exceed the limit. This service is not payable with another service on the same Date Of Service(DOS) due to National Correct Coding Initiative. Initial Visit/Exam limited to once per lifetime per provider. Accommodation Days Missing/invalid. Remittance Advice Remark Code (RARC) and Claim Adjustment Reason Code (CARC) Update ; Note: This article was revised on April 11, 2018, to update Web addresses. Denied/Cutback. Do not leave blank fields between the multiple occurance codes. Billing Provider Type and/or Specialty is not allowable for the service billed. Please Obtain A Valid Number For Future Use. Claim Submitted To Good Faith Without Proper Documentation. Inpatient mental health services performed by masters level psychotherapists or substance abuse counselors are not covered. Other Payer Coverage Type is missing or invalid. Preventive Medicine Code Billed Is Allowed For Health Check Agencies Only With The Appropriate Healthcheck Modifier. Has Already Issued A Payment To Your NF For A Level I Screen With The Same Admission Date. Procedue Code is allowed once per member per calendar year. Benefit Payment Determined By DHS Medical Consultant Review. Out-of-State non-emergency services require Prior Authorization. The Secondary Diagnosis Code is inappropriate for the Procedure Code. This Request Can Only Be Backdated To The Date EDS First Receives The Request In The Mailroom. Surgical Procedure Code is not related to Principal Diagnosis Code. Service not payable with other service rendered on the same date. Service Denied. Denied due to Discharge Diagnosis 1 Missing Or Invalid, Denied due to Diagnosis Pointer To Diagnosis Code 1 Invalid, Denied due to Diagnosis Pointer To Diagnosis Code 2 Invalid, Denied due to Diagnosis Pointer To Diagnosis Code 3 Invalid, Denied due to Diagnosis Pointer To Diagnosis Code 4 Invalid, Denied due to Diagnosis Pointer To Diagnosis Code 5 Invalid, Denied due to Diagnosis Pointer(s) Are Invalid. The Members Clinical Profile/diagnosis Is Not Within Diagnostic Limitations for Psychotherapy Services. Default Prescribing Physician Number XX9999991 Was Indicated. The Requested Procedure Is Cosmetic In Nature, Therefore Not Covered By . Denied. According to the American Association of Neuromuscular & Electro-Diagnostic Medicine and CMS Policy, nerve conduction studies and a needle electromyography (EMG) must both be performed in order to diagnose radiculopathy (pinched nerve in back or neck). Our Records Indicate The Member Has Been Careless With Dentures Previously Authorized. 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. Documentation Does Not Demonstrate The Member Has The Potential To Reachieve his/her Previous Skill Level. Do Not Use Informational Code(s) When Submitting Billing Claim(s). Pricing Adjustment/ Usual & Customary Charge (UCC) flat fee pricing applied. Description. This procedure is limited to once per day. 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). Req For Acute Episode Is Denied. Eighth Diagnosis Code (dx) is not on file. EOB. Your latest EOB will be under Claims on the top menu. Please Select A Procedure Code In The 58980-58988 Range That Best Describes The Procedure Being Performed. Pricing Adjustment. Per Information From Insurer, Requested Information Was Not Supplied By The Provider. Billing Provider ID is missing or unidentifiable. An Alert willbe posted to the portal on how to resubmit. NDC- National Drug Code is not covered on a pharmacy claim. As a result, providers experience more continuity and claim denials are easier to understand. This Service Is Covered Only In Emergency Situations. Excessive height and/or weight reported on claim. Our Records Indicate This Provider Is Not Certified For AODA Day Treatment. Consultation or surgical procedures are not reimbursable in conjuctions with Emergency Room services. Learns to use professional . To Date Of Service(DOS) Precedes From Date Of Service(DOS). Training Request Denied Because Either The Training Date On The Request Is After The CNAs Certification Test Date Or Its Not Within A Year Of That Date. 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. Prior Authorization Is Required For Payment Of Hospital Exceptional Claims. Please Refer To The Original R&S. Adjustment To Eyeglasses Not Payable As A Repair Service. Printable . Reason Code 234 | Remark Codes N20 - JD DME - Noridian Submitted referring provider NPI in the detail is invalid. Good Faith Claim Correctly Denied. Compound Drug Service Denied. Recouped. 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. This detail is denied. 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. Claim Denied. Laboratory Is Not Certified To Perform The Procedure Billed. Claims may deny when DXA bone density studies (CPT 77080 or 77081) are billed and the only diagnosis on the claim is osteoporosis screening (ICD-10 code Z13.820) for a woman who is under age 65 or for a man who is under age 70. Combine Like Details And Resubmit. Member is assigned to a Hospice provider. Medical Billing and Coding Information Guide. Outside Lab Indicator Must Be Y For The Procedure Code Billed. By continuing to use our site, you agree to our Privacy Policy and Terms of Use. Occurance code or occurance date is invalid. Review Billing Instructions. 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. Second Surgical Opinion Guidelines Not Met. Timely Filing Deadline Exceeded. Good Faith Claim Denied. Handwritten Changes/corrections On The Medicare EOMB Are Not Acceptable. Detail To Date Of Service(DOS) is required. Member does not meet the age restriction for this Procedure Code. Total Rental Payments For This Item Have Exceeded The Maximum Allowable Forthe Purchase Of This Item. You can even print your chat history to reference later! Only Four Dates Of Service Are Allowed Per Line Item (detail) For Each Procedure. OA 13 The date of death precedes the date of service. This claim has been adjusted due to a change in the members enrollment. Billed Amount On Detail Paid By WWWP. Service Not Covered For Members Medical Status Code. Outpatient Services To Be Billed As Inpatient Ancillaries When Same Day Stay Occurs Please File An Adjustment/reconsideration Request To Correct Inpatiet Billing. Prior authorization is required for Maxalt when Maxalt or sumatriptan productshave not been reimbursed within 365 days. Find top links about Wellcare Cvs Caremark Login along with social links, FAQs, and more. Reason Code 161: Attachment referenced on the claim was not received in a timely fashion. Procedure Dates Do Not Fall Within Statement Covers Period. This Claim HasBeen Manually Priced Using The Medicare Coinsurance, Deductible, And Psyche RedUction Amounts As Basis For Reimbursement. The Provider Type/specialty Is Not Recognized For These Date(s) Of Service. The Service Requested Is Not Medically Necessary. Training Completion Date Must Be Prior To And Within A Year Of The CNAs Certification Date. Members Age 3 And Older Must Have An Oral Assessment And Blood Pressure Check.With Appropriate Referral Codes, For Payment Of A Screening. Ongoing assessment is not reimbursable when skilled nursing visits have been performed within the past sixty days. The Documentation Submitted Does Not Indicate Medically Oriented Tasks Are Medically Necessary, Therefore Personal Care Services Have Been Approved. No Action On Your Part Required. Detail To Date Of Service(DOS) is invalid. Other Therapies Currently Provide Sufficient Services To Meet The Members Needs. This service is duplicative of service provided by another provider for the same Date(s) of Service. Claim Explanation Codes | Providers | Excellus BlueCross BlueShield An amount in the Gross Amount Due field and/or Usual and Customary Charge field is required. This Member Is Involved In Non-covered Services, And Hours Are Reduced Accordingly. Therapy visits in excess of one per day per discipline per member are not reimbursable. Please Bill Your Medicare Intermediary Prior To Submitting To . The detail From Date Of Service(DOS) is after the detail To Date Of Service(DOS). Claim or Adjustment received beyond 730-day filing deadline. Denied due to Provider Number Missing Or Invalid. Other Insurance Disclaimer Code Used Is Inappropriate For This Members Insurance Coverage. Incorrect Liability Start/end Dates Or Dollar Amounts Must Be Corrected Through County Social Services Agency Before Claim/Adjustment/Reconsideration RequestCan be Processed. Correct Claim Or Resubmit With X-ray. These Supplies/items Are Included In The Purchase Of The Dme Item Billed On The Same Date Of Service(DOS). Denied due to Procedure Billed Not A Covered Service For Dates Indicated. RN And LPN Subsequent Care Visits Limited To 6 Hrs Per Day/per Member/per Provider. Denied. Pricing Adjustment/ Maximum allowable fee pricing applied. Other Medicare Managed Care Response not received within 120 days for providerbased bill. One or more To Date(s) of Service is invalid for Occurrence Span Codes in positions three through 24. Services Submitted On Improper Claim Form. The detail From Date Of Service(DOS) is invalid. Claim or adjustment/reconsideration request must have both a Revenue Code and either a HCPCS Code or CPT Code. Pricing Adjustment/ Prior Authorization pricing applied. Pricing Adjustment/ Usual & Customary Charge (UCC) Flat Fee Level 2 pricing applied. Value Code 48 And 49 Must Have A Zero In The Far Right Position. Denied. Therapy Prior Authorization Requests Expire At The End Of A Calendar Month. No policy override available for BadgerCare Plus Benchmark Plan, Core Plan or Basic Plan. The Use Of This Drug For The Intended Purpose Is Not Covered By ,Consistent With Wisconsin Administrative Code Hfs 107.10(4) And 1396r-8(d). Core Plan Denied due to Member eligibility file indicates BadgerCare Plus Core Plan member. Independent RHCs Must Bill Codes W6251, W6252, W6253, W6254 Or W6255. Denied. Claim Denied. Please Disregard Additional Informational Messages For This Claim. This procedure is age restricted. Service(s) Denied. What Is an Explanation of Benefits (EOB)? | MetLife Claims may be denied if an advanced imaging procedure is billed with a diagnosis of syncope and there is no history of a 12-lead EKG being performed/billed the same date or in the previous 90 days. The Quantity Allowed Was Reduced To A Multiple Of The Products Package Size. Prior Authorization is required for service(s) exceeding mental health and/or substance abuse benefit guidelines. You Must Either Be The Designated Provider Or Have A Referral. ACTION TYPE LEGEND: Orthosis additions is limited to two per Orthosis within the two year life expectancy of the item without Prior Authorization. Training Reimbursement DeniedDue To late Billing. One or more Diagnosis Codes has a gender restriction. Service Denied. Multiple Referral Charges To Same Provider Not Payble. Correct And Resubmit. Prior Authorization is needed for additional services. Pricing Adjustment/ Payment amount increased based on hospital access paymentpolicies. Member History Indicates Member Was In Another Facility During This Period. Treatment With More Than One Drug Per Class Of Ulcer Treatment Drug At The Same Time Is Not Allowed Through Stat PA. A Payment Has Already Been Issued To A Different Nf. Other Coverage Code is missing or invalid. Multiple Tooth Extract On Same Date Of Service(DOS) Must Be Billed As Single And Additional Tooth Extract In Same Quadrant. Indicated Diagnosis Is Not Applicable To Members Sex. Home Health, Personal Care And Private Duty Nursing Services Are Subject To A Monthly Cap. Part A Reason Codes are maintained by the Part A processing system. Prior Authorization (PA) is required for this service. Will Not Authorize New Dentures Under Such Circumstances. The condition code is not allowed for the revenue code. All services should be coordinated with the primary provider. Four X-rays are allowed per spell of illness per provider. Submitted rendering provider NPI in the header is invalid. Contact The Nursing Home. Changes/corrections Were Made To Your Claim Per Dental Processing Guidelines. The Maximum limitation for dosages of EPO is 500,000 UIs (value code 68) per month and the maximum limitation for dosages of ARANESP is 1500 MCG (1 unit=1 MCG) per month. A NAT Reimbursement Request Must Be Submitted To WI Within A Year Of The CNAs Hire Date. Fifth Other Surgical Code Date is required. Timeframe Between The CNAs Training Date And Test Date Exceeds 365 Days. Child Care Coordination services are reimbursable only if both the member and provider are located in Milwaukee County. Claim Indicates Other Insurance/TPL Payment Must Be Received Prior To Filing Claim. Claim Number Given On The Adjustment/reconsideration Request Form Does Not Match Services Originally Billed. Wellcare Explanation Of Payment Codes USA Health An ICD-9-CM Diagnosis Code of greater specificity must be used for the SeventhDiagnosis Code. Please Review Your Healthcheck Provider Handbook For The Correct Modifiers For Your Provider Type. The respiratory care services billed on this claim exceed the limit. Billed Amount Is Greater Than Reimbursement Rate. The content shared in this website is for education and training purpose only. According to CMS Medicare Claims Processing Manual, Place of Service codes (POS) are used to identify where, i.e., physician office, inpatient hospital, a procedure or service is furnished to a patient. NDC is obsolete for Date Of Service(DOS). The Members Demonstrated Response To Current Therapy Does Not Warrant The Intense Freqency Requested. Billing Provider is restricted from submitting electronic claims. Quantity submitted matches original claim. BMN prior authorization may be submitted for Mental Health drugs for which a Core Plan transitioned member has been previously grandfathered. Principle Surgical Procedure Code Date is missing. The Screen Date Is Either Missing Or Invalid. CPT Code And Service Date For Member Is Identical To Another Claim Detail On File For Provider On Claim. WCDP is the payer of last resort. The National Drug Code (NDC) is not on file for the Dispense Date Of Service(DOS). All ESRD clinical diagnostic laboratory tests must be billed individually to ensure that automated multi-chanel chemistry tests are paid in accordance with the Medicare Provider Reimbursement Manual (PRM) 2711. Certifying Agency Verified Member Was Not Eligible for Dates Of Services. Services Not Allowed For Your Provider T. The Procedure Code has Place of Service restrictions. WCDP member enrolled in Medicare Part D. Claim is excluded from Drug Rebate Invoicing. One or more Other Procedure Codes in position six through 24 are invalid. HTTP Status Code Connect Time (ms) Result; 2023-03-01 04:10:52: 200: 255: Page Active: Unable To Process Your Adjustment Request due to. Service(s) Must Be Submitted On Paper Claim Form Along With Preoperative History And Physical Report And Operation Report. Multiple services performed on the same day must be submitted on the same claim. Denied. The Header and Detail Date(s) of Service conflict. Seventh Diagnosis Code (dx) is not on file. Header From Date Of Service(DOS) is after the date of receipt of the claim. Medicare Deductible Is Paid In Full. Prescription Drug Plan (PDP) payment/denial information is required on the claim to SeniorCare. OA 11 The diagnosis is inconsistent with the procedure. Has Processed This Claim With A Medicare Part D Attestation Form. An ICD-9-CM Diagnosis Code of greater specificity must be used for the Fourth Diagnosis Code.