These Urinalysis Procedures Reimbursed Collectively At The Maximum For Routine Urinalysis With Microscopy. Procedure Code and modifiers billed must match approved PA. Unable To Process Your Adjustment Request due to Provider ID Not Present. If you are having difficulties registering please . Claims may deny when reported with mutually exclusive code combinations according to the ICD-10-CM Excludes 1 Notes guideline policy. This member is eligible for Medication Therapy Management services. An ICD-9-CM Diagnosis Code of greater specificity must be used for the Ninth Diagnosis Code. Medicare Part A Services Must Be Resubmitted. Hospital discharge must be within 30 days of from Date Of Service(DOS). Please Indicate Computation For Unloaded Mileage. Pricing Adjustment/ SeniorCare claim cutback because of Patient Liability and/or other insurace paid amounts. This Member Has Completed Primary Intensive Services And Is Now Only Eligible For after Care/follow-up Hours. No Separate Payment For IUD. The Ninth Diagnosis Code (dx) is invalid. From Date Of Service(DOS) is before Admission Date. All services should be coordinated with the Inpatient Hospital provider. Effective 04/01/09, the BadgerCare Plus Core Plan will limit coverage for Glucocorticoids-Inhaled to Flovent. Please Refer To The Original R&S. Claim Is Being Special Handled, No Action On Your Part Required. Members Aged 3 Through 21 Years Old Are Limited To One Healthcheck Screening per 12 months. Admission Date is on or after date of receipt of claim. Handwritten Changes/corrections On The Medicare EOMB Are Not Acceptable. Revenue Code Required. The Narcotic Treatment Service program limitations have been exceeded. Comprehension And Language Production Are Age-appropriate. Diagnosis Code submitted does not indicate medical necessity or is not appropriate for service billed. Discharge Diagnosis 3 Is Not Applicable To Members Sex. Adjustment and original claim do not have the same finanical payer, 6355 replacing 635R diagnosis (For use of Category of Service only), 6360 replacing 635S diagnosis (For use of Category of Service only), 6365 replacing 635T diagnosis (For use of Category of Service only). Drug Dispensed Under Another Prescription Number. This Is Not A Good Faith Claim. Resubmit The Original Medicare Determination (EOMB) Along With Medicares Reconsideration. Wellcare uses cookies. The Billing Providers taxonomy code is missing. Payment Subject To Pharmacy Consultant Review. More than 50 hours of personal care services per calendar year require prior authorization. X-rays and some lab tests are not billable on a 72X claim. Review Patient Liability/paid Other Insurance, Medicare Paid. Unable To Process Your Adjustment Request due to Financial Payer Not Indicated. Pricing Adjustment/ Resource Based Relative Value Scale (RBRVS) pricing applied. Tooth surface is invalid or not indicated. Denied due to Claim Contains Future Dates Of Service. Denied. A Version Of Software (PES) Was In Error. Contact The Nursing Home. 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. Level, Intensity Or Extent Of Service(s) Requested Has Been Modified Consistent With Medical Need As Defined In The Plan Of Care. Normal delivery reimbursement includes anesthesia services. Denied due to Services Billed On Wrong Claim Form. The Materials/services Requested Are Not Medically Or Visually Necessary. Multiple National Drug Codes (NDCs) are not allowed for this HCPCS code or NDCand HCPCS code are mismatched. August 14, 2013, 9:23 am . If some of the services were previously paid, submit an adjustment/reconsideration request for the paid claim. Modifier Submitted Is Invalid For The Member Age. Modifier invalid for Procedure Code billed. For example, a claim from a physician provider with place of service 11 (Office) would be considered incorrectly coded when a claim from an outpatient facility (e.g. Dental X-rays Indicate A Dental Cleaning, Followed By Good Dental Care At Home, Would Be Sufficient To Maintain Healthy Gums. 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. Unable To Process Your Adjustment Request due to Member ID Number On The Claim And On The Adjustment Request Do Not Match. A valid Prior Authorization is required for non-preferred drugs. The Functional Assessment And/or Progress Status Report Does Not Indicate Any Change, and/or Positive Rehabilitation Potential. DME rental is limited to 90 days without Prior Authorization. Procedure Code Changed To Permit Appropriate Claims Processing. The Procedure Code/Modifier combination is not payable for the Date Of Service(DOS). Medical Necessity For Food Supplements Has Not Been Documented. codes are provided per day by the same individual physician or other health care professional. Service Denied. Reimbursement also may be subject to the application of Denied. Payment reduced. Pricing Adjustment/ Payment reduced due to benefit plan limitations. Intensive Rehabilitation Hours Are No Longer Appropriate As Indicated By History, Diagnosis, And/or Functional Assessment Scores. It Must Be In MM/DD/YY Format AndCan Not Be A Future Date. Claim or line denied. Service Billed Exceeds Restoration Policy Limitation. Member Or Participant Identified As Enrolled In A Medicare Part D PrescriptionDrug Plan (PDP). Claim Reduced Due To Member Income Available Toward Cost Of Care (Nursing Home Liability). Home Health visits (Nursing and therapy) in excess of 30 visits per calendar year per member require Prior Authorization. Claim reimbursement has been cutback to reimbursement limits for denture repairs performed within 6 months. Birth to 3 enhancement is not reimbursable for place of service billed. Medicare paid amount(s) have been incorrectly applied to both the claim headerand details. Submitted referring provider NPI in the header is invalid. AODA Day Treatment Is Not A Covered Service For Members Who Are Residents Of Nursing Homes or Who Are Hospital Inpatients. Payment has been reduced or denied because the maximum allowance of this ESRD service has been reached. Procedure Denied Per DHS Medical Consultant Review. An ICD-9-CM Diagnosis Code of greater specificity must be used for the Eighth Diagnosis Code. Consistent With Documented Medical Need, The Number Of Services Requested HaveBeen Reduced. Member is not Medicare enrolled and/or provider is not Medicare certified. Duplicate/second Procedure Deemed Medically Necessary And Payable. Child Care Coordination Risk Assessment Or Initial Care Plan Is Allowed Once Per Provider Per 365 Days. Additional Encounter Service(s) Denied. Valid Numbers Are Important For DUR Purposes. The three key components when selecting the appropriate level of E&M services provided are history, examination, and medical decision-making. Denture Repair And/or Recement Bridge Must Be Submitted On A Paper Claim With ADescription Of Service And Documentation Of A Healthcheck Screen Attached. Rendering Provider is not a certified provider for Wisconsin Chronic Disease Program. Please Resubmit. Claimchecks Editing And Your Supporting Documentation Was Reviewed By The DHS Medical Consultant. Denied. No payment allowed for Incidental Surgical Procedure(s). Header and/or Detail Dates of Service are missing, incorrect or contain futuredates. MassHealth List of EOB Codes Appearing on the Remittance Advice. The Functional Assessment Indicates This Member Has Less Than A 50% Likelihoodof Benefit, Therefore Day Treatment Is Not Appropriate. Resubmit Private Duty Nursing Services For Complex Children With Documentation Supporting The Level Of Care. This claim is a duplicate of a claim currently in process. Claim reduced to fifteen Hospital Bedhold Days for stays exceeding fifteen days. Member has Medicare Managed Care for the Date(s) of Service. Unable To Process Your Adjustment Request due to Provider ID Number On The Claim And On The Adjustment Request Do Not Match. Denied. A Payment Has Already Been Issued For This SSN. If laboratory costs exceed reimbursement, submit a claim adjustment request with lab bills for reconsideration. Denied. Denied due to Medicare Allowed, Deductible, Coinsurance And Paid Amounts Do Not Balance. EOB Any EOB code that applies to the entire claim (header level) prints here. Quantity Billed is restricted for this Procedure Code. Pharmaceutical Care is not covered by the Wisconsin Chronic Disease Program. Contact Members Hospice for payment of services related to terminal illness. Only Medicare crossover claims are reimbursable. Claims may deny when reported with incompatible ICD-10-CM Laterality policy for Diagnosis-to-Modifier comparison. Denied due to Procedure Billed Not A Covered Service For Dates Indicated. Day Treatment Services For Members With Inpatient Status Limited To 20 Hours. Dental service is limited to once every six months. Cannot bill for both Assay of Lab and other handling/conveyance of specimen. Services billed exceed prior authorized amount. Use This Claim Number For Further Transactions. Rebill On Pharmacy Claim Form. Principal Diagnosis 9 Not Applicable To Members Sex. Please Request A Corrected EOMB Through The Medicare Carrier And Adjust With The Corrected EOMB. 51.42 Board Directors Or Designees Statement & Signature Required OnThe Claim Form For Payment Of Functional Assessment. Only one initial visit of each discipline (Nursing) is allowedper day per member. Errors in one of the following data elements exceed their field size: Statement covered FROM Date, Admission date, Date Of Service(DOS), Revenue code. The Service Requested Is Not A Covered Benefit As Determined By . Proposed Orthodontic Service Denied; Examination/study Models Are Approved. Adjustment Requested Member ID Change. Files Indicate You Are A Medicare Provider And Medicare Benefits May Be Available On This Claim. DRG cannotbe determined. Denied. Non-scheduled drugs are limited to the original dispensing plus 11 refills or 12 months. Member must receive this service from the state contractor if this is for incontinence or urological supplies. Please Do Not Resubmit Your Claim, And Disregard Additional Informational Messages for this claim. Diagnosis Code indicated is not valid as a primary diagnosis. The Existing Appliance Has Not Been Worn For Three Years. Effective 5/31/2019, we will introduce new Coding Integrity Reimbursement Guidelines. Claim Denied. Claim Number Given On The Adjustment/reconsideration Request Form Does Not Match Services Originally Billed. Pricing Adjustment/ Traditional dispensing fee applied. TPA Certification Required For Reimbursement For This Procedure. Rendering Provider is not certified for the From Date Of Service(DOS). Claim or Adjustment received beyond 730-day filing deadline. Submitclaim to the appropriate Medicare Part D plan. Modification Of The Request Is Necessitated By The Members Minimal Progress. Revenue Code 0001 Can Only Be Indicated Once. Provider Reminders: Claims Definitions. Has Recouped Payment For Service(s) Per Providers Request. Denied. Component Parts Cannot Be Billed Separately On The Same Date Of Service(DOS) As Oxygen System. Denied due to The Members Last Name Is Incorrect. Claim Detail Is Pended For 60 Days. 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). If it is medical necessary for more than 13 or 14 services per calendar month, submit an adjustment request with supporting documentation. Medicaid id number does not match patient name. Denied. Revenue codes 0822, 0823, 0825, 0832, 0833, 0835, 0842, 0843, 0845, 0852, 0853, or 0855 exist on the ESRD claim that does not contain condition code 74. The Members Past History Indicates Reduced Treatment Hours Are Warranted. Example: Diagnosis code 285.21 is entered as 28521, without a period or space. Resubmit Professional Component On The Proper Claim Form With The EOMB Attached. EDI TRANSACTION SET 837P X12 HEALTH CARE . Claim Number Given Is Not The Most Recent Number. Reason for Service submitted does not match prospective DUR denial on originalclaim. LO DENIED - RCVD MORE THAN 60 DAYS AFTER DATE ON EOB FROM OTHER MA67 2D ADJUSTMENT - DENIAL UPHELD-TIMELINESS NOT JUSTIFIED: 31 N30 34: DENIED - NOT A PLAN MEMBER,PROVIDER MUST BILL E.D.S. Computed tomography (CT) of the head or brain (CPT 70450, 70460, 70470), Computed tomographic angiography (CTA) of the head (CPT 70496), Magnetic resonance angiography (MRA) of the head (CPT 70544, 70545, 70546), Magnetic resonance imaging (MRI) of the brain (CPT 70551, 70552, 70553), Duplex scan of extracranial arteries (CPT 93880,93882), Computed tomographic angiography (CTA) of the neck(CPT 70498), Magnetic resonance angiography (MRA) of the neck(CPT 70547, 70548, 70549), ICD-10 Diagnosis codes G43.009, G43.109, G43.709, G43.809, G43.829, G43.909. Unable To Process Your Adjustment Request due to. 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. Reimbursement Based On Members County Of Residence. When diagnoses 800.00 through 999.9 are present, an etiology (E-code) diagnosis must be submitted in the E-code field. Header To Date Of Service(DOS) is required. New Prescription Required. Claim Denied Due To Invalid Pre-admission Review Number. 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. Treatment With More Than One Drug Per Class Of Ulcer Treatment Drug At The Same Time Is Not Allowed Through Stat PA. Only non-innovator drugs are covered for the members program. 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. Diagnosis Indicated Is Not Allowable For Procedures Designated As Mycotic Procedures. The Procedure Code Indicated Is For Informational Purposes Only. This drug is not covered for Core Plan members. Reimbursement For This Detail Does Not Include Unit DoseDispensing Fee. The Surgical Procedure Code is not payable for the Date Of Service(DOS). Number Is Missing Or Incorrect. THE WELLCARE GROUP OF COMPANIES . No More Than 2 Medication Check Services (30 Minutes) Are Payable Per Date Of Service(DOS). Intermittent Peritoneal Dialysis hours must be entered for this revenue code. WCDP member enrolled in Medicare Part D. Claim is excluded from Drug Rebate Invoicing. Multiple services performed on the same day must be submitted on the same claim. Only Healthcheck Modifiers Can Be Billed With Healthcheck Services. One or more Condition Code(s) is invalid in positions eight through 24. Training Completion Date Must Be Within A Year Of The CNAs Certification, Test, Date. Alternatively, CPT XXXXX has been billed in the previous 10 days for a CPT code with a 10-day post-operative period, or in the previous 90 days for a code with a 90-day post-operative period by the same provider. The Rendering Providers taxonomy code in the header is not valid. This National Drug Code Has Diagnosis Restrictions. This claim was processed using a program assigned provider ID number, (e.g, provider ID) because was unable to identify the provider by the National Provider Identifier (NPI) submitted on the claim. Claim Is Pended For 60 Days. Claim Denied. The Second Other Provider ID is missing or invalid. Please Disregard Additional Information Messages For This Claim. Billing Provider is not certified for the Date(s) of Service. Due To Non-covered Services Billed, The Claim Does Not Meet The Outlier Trim Point. Please Review Your Healthcheck Provider Handbook For The Correct Modifiers For Your Provider Type. This National Drug Code (NDC) has Encounter Indicator restrictions. 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. Service billed is bundled with another service and cannot be reimbursed separately. Occurrence Code is required when an Occurrence Date is present. This procedure is limited to once per day. Ability to proficiently use Microsoft Excel, Outlook and Word. Pricing Adjustment/ Patient Liability deduction applied. WI Can Not Issue A NAT Payment Without A Valid Hire Date. Critical care performed in air ambulance requires medical necessity documentation with the claim. Please Resubmit Corr. Watch FutureRemittance And Status Reports For Its Finalization Before Resubmitting. CORE Plan Members are limited to 25 non-emergency outpatient hospital visits per enrollment year. It Corrects A Mispayment FoundDuring Claims Processing Or Resulting From Retroactive File Changes. This Dental Service Limited To Once Every Six Months, Unless Prior Authorized. Explanation of Benefits (EOB) The four-digit explanation of benefits (EOB) codes and the corresponding narratives indicate that the submitted claim paid as billed or describe the reason the claim suspended, was denied, or did not pay in full. NDC is obsolete for Date Of Service(DOS). Less Expensive Alternative Services Are Available For This Member. Nine Digit DEA Number Is Missing Or Incorrect. Denied/Cutback. Outside Lab,element 20 On CMS 1500 Claim Form Must Be Checked Yes When Handling Charges Are Billed. Reimbursement For This Certification, Test, Segment Has Been Issued To AnotherNF. Based on these reimbursement guidelines, claims may deny when the following revenue codes are billed without the appropriate HCPCS code: Please Review The Cover Letter Attached To Your Claim, Any Informational Messages, And Provide The Requested Information BeforeResubmitting the Claim. 3101. This National Drug Code (NDC) is not covered. Denied. Recasing Or Replacement Of Hearing Aid Case Is Limited To Once Per 2 Year Period Per Member Per Provider. A valid Referring Provider ID is required. Benefit Payment Determined By Fiscal Agent Review. Pap Smears, Hematocrit, Urinalysis Are Not Reimbursable Separately In Conjunction With Family Planning Medical Visits. Members File Shows Other Insurance. Individual Test Paid. Denied/Cutback. Denied. Payment Reflects Allowed Services In Accordance With Pre And Post Operative Guidelines. Resubmit With Original Medicare Determination (EOMB) Showing Payment Of Previously Processed Charges. Denied due to Detail Add Dates Not In MM/DD Format. Hearing aid repairs are limited to once per six months, per provider, per hearing aid. Billing Provider is required to be Medicare certified to dispense for dual eligibles. Dialysis/EPO treatment is limited to 13 or 14 services per calendar month. Only One Outpatient Claim Per Date Of Service(DOS) Allowed. Capitation Payment Recouped Due To Member Disenrollment. Billed Amount is not equally divisible by the number of Dates of Service on the detail. Please Correct And Resubmit. If authorization number available . Claim Is Pended For 60 Days. Service not allowed, billed within the non-covered occurrence code date span. Hospice Member Services Related To The Terminal Illness Must Be Billed By Hospice Or Attending Physician. Reimburse Is Limited To Average Monthly NHCost And Services Above That Amount Are Consider non-Covered Services. Rendering Provider may not submit claims for reimbursement as both the Surgeonand Assistant Surgeon For The Same Member On The Same DOS. We Are Recouping The Payment. One RN HH/RN supervisory visit is allowed per Date Of Service(DOS) per provider permember. Medicare Deductible Is Paid In Full. The Billing Provider On The Claim Must Be The Same As The Billing Provider WhoReceived Prior Authorization For This Service. Denied. This Procedure Is Limited To Once Per Day. Referring Provider ID is not required for this service. Contact Wisconsin s Billing And Policy Correspondence Unit. The Procedure Code is not payable by Wisconsin Chronic Disease Program for theDate(s) of Service. Denied. Routine Foot Care Procedures Must Be Billed With Valid Routine Foot Care Diagnosis. Incorrect Liability Start/end DatesOr Dollar Amounts Must Be Corrected Through County Social Services Agency. Payment(s) For Capital Or Medical Education Are Generated By EDS And May Not Be Billed By The Provider. Second Surgical Opinion Guidelines Not Met. Reimbursement For IUD Insertion Includes The Office Visit. Documentation Does Not Justify Medically Needy Override. Procedue Code is allowed once per member per calendar year. Please Add The Coinsurance Amount And Resubmit. Claim count of Present on Admission (POA) indicators does not match count of non-admitting and non-emergency diagnosis codes. Request Denied Due To Late Billing. An approved PA was not found matching the provider, member, and service information on the claim. The Member Is Enrolled In An HMO. Denied due to The Member WCDP Id Number Is Incorrect Or Not On Our Current Eligibility File. Claim Denied For Invalid Billing Type Frequency Code, Claim Type, Or SubmittedAdjustment Provider Number Does Not Match Original Claims Provider Number. Only One Panel Code Within Same Category (CBC Or Chemistry) Maybe Performed Per Member/Provider/Date Of Service. Pricing Adjustment/ Reimbursement reduced by the members copayment amount. This Service Is Included In The Hospital Ancillary Reimbursement. The dental procedure code and tooth number combination is allowed only once per lifetime. Refer To Notice From DHS. 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). Requires A Unique Modifier. Header Bill Date is before the Header From Date Of Service(DOS). PA required for payment of this service. Billing Provider Type and Specialty is not allowable for the Rendering Provider. Effective With Claims Received On And After 10/01/03 , Occurrence Codes 50 And 51 Are Invalid. This dental service limited to once per five years.Prior Authorization is needed to exceed this limit. One BMI Incentive payment is allowed per member, per renderingprovider, per calendar year. An ICD-9-CM Diagnosis Code of greater specificity must be used for the Second Diagnosis Code. Medical Need For Equipment/supply Requested Is Not Supported By Documentation Submitted. Additional rental of a negative pressure wound therapy pump is limited to 90 days in a 12 month period. Denied due to Statement Covered Period Is Missing Or Invalid. Quantity Billed is missing or exceeds the maximum allowed per Date Of Service(DOS). Prior Authorization is needed for additional services. The respiratory care services billed on this claim exceed the limit. Pharmaceutical care code must be billed with a valid Level of Effort. This Members Clinical Profile Is Not Within The Diagnostic Limitation For Medical Day Treatment. Reimbursement Is At The Unilateral Rate. Multiple Referral Charges To Same Provider Not Payble. Authorizations. Invalid Provider Type To Claim Type/Electronic Transaction. This Member Is Receiving Concurrent AODA/Psychotherapy Services And Is Therefore Only Eligible For Maintenance Hours. A valid Level of Effort is also required for pharmacuetical care reimbursement. An Explanation of Benefits (EOB) code corresponds to a printed message about the status or action taken on a claim.