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All services should be coordinated with the primary provider. Information Required For Claim Processing Is Missing. The To Date Of Service(DOS) for the Second Occurrence Span Code is invalid. CO/204/N182 . Please adjust quantities on the previously submitted and paid claim. Discharge Date is before the Admission Date. WellCare 2016 NA_11_16 NA6PROGDE80121E_1116 . This Procedure Is Denied Per Medical Consultant Review. If it is medically necessary to exceed the limitation, submit an Adjustment/Reconsideration request with supporting documentation. NDC was reimbursed at AWP (Average Wholesale Price) (Average Wholesale Price) rate. Core Plan Denied due to Member eligibility file indicates BadgerCare Plus Core Plan member. If Required Information Is not received within 60 days, the claim detail will be denied. There are many different remittance adjustment reason codes (RARCs) established for Medicare and we understand their explanations may be "generic" and confusing, so we have provided a listing in the table below of the most commonly used denial messages and RARCs utilized by Medical Review Part B during medical record review. NDC- National Drug Code is not covered on a pharmacy claim. Handwritten Changes/corrections On The Medicare EOMB Are Not Acceptable. Timely Filing Request Denied. Medicare Copayment Out Of Balance. Independent Nurses, Please Note Payable Services May Not Exceed 12 Hours/dayOr 60 Hours/week. Denied/recouped. The Procedure Code billed not payable according to DEFRA. This claim is a duplicate of a claim currently in process. Pricing Adjustment/ Reimbursement reduced by the members copayment amount. Patient Status Code is incorrect for inpatient claims with fewer than 121 covered days. Claim paid at the program allowed amount. When diagnoses 800.00 through 999.9 are present, an etiology (E-code) diagnosis must be submitted in the E-code field. Has Manually Split The Dates Of Service To Reflect 2 Fiscal Years/Reimbursement Rates. Maximum Reimbursement Amount Has Been Determined By Professional Consultant. Pricing Adjustment/ Usual & Customary Charge (UCC) flat fee pricing applied. Claim Denied For Invalid Billing Type Frequency Code, Claim Type, Or SubmittedAdjustment Provider Number Does Not Match Original Claims Provider Number. Documentation Does Not Justify Fee For ServiceProcessing . Please Bill Medicare First. Denied. Fifth Other Surgical Code Date is required. Members Age 3 And Older Must Have An Oral Assessment And Blood Pressure Check.With Appropriate Referral Codes, For Payment Of A Screening. Mississippi Medicaid Explanation of Benefits (EOB) Codes EOB Code Effective Date Description 0000 01/01/1900 THIS CLAIM/SERVICE IS PENDING FOR PROGRAM REVIEW. Payment(s) For Capital Or Medical Education Are Generated By EDS And May Not Be Billed By The Provider. Member Expired Prior To Date Of Service(DOS) On Claim. OA 11 The diagnosis is inconsistent with the procedure. BY . Revenue code 082X is present on an ESRD claim which also contains revenue code088X (X frequency non equal to 9). HTTP Status Code Connect Time (ms) Result; 2023-03-01 04:10:52: 200: 255: Page Active: Service Denied. Reimbursement For IUD Insertion Includes The Office Visit. This Claim Has Been Denied Due To A POS Reversal Transaction. NDC- National Drug Code is restricted by member age. The National Drug Code (NDC) has a quantity restriction. Based on these reimbursement guidelines, claims may deny when the following revenue codes are billed without the appropriate HCPCS code: Missing Processor Control Number (PCN) for SeniorCare member over 200% FPL or invalid PCN for WCDP member, member or SeniorCare member at or below 200% FPL. The topic of Requirements for Compression Garments can be found in the Claims Section, Submission Chapter. Adjustment Denied For Insufficient Information. I'm getting a 2% CMS Mandate on my Wellcare EOB's. What is that? Home Health, Personal Care And Private Duty Nursing Services Are Subject To A Monthly Cap. Procedure Code Changed To Permit Appropriate Claims Processing. Service is covered only during the first month of enrollment in the Home and Community Based Waiver. The Number In The National Provider Identifier (NPI) Section On This Request IsNot A Number Assigned To A Certified Nursing Facility For This Date Of Service(DOS). Members I.d. Individual Test Paid. A Primary Occurrence Code Date is required. The Surgical Procedure Code is not payable for the Date Of Service(DOS). Timely Filing Deadline Exceeded. Denied due to Member Not Eligibile For All/partial Dates. Rendering Provider may not submit claims for reimbursement as both the Surgeonand Assistant Surgeon For The Same Member On The Same DOS. The sum of all Value Code amounts must be numeric and less than or equal to 999.999.999. The American College of Emergency Physicians (ACEP) also indicates that it is not appropriate to perform screening with advanced imaging for syncope patients, however be guided by the patients history and physical exam findings. Procedure Not Payable for the Wisconsin Well Woman Program. Claim paid at program allowed rate. Secondary Diagnosis Code(s) in positions 2-9 cannot duplicate the Primary Discharge Diagnosis. Services Denied. Questionable Long-term Prognosis Due To Apparent Root Infection. DX Of Aphakia Is Required For Payment Of This Service. Pricing Adjustment/ Third party liability amount applied is greater than the amount paid by the program. Pricing AdjustmentUB92 Hospice LTC Pricing. Valid group codes for use on Medicare remittance advice are:. Please Add The Coinsurance Amount And Resubmit. Prior authorization is required for Maxalt when Maxalt or sumatriptan productshave not been reimbursed within 365 days. The submitted claim contains value code 68 and 48 or 49 but does not contain revenue code 0634 or 0635 and HCPCS Q4055. Pricing Adjustment/ Long Term Care pricing applied. 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. Service(s) exceeds four hour per day prolonged/critical care policy. Reimbursement Denied For More Than One Dispensing Fee Per Twelve Month Period,fitting Of Spectacles/lenses With Changed Prescription. Providers should submit adequate medical record documentation that supports the claim (services) billed. Please Correct And Re-bill. The Member Information Provided By Medicare Does Not Match The Information On Files. Questionable Long Term Prognosis Due To Gum And Bone Disease. Service not payable with other service rendered on the same date. SMV Or Prescribing Provider Description Code(s) Missing OrInvalid. You Must Adjust The Nursing Home Coinsurance Claim. Rinoplastia; Blefaroplastia Please submit claim to BadgerRX Gold. The Maximum Allowable Was Previously Approved/authorized. Pricing Adjustment/ Traditional dispensing fee applied. Effective September 1, 2021: Benefit Changes to Total Disc Arthroplasty for Medicaid and CHIP. Non-scheduled drugs are limited to the original dispensing plus 11 refills or 12 months. The Information Provided Indicates This Member Is Not Willing Or Able To Participate Inaftercare/continuing Care Services And Is Therefore Not Eligible For AODA Day Treatment. Denied. PDN Codes W9045/w9046 Are Not Payable On The Same Date As PDN Codes W9030/W9031 For The Same Provider And Member. The Other Payer ID qualifier is invalid for . Reason Code: 234. Intraoral Complete Series/comprehensive Oral Exam Limited To Once Every Three Years, Unless Prior Authorized. Only Healthcheck Modifiers Can Be Billed With Healthcheck Services. For FQHCs, place of service is 50. Please Correct and Resubmit. Discharge Diagnosis 4 Is Not Applicable To Members Sex. Will Not Authorize New Dentures Under Such Circumstances. Services Billed Denied As Being Covered In The Payment For Day Rx Per Medical Day Treatment Guidelines. Independent Laboratory Provider Number Required. Compound drugs require a minimum of two components with at least one payable FowardHealth covered drug. 2D3D CODES: Radiation treatment delivery, superficial and/or ortho voltage, per day 77401 Radiation treatment delivery, >1 MeV; simple 77402 . Excessive height and/or weight reported on claim. 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. Charges For Anesthetics Are Included In Charge For All Surgical Procedures. Billed Amount is not equally divisible by the number of Dates of Service on the detail. Received Beyond Special Filing Deadline For ThisType Of Claim Or Adjustment/reconsideration. Anesthesia Modifying Services Must Be Billed Separately From The Charge For Anesthesia Base And Time Units. Treatment With More Than One Drug Per Class Of Ulcer Treatment Drug At The Same Time Is Not Allowed Through Stat PA. Acknowledgement Of Receipt Of Hysterectomy Info Form Is Missing, Incomplete, Or Contains Invalid Information. Service Billed Limited To Three Per Pregnancy Per Guidelines. Up to a $1.10 reduction has been applied to this claim payment. The Member Is Involved In group Physical Therapy Treatment. Effective 5/31/2019, we will introduce new Coding Integrity Reimbursement Guidelines. A SeniorCare drug rebate agreement is not on file for this drug for the Date Of Service(DOS). A National Provider Identifier (NPI) is required for the Performing Provider listed in the header. The Service Requested Is Considered To Be Professionally Unacceptable, Unproven and/or Experimental. The Provider Type/specialty Is Not Recognized For These Date(s) Of Service. This drug/service is included in the Nursing Facility daily rate. Denied due to Service Is Not Covered For The Diagnosis Indicated. Please Verify That Physician Has No DEA Number. There are approximately 20 Medicaid Explanation Codes which map to Denial Code 16. A Separate Notification Letter Is Being Sent. Continue ToUse Appropriate Codes On Billing Claim(s). Rendering Provider is not certified for the Date(s) of Service. Psychotherapy Provided In The Members Home Is Not A Covered Benefit Of . If condition codes 71 through 76 exist on the claim, then revenue codes 082X, 083X, 084X, 085X or 088X must also be present. The Service Requested Is Not A Covered Benefit Of The Program. The Surgical Procedure Code is not payable for Wisconsin Chronic Disease Program for the Date Of Service(DOS). We update the Code List to conform to the most recent publications of CPT and HCPCS . This is a same-day claim for bill types 13X, 14X, 71X, or 83X and there are multiple units or combination of chemistry/hemotology tests. Pharmaceutical Care is not covered by the Wisconsin Chronic Disease Program. Services Beyond The Six Week Postpartum Period Are Not Covered, Per DHS. The Clinical Status Of The Member Does Not Meet Standards Accepted By The Department Of Health And Family Services For Transplant. Bill The Single Appropriate Code That Describes The Total Quantity Of Tests Performed. This Claim Is Being Reprocessed As An Adjustment On This R&s Report. Procedure Code and modifiers billed must match approved PA. The detail From or To Date Of Service(DOS) is missing or incorrect. 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. Claim Currently Being Processed. Member has Medicare Managed Care for the Date(s) of Service. According to the American College of Radiology and the International Society for Clinical Densitometry, dual-energy X-ray absorptiometry (DXA) bone density screening (77080 or 77081) is not indicated for women under age 65 or men under age 70 without risk factors for osteoporosis. These are EOB codes, revised for NewMMIS, that may appear on your PDF remittance advice. wellcare explanation of payment codes and comments. Header and/or Detail Dates of Service are missing, incorrect or contain futuredates. Medication checks by a Psychiatrist and/or Registered Nurse are limited to four services per calendar month. CNAs Eligibility For Nat Reimbursement Has Expired. This National Drug Code (NDC) has diagnosis restrictions. The Comprehensive Community Support Program reimbursement limitations have been exceeded. Denied due to Medicare Allowed Amount Required. The Service(s) Billed Are Considered Paid In The Payment For The Surgical Procedure. See Physicians Handbook For Details. Please Disregard Additional Messages For This Claim. The Total Billed Amount is missing or incorrect. General Exercise To Promote Overall Fitness And Flexibility Are Non-covered Services. The taxonomy code for the attending provider is missing or invalid. Oral exams or prophylaxis is limited to once per year unless prior authorized. Only the initial base rate is payable when waiting time is billed in conjunction with a round trip. Timely Filing Deadline Exceeded. 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 . Hospital discharge must be within 30 days of from Date Of Service(DOS). Denied. No Matching, Complete Reporting Form Is On File For This Client. 1 PC Dispensing Fee Allowed Per Date Of Service(DOS). Claim Denied. Denied. Default Prescribing Physician Number XX9999991 Was Indicated. Has Recouped Payment For Service(s) Per Providers Request. The Value Code and/or value code amount is missing, invalid or incorrect. If the KT/V reading was not performed, then the value code D5 with 9.99 must be present without the occurrence code 51. Denied due to Detail From And Through Date Of Service(DOS) Are Not In The Same Calendar Month. 2. Take care to review your EOB to ensure you understand recent charges and they all are accurate. Billing Provider indicated is not certified as a billing provider. The service requested is not allowable for the Diagnosis indicated. Denied due to Per Division Review Of NDC. Basic Knowledge of Explanation of Benefits (EOB) interpretation. A HCPCS code is required when condition code A6 is included on the claim. Calls are recorded to improve customer satisfaction. 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. Find top links about Wellcare Cvs Caremark Login along with social links, FAQs, and more. Billing Provider Name Does Not Match The Billing Provider Number. Per Information From Insurer, Prior Authorization Was Not Requested/approved Prior To Providing Services. Denied. Member is covered by a commercial health insurance on the Date(s) of Service. Denied. Medicare Disclaimer Code invalid. Cannot bill for both Assay of Lab and other handling/conveyance of specimen. Denied due to The Members Last Name Is Incorrect. A covered DRG cannot be assigned to the claim. Pricing Adjustment/ Payment amount increased based on hospital access paymentpolicies. Denied due to Procedure/Revenue Code Is Not Allowable. 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. These Services Paid In Same Group on a Previous Claim. The Third Occurrence Code Date is invalid. Claim Reduced Due To Member/participant Deductible. Reimbursement Based On Members County Of Residence. Department of Health Services (DHS) Authorized Payment Is Being Withheld Due toa Department Of Justice Settlement. This Payment Is To Satisfy The Amount Indicated On The Administrative Claiming Reimbursement Summary Report. Multiple Unloaded Trips For Same Day/same Recip. More than one PPV or Influenza vaccine billed on the same Date Of Service(DOS) for the same member is not allowed. Do Not Indicate A Hcpcs Or Cpt Procedure Code On An Inpatient Claim. Denied. The Rendering Providers taxonomy code in the header is invalid. Records Indicate This Tooth Has Previously Been Extracted. The relationship between the Billed and Allowed Amounts exceeds a variance threshold. Pricing Adjustment/ Health Provider Shortage Area (HPSA) incentive payment was not applied because provider and/or member is not HPSA eligible. Activities To Promote Diversion Or General Motivation Are Non-covered Services. You Received A PaymentThat Should Have gone To Another Provider. Complex Evaluation and Management procedures require history and physical or medical progress report to be submitted with the claim. Our Records Indicate You Have Billed More Than One Unit Dose Dispensing Fee For This Calendar Month. Denied due to Claim Exceeds Detail Limit. HIPAA EOB codes are returned on the 835 Remittance Advice file and are maintained by the Washington Publishing Company. FACIAL. For dates of service on or after 7/1/10 for TOB 72X an occurrence code 51 and value code D5 are required when the KT/V reading was performed. Performed After Therapy/dayTreatment Have Begun Must Be Billed As Therapy Or Limit-exceed Psych/aoda/func.