Medicare Coinsurance Amount Was Not Provided On Crossover Claim. Department of Health Services (DHS) Authorized Payment Is Being Withheld Due toan Audit. Modification Of The Request Is Necessitated By The Members Minimal Progress. All Day Treatment Services For Members With Nursing Home Status Should Be Billed Under Procedure Code W8912(pre 10/1/03)/h2012(post 10/1/03) And Require PriorAuthorization. Compound Drug Service Denied. This Service Is Not Payable Without A Modifier/referral Code. wellcare explanation of payment codes and comments. Payment For Immunotherapy Service Included In Reimbursement For Allergy Extract Injection. No Substitution Indicator Invalid For Non-innovator Drugs Not On The Current Wisconsin MAC List. This National Drug Code (NDC) has been terminated by CMS for the Date Of Service(DOS). Laboratory Is Not Certified To Perform The Procedure Billed. The Documentation Submitted Does Not Substantiate Additional Care. Claim Denied Due To Incorrect Billed Amount. Denied due to Provider Number Missing Or Invalid. This claim is a duplicate of a claim currently in process. Member Expired Prior To Date Of Service(DOS) On Claim. Second modifier code is invalid for Date Of Service(DOS) (DOS). No Interim Billing Allowed On Or After 01-01-86. Acute Care General And Specialty Hospitals Are Subject To Pre-admission Requirements Or The Pre-admission Review Number Indicated Is Invalid. This procedure is duplicative of a service already billed for same Date Of Service(DOS). Services Beyond The Six Week Postpartum Period Are Not Covered, Per DHS. Please submit future claims with the appropriate NPI, taxonomy and/or Zip +4 Code. Pharmaceutical Care is not covered by the Wisconsin Chronic Disease Program. Please Check The Adjustment Icn For The Reprocessed Claim. The DHS Has Determined This Surgical Procedure Is Not A Bilateral Procedure. Dispense Date Of Service(DOS) is after Date of Receipt of claim. An ICD-9-CM Diagnosis Code of greater specificity must be used for the Ninth Diagnosis Code. Critical care performed in air ambulance requires medical necessity documentation with the claim. Please Furnish A NDC Code And Corresponding Description. Prescription Drug Plan (PDP) payment/denial information required on the claim to WCDP. Invalid/obsolete Procedure Code For Determination Of Refraction, Service Denied. Modifiers are required for reimbursement of these services. 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. Review Patient Liability/paid Other Insurance, Medicare Paid. These are EOB codes, revised for NewMMIS, that may appear on your PDF remittance advice. Supplemental tests billed on the same Date Of Service(DOS) as vision examination are not payable. These same rules are used by most healthcare claims payers and enforced by the Centers for Medicare and Medicaid Services. Rqst For An Exempt Denied. The member has no Level of Care (LOC) authorization on file or the LOC on filedoes not match the LOC on the claim. Please Disregard Additional Messages For This Claim. Pregnancy Indicator must be "Y" for this aid code. Quick Tip: In Microsoft Excel, use the " Ctrl + F " search function to look up specific denial codes. Provider is not eligible for reimbursement for this service. Non-preferred Drug Is Being Dispensed. One or more Surgical Code(s) is invalid in positions six through 23. The Narrative History Does Not Indicate the Members Functioning is Impaired due To AODA Usage. Pricing Adjustment/ Patient Liability deduction applied. The Reimbursement Code Assigned To This CNA Does Not Authorize A NAT Payment. Procedure Not Payable As Submitted. Claim Denied/cutback. For Revenue Code 0820, 0821, 0825 or 0829, HCPCS Code 90999 or Modifier G1-G6 must be present. Claim Corrected. A HCPCS code is required when condition code A6 is included on the claim. Discharge Diagnosis 4 Is Not Applicable To Members Sex. Multiple Referral Charges To Same Provider Not Payble. You Must Either Be The Designated Provider Or Have A Referral. This drug/service is included in the Nursing Facility daily rate. Procedure Dates Do Not Fall Within Statement Covers Period. Please Provide Copy Of Medicare Explanation Of Benefits/medicare Remittance Advice Attached To Claim. Refer to the DME area of the Online Handbook for claims submission requirements for compression garments. You Must Adjust The Nursing Home Coinsurance Claim. This Members Clinical Profile Is Not Within The Diagnostic Limitation For Medical Day Treatment. Individual Vaccines And Combination Vaccine Code May Not Be Billed For The Same Dates Of ervice. The Screen Date Must Be In MM/DD/CCYY Format. Timely Filing Deadline Exceeded. Denied. Reimbursement limits for Community Care Services for the calendar year are close to being exceeded. Election Form Is Not On File For This Member. FFS CLAIM PROFESSIONAL ASC X12N VERSION . Denied/Cutback. Denied due to Provider Signature Date Is Missing Or Invalid. Claim contains an unclassified drug HCPCS procedure code or a drug HCPCS procedure code included in the composite rate. Please Rebill Inpatient Dialysis Only. Department of Health Services (DHS) Authorized Payment Is Being Withheld Due toa Final Rate Settlement. Medicaid id number does not match patient name. the patient (or parent or guardian) at the address noted on the claim, be sure your doctor has updated your records with your current address. 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. An amount in the Gross Amount Due field and/or Usual and Customary Charge field is required. This Incidental/integral Procedure Code Remains Denied. Voided Claim Has Been Credited To Your 1099 Liability. Please Provide The Type Of Drug Or Method Used To Stop Labor. A valid procedure code is required on WWWP institutional claims. OA 14 The date of birth follows the date of service. A discrepancy exists between the Other Coverage Indicator and the Other Paid Amount. Reason Code Remark Code(s) Denial Denial Description; 16: M51 | N56: Correction Made Per Medical Consultant Review. Procedure not allowed for the CLIA Certification Type. When the nerve conduction study or the needle EMG is performed on its own, the results can be misleading and important diagnoses may be missed. According To Our Records, The Surgeon For This Sterilization Procedure Has NotSubmitted The Members Consent Form. The Member Is Enrolled In An HMO. Pricing Adjustment/ Reimbursement reduced by the members copayment amount. Claim Denied. A claim cannot contain only Not Otherwise Specified (NOS) Surgical Procedure Codes. If required information is not received within 60 days, the claim will be. Rendering Provider Type and/or Specialty is not allowable for the service billed. Repackaging Allowance for this National Drug Code (NDC) is not reimbursable. NDC is obsolete for Date Of Service(DOS). Denied. "Laterality" (side of the body affected) is a coding convention added to relevant ICD-10 codes to increase specificity. Denied due to Procedure Is Not Allowable For Diagnosis Indicated. Procedure Code Modifier(s) Invalid For Date Of Service(DOS) Or For Prior Authorization Date Of Receipt. Header From Date Of Service(DOS) is required. 2. Submitted referring provider NPI in the detail is invalid. Purchase Only Allowed; Medical Need For Rental Has Not Been Documented. Adequate Justification For Starting Member In AODA Day Treatment Prior To Authorization being Obtained Has Not Been Provided. These Individual Vaccines Must Be Billed Under The Appropriate Combination Injection Code. The Surgical Procedure Code has Diagnosis restrictions. . The Services Requested Are Not Reasonable Or Appropriate For The AODA-affectedmember. Incidental modifier is required for secondary Procedure Code. Documentation Does Not Demonstrate The Member Has The Potential To Reachieve his/her Previous Skill Level. We have redesigned our website to help you find the information you need more easily. No matching Reporting Form on file for the detail Date Of Service(DOS). Unable To Process Your Adjustment Request due to Provider Not Found. Denied due to Services Billed On Wrong Claim Form. 3101. Reason Code 234 | Remark Codes N20. This National Drug Code (NDC) is only payable as part of a compound drug. . General Exercise To Promote Overall Fitness And Flexibility Are Non-covered Services. The Timeframe Between Certification, Test, Date And Hire Date Exceeds A Year. One or more Diagnosis Code(s) is invalid for the Date(s) of Service. Home Health services for CORE plan members are covered only following an inpatient hospital stay. Reimbursement of this service is included in the reimbursement of the most complex/complete procedure performed. All Outpatient Services/or Accommodations And Ancillaries Are Denied, Therefore The Total Charge Is Denied. Pricing Adjustment/ The submitted charge exceeds the allowed charge. Please submit claim to HIRSP or BadgerRX Gold. A Third Occurrence Code Date is required. CO/204/N30. Prior Authorization Is Required For Payment Of Hospital Exceptional Claims. Please Re-submit This Claim With The Insurance EOB Showing A Denial OrPartial Payment. Provider signature and/or date is required. Denied due to The Member WCDP Id Number Is Incorrect Or Not On Our Current Eligibility File. Endurance Activities Do Not Require The Skills Of A Therapist. Denied. When billing multiple diagnosis codes, the recoding is based on the highest level of service associated to one or more of the diagnosis codes billed. 0; To Continue Treatment With Two Anti-ulcer Drugs Beyond Authorized Limit Please Submit Request On Paper With Clinical Documentation Clearly Indicating medical necessity. Header From Date Of Service(DOS) is after the date of receipt of the claim. Please Correct And Resubmit. 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. The diagnosis code on the claim requires Condition code A6 be present on the Type of Bill. NDC was reimbursed at brand WAC (Wholesale Acquisition Cost) (Wholesale Acquisition Cost) rate. Ulcerations Of The Skin Do Not Warrant A New Spell Of Illness. Adjustment/reconsideration Request Denied Due To Incorrect/insufficient Information. The Total Number Of Hours Per Day Requested For AODA Day Treatment Exceeds Guidelines And The Request Has Been Adjusted Accordingly. This Adjustment Was Initiated By . Service Allowed Once Per Lifetime, Per Tooth. Thank You For The Payment On Your Account. This Member Has Completed Primary Intensive Services And Is Now Only Eligible For after Care/follow-up Hours. Resubmit Claim Once Election Form Requirements Are Met Per The Hospice Provider Handbook. Prescription limit of five Opioid analgesics per month. 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 . Lab Procedures Billed In Conjunction With Family Planning Pharmacy Visit Denied as not a Benefit. Early Refill Alert. This claim has been adjusted due to Medicare Part D coverage. Pricing Adjustment/ Usual & Customary Charge (UCC) flat fee pricing applied. For additional information on HIPAA EOB codes, visit the Code List section of the WPC website at www.wpc-edi.com. Claim Denied For Invalid Billing Type Frequency Code, Claim Type, Or SubmittedAdjustment Provider Number Does Not Match Original Claims Provider Number. Resubmit The Original Medicare Determination (EOMB) Along With Medicares Reconsideration. Unable To Process This Request Due To Either Missing, Invalid OrMismatched National Provider Identifier # (NPI)/Provider Name/POP ID. Service paid in accordance with program requirements. No Separate Payment For IUD. Unable To Reach Provider To Correct Claim. HTTP Status Code Connect Time (ms) Result; 2023-03-01 04:10:52: 200: 255: Page Active: Therapy visits in excess of one per day per discipline per member are not reimbursable. Four X-rays are allowed per spell of illness per provider. Date of service is on or after July 1, 2010 and TOB is 72X, value code D5 mustbe present. This Procedure Code Is Denied As Incidental/Integral To Another Procedure CodeBilled On This Claim. An NCCI-associated modifier was appended to one or both procedure codes. 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. Modifier invalid for Procedure Code billed. The Revenue Code is not payable for the Date Of Service(DOS). The To Date Of Service(DOS) for the Second Occurrence Span Code is invalid. Service Provided Before Prior Authorization Was Obtained Is Not Allowable. Denied. There are approximately 20 Medicaid Explanation Codes which map to Denial Code 16. Copayment Should Not Be Deducted From Amount Billed. Member enrolled in QMB-Only Benefit plan. Modifier Submitted Is Invalid For The Member Age. Claim paid at program allowed rate. Claim Denied Due To Invalid Occurrence Code(s). Payment Subject To Pharmacy Consultant Review. The Procedure Code has Diagnosis restrictions. Do Not Submit Claims With Zero Or Negative Net Billed. PleaseResubmit Charges For Each Condition Code On A Separate Claim. Please Use This Claim Number For Further Transactions. Resubmit Private Duty Nursing Services For Complex Children With Documentation Supporting The Level Of Care. 1. This Is A Manual Decrease To Your Accounts Receivable Balance. Please Reference Payment Report Mailed Separately. CPT/HCPCS codes are not reimbursable on this type of bill. Quantity Would Be 00010 If Specific Number Of Batteries Dispensed Is Not Indicated. Crosswalk - Adjustment Reason Codes and Remittance Advice (RA) Remark Codes to PHC Explanation (EX) Codes Revised 11/16/2020 Page 1 Key: If RA has . Effective 04/01/09, the BadgerCare Plus Core Plan will limit coverage for Hypoglycemics-Insulin to Humalog and Lantus. Correct Claim Or Resubmit With X-ray. This Service Is Covered Only In Emergency Situations. Member is in a divestment penalty period. Services on this claim were previously partially paid or paid in full. Assistant Surgery Must Be Billed Separately By The Assistant Surgeon With Modifier 80. . The Evaluation Was Received By Fiscal Agent More Than Two Weeks After The Evaluation Date. Services billed are included in the nursing home rate structure. Annual Nursing Home Member Oral Exam Is Allowed Once Per 355 Days Per Recip Per Prov. 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. Denied. This Procedure Code Is Not Valid In The Pharmacy Pos System. We update the Code List to conform to the most recent publications of CPT and HCPCS . Authorization For Surgery Requiring Second Opinion Valid For 6Months After Date Approved. Please verify billing. (part JHandbook). Denied due to Claim Or Adjustment Received After The Late Billing Filing Limit. The service is not reimbursable for the members benefit plan. Additional Psychotherapy Is Not Considered Appropriate Or Inline With More Effective, Available Services. Personal care subsequent and/or follow up visits limited to seven per Date Of Service(DOS) per member. Other Amount Submitted Not Reimburseable. Recasing Or Replacement Of Hearing Aid Case Is Limited To Once Per 2 Year Period Per Member Per Provider. 2. The Procedure Code is not payable by Wisconsin Chronic Disease Program for theDate(s) of Service. Denied due to Add Dates Not In Ascending Order Or DD/DD/DD Format. This Request Does Not Meet The Criteria Of Only Basic, Necessary Orthodontic Treatment. Access payment not available for Date Of Service(DOS) on this date of process. 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. Good Faith Claim Denied. Request Denied Because The Screen Date Is After The Admission Date. -OR- The claim contains value code 49but does not contain revenue code 0636 and HCPCS Q4054. Member is assigned to an Inpatient Hospital provider. SeniorCare member enrolled in Medicare Part D. Claim is excluded from Drug Rebate Invoicing. Reimbursement rate is not on file for members level of care. The Member Has Shown No Significant Functional Progress Toward Meeting Or Maintaining Established & Measurable Treatment Goals Over A 6 Month Period. WellCare has established maximum frequency per day (MFD) values, which are the highest number of units eligible for reimbursement of services on a single date of service. 2D3D CODES: Radiation treatment delivery, superficial and/or ortho voltage, per day 77401 Radiation treatment delivery, >1 MeV; simple 77402 . This Is A Manual Increase To Your Accounts Receivable Balance. Billed Amount On Detail Paid By WWWP. Value codes 48 Homoglobin Reading and 49 Hematocrit Reading, must have a zero in the far right position. Member is enrolled in a commercial health insurance on the Dispense Date Of Service(DOS). Header Rendering Provider number is not found. Discharge Diagnosis 2 Is Not Applicable To Members Sex. Denied due to Per Division Review Of NDC. This Diagnosis Code Has Encounter Indicator restrictions. Other Insurance Disclaimer Code Invalid. 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. Maximum Reimbursement Amount Has Been Determined By Professional Consultant. This National Drug Code (NDC) has diagnosis restrictions. The three key components when selecting the appropriate level of E&M services provided are history, examination, and medical decision-making. A New Prior Authorization Number Has Been Assigned To This Request In Order ToProcess. This Is An Adjustment of a Previous Claim. Please Correct And Resubmit. Less Expensive Alternative Services Are Available For This Member. The Modifier For The Proc Code Is Invalid. This Information Is Required For Payment Of Inhibition Of Labor. The Number Of Weeks Has Been Reduced Consistent With Goals And Progress Documented. EOB. Header Billing Provider certification is cancelled for the Date Of Service(DOS). View the Part C EOB materials in the Downloads section below. Revenue code requires submission of associated HCPCS code. Previously Denied Claims Are To Be Resubmitted As New Day Claims. The Procedure Code has Encounter Indicator restrictions. Please Indicate One Prior Authorization Number Per Claim. Member enrolled in Medicare Part D for the Dispense Date Of Service(DOS). Supervisory visits for Unskilled Cases allowed once per 60-day period. Pharmacy Clm Submitted Exceeds The Number Of Clms Allowed Per Cal. BMN prior authorization may be submitted for Mental Health drugs for which a Core Plan transitioned member has been previously grandfathered. Payspan's Core Payment Network comes with a feature that allows payers to send members an electronic version of their Explanation of Benefits (eEOB). Members Are Limited To 45 Dates Of Service Per Therapy/spell Of Illness without Prior Authorization. Do not resubmit. Service(s) paid at the maximum daily amount per provider per member. Will Only Pay For One. Detail From Date Of Service(DOS) is after the ICN Date. Please Request Prior Authorization For Additional Days. Oral exams or prophylaxis is limited to once per year unless prior authorized. According To Our Records, The Hospital Has Not Received Prior Authorization For This Surgery. Please Refer To Update No. The header total billed amount is required and must be greater than zero. Questionable Long-term Prognosis Due To Poor Oral Hygiene. The canister, dressings and related supplies are included as part of the reimbursement for the negative pressure wound therapy pump. Service(s) Must Be Submitted On Paper Claim Form Along With Preoperative History And Physical Report And Operation Report. Additional servcies may be billed with H0046 and will count toward mental health and/or substance abuse treatment policy limits for prior authorization. Second Rental Of Dme Requires Prior Authorization For Payment. Medicare paid amount(s) have been incorrectly applied to both the claim headerand details. Good Faith Claim Has Previously Been Denied By Certifying Agency. The From Date Of Service(DOS) for the Second Occurrence Span Code is required. This care may be covered by another payer per coordination of benefits. This Is Not A Reimbursable Level I Screen. Member Name Missing. Out of State Billing Provider not certified on the Dispense Date. WellCare 2016 NA_11_16 NA6PROGDE80121E_1116 . Please Contact The Hospital Prior Resubmitting This Claim. Code. Service Denied. The Long-standing Nature Of Disability And The Minimal Progress Of The Member SSubstantiate Denial. Other payer patient responsibility grouping submitted incorrectly. Transplant services not payable without a transplant aquisition revenue code. Services have been determined by DHCAA to be non-emergency. Rn Visit Every Other Week Is Sufficient For Med Set-up. Do Not Use Informational Code(s) When Submitting Billing Claim(s). The detail From Date Of Service(DOS) is after the detail To Date Of Service(DOS). Multiple Prescriptions For Same Drug/ Same Fill Date, Not Allowed. Occupational therapy limited to 35 treatment days per lifetime without prior authorization. Medically Unbelievable Error. Use Of Therapy Equipment Alone Is Not Sufficient To Justify Maintenance Therapy. Acknowledgement Of Receipt Of Hysterectomy Info Form Is Missing, Incomplete, Or Contains Invalid Information. Principle Surgical Procedure Code Date is missing. Qty And/or Detail Charge Do Not Divide Out Equally For Dates Of Service and/orQty Given. Intermittent Peritoneal Dialysis hours must be entered for this revenue code. Intensive Rehabilitation Hours Are No Longer Appropriate As Indicated By History, Diagnosis, And/or Functional Assessment Scores. Prescription limit of five Opioid analgesics per month. Header Billing Provider used as Detail Performing Provider, Header Performing Provider used as Detail Performing Provider. The Diagnosis Code is not payable for the member. Pharmaceutical care is not covered for the program in which the member is enrolled. Second Other Surgical Code Date is invalid. Part C Explanation of Benefits (EOB) Materials. Fifth Other Surgical Code Date is required. The content shared in this website is for education and training purpose only. A1 This claim was refused as the billing service provider submitted is: . A National Drug Code (NDC) is required for this HCPCS code. Charges Paid At Reduced Rate Based Upon Your Usual And Customary Pricing Profile. First modifier code is invalid for Date Of Service(DOS). Learns to use professional . Referring Provider is not currently certified. Please Supply The Appropriate Modifier. Received Beyond Special Filing Deadline For ThisType Of Claim Or Adjustment/reconsideration. Amount Recouped For Duplicate Payment on a Previous Claim. Pricing Adjustment/ Provider Level of Care (LOC) pricing applied. Physical Therapy Limited To 35 Treatment Days Per Spell Of Illness W/o Prior Authorization. Previously Denied Claims Are To Be Resubmitted As New-day Claims. Research Has Determined That The Member Does Not Qualify For Retroactive Eligibility According To Hfs 106.03(3)(b) Of The Wisconsin Administrative Code. Consultation or surgical procedures are not reimbursable in conjuctions with Emergency Room services. Denied. Training Completion Date Is Not A Valid Date. An approved PA was not found matching the provider, member, and service information on the claim. A WCDP drug rebate agreement for this drug is not on file for the Date Of Service(DOS). Providers should submit adequate medical record documentation that supports the claim (services) billed. Medicare Allowed Amount Was Incorrect Or Not Provided On Crossover Claim. Claim Denied. Pricing Adjustment/ Paid according to program policy. A Hospital Stay Has Been Paid For DOS Indicated. Denied due to Detail Fill Date Is A Future Date. Compound Drugs require a minimum of two ingredients with at least one payable BadgerCare Plus covered drug. This Check Automatically Increases Your 1099 Earnings. Denied. NDC- National Drug Code is not allowed for the member on the Date Of Service(DOS). Reading your EOB. The Clinical Profile, Narrative History, And Treatment History Indicate The Recipient Is Only Eligible For Maintenance Hours. Personal Care Services Exceeding 30 Hours Per 12 Month Period Per Member Require Prior Authorization. Provider Not Eligible For Outlier Payment. Each month you fill a prescription, your Medicare Prescription Drug Plan mails you an "Explanation of Benefits" (EOB). Service Fails To Meet Program Requirements. Active Treatment Dose Is Only Approved Once In Six Month Period. Established in 1975 and incorporated in 1987, WPC is widely recognized as a leading expert in supporting the development, publishing, and licensing of complex .
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