A Pharmaceutical Care Code (PCC) must include a valid diagnosis code. Pricing Adjustment/ Level of effort dispensing fee applied. 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. Providers May Only Bill For Assessments And Care Plans Twice Per Calendar Year. Additional Psychotherapy Is Not Considered Appropriate Or Inline With More Effective, Available Services. Provider Is Responsible For Averaging Costs During Cal Year Not To Exceed YrlyTotal (12 x $2325.00). ACCOM REV CODE QTY BILLED NOT EQUAL TO DTL DOS. Please Refer To The PDL For Preferred Drugs In This Therapeutic Class. 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. Incidental modifier is required for secondary Procedure Code. . Bilateral Procedures Must Be Billed On One Detail With Modifier 50, Quantity Of 1.detail With Modifier 50 May Be Adjusted If Necessary. Please Use This Claim Number For Further Transactions. This member is eligible for Medication Therapy Management services. A valid procedure code is required on WWWP institutional claims. Benefit Payment Determined By DHS Medical Consultant Review. Reason Code 160: Attachment referenced on the claim was not received. Claims may deny for audiology screening (CPT 92551, 92560, V5008) may be denied when a provider bills for auditory screening services at the same time as a preventive medicine visit (CPT 99381-99397) or wellness visit (CPT G0438-G0439), without appropriate modifier appended to the E&M service to identify a separately identifiable procedure. If A Reporting Form Is Not Submitted Within 60 Days, The claim detail will be denied. Also, to ensure claims process and pay accurately, Staywell may deny a claim and ask for pertinent medical documentation from the provider or supplier who submitted the claim. Reimburse Is Limited To Average Monthly NHCost And Services Above That Amount Are Consider non-Covered Services. Services Requested Do Not Meet The Criteria for an Acute Episode. Pricing Adjustment/ Inpatient Per-Diem pricing. Did You check More Than One Box?If So, Correct And Resubmit. This Member Appears To Continue To Abuse Alcohol And/or Other Drugs And Is Therefore Not Eligible For Day Treatment. An ICD-9-CM Diagnosis Code of greater specificity must be used for the Second Diagnosis Code. Denied/cutback. The Functional Assessment And/or Progress Status Report Does Not Indicate Any Change, and/or Positive Rehabilitation Potential. The Primary Diagnosis Code is inappropriate for the Surgical Procedure Code. A WCDP drug rebate agreement for this drug is not on file for the Date Of Service(DOS). General Assistance Payments Should Not Be Indicated On Claims. Claim paid at program allowed rate. Authorization For Surgery Requiring Second Opinion Valid For 6Months After Date Approved. Diag Restriction On ICD9 Coverage Rule edit. A Fourth Occurrence Code Date is required. Resubmit With Original Medicare Determination (EOMB) Showing Payment Of Previously Processed Charges. The Revenue Code is not payable by Wisconsin Chronic Disease Program for the Date(s) of Service. Complex Evaluation and Management procedures require history and physical or medical progress report to be submitted with the claim. The Total Number Of Sessions Requested Exceeds Quarterly Guidelines. Denied. Services Requiring Prior Authorization Cannot Be Submitted For Payment On A Claim In Conjunction With Non Prior Authorized Services. Claims adjustments. The detail From Date Of Service(DOS) is required. Sixth Diagnosis Code (dx) is not on file. All services should be coordinated with the primary provider. One or more From Date Of Service(DOS) (DOS) is invalid for Occurrence Span Codes in positions three through 24. WellCare Known Issues List This Procedure Is Limited To Once Per Day. See Physicians Handbook For Details. Outside Lab Indicator Must Be Y For The Procedure Code Billed. Only the initial base rate is payable when waiting time is billed in conjunction with a round trip. Fifth Other Surgical Code Date is invalid. This National Drug Code (NDC) has Encounter Indicator restrictions. Rendering Provider Type and/or Specialty is not allowable for the service billed. Use the most current year's ICD-9-CM or ICD-10-CM codes, depending on the date(s) of service. DRG cannotbe determined. When Billing For Basic Screening Package, Charge Must Be Indicated Under Procedure W7000. Procedure Code is not covered for members with a Nursing Home Authorization onthe Date(s) of Service. 2% CMS MANDATE | Medical Billing and Coding Forum - AAPC Dispensing fee denied. Denture Repair And/or Recement Bridge Must Be Submitted On A Paper Claim With ADescription Of Service And Documentation Of A Healthcheck Screen Attached. The CNA Is Only Eligible For Testing Reimbursement. Member Is Enrolled In A Family Care CMO. External Cause Diagnosis May Not Be The Single Or Primary Diagnosis. Unable To Process Your Adjustment Request due to Financial Payer Not Indicated. NFs Eligibility For Reimbursement Has Expired. Members I.d. The Service Billed Does Not Match The Prior Authorized Service. RN And LPN Subsequent Care Visits Limited To 6 Hrs Per Day/per Member/per Provider. This Member, As Indicated By Narrative History, Does Not Agree To Abstinence from Alcohol Or Other Drugs And Is Ineligible For AODA Treatment. Rebill On Pharmacy Claim Form. The Ninth Diagnosis Code (dx) is invalid. Claim Denied. Please Submit With Completed timely Filing Form In The All Provider Handbook And Supporting Documentation. Denied. Please Furnish A UB92 Revenue Code And Corresponding Description. The Services Requested Are Not Reasonable Or Appropriate For The AODA-affectedmember. Pricing Adjustment/ Maximum allowable fee pricing applied. Billing or Rendering Provider certification is cancelled for the From Date Of Service(DOS). Avoiding denial reason code CO 22 FAQ Q: We received a denial with claim adjustment reason code (CARC) CO 22. Billing Provider Name Does Not Match The Billing Provider Number. Rendering Provider is not a certified provider for Wisconsin Chronic Disease Program. Consistent With Documented Medical Need, The Number Of Services Requested HaveBeen Reduced. This care may be covered by another payer per coordination of benefits. Continuous home care and routine home care may not be billed for the same member on the same Date Of Service(DOS). Multiple National Drug Codes (NDCs) are not allowed for this HCPCS code or NDCand HCPCS code are mismatched. Type of Bill indicates services not reimbursable or frequency indicated is notvalid for the claim type. This Diagnosis Code Has Encounter Indicator restrictions. 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. NDC was reimbursed at brand WAC (Wholesale Acquisition Cost) (Wholesale Acquisition Cost) rate. Claim contains duplicate segments for Present on Admission (POA) indicator. Pharmaceutical Care Codes Are Billable On Non-compound Drug Claims Only. This Claim Has Been Excluded From Home Care Cap To Allow For Acute Episode. Denied due to Procedure Billed Not A Covered Service For Dates Indicated. Claim Detail Denied For Invalid CPT, Invalid CPT/modifier Combination, Or Invalid Type Of Quantity Billed. Claim Explanation Codes. Third modifier code is invalid for Date Of Service(DOS). Pricing AdjustmentUB92 Hospice LTC Pricing. Reimbursement also may be subject to the application of Procedure Code and modifiers billed must match approved PA. Condition Code is missing/invalid or incorrect for the Revenue Code submitted. Rendering Provider is not certified for the From Date Of Service(DOS). Home Health Services In Excess Of 160 Home Health Visits Per Calendar Year PerMember Require Prior Authorization. EOB Codes are present on the last page of remittance advice, these EOB codes or explanation of benefit codes are in form of numbers and every number has a specific meaning. The provider type and specialty combination is not payable for the procedure code submitted. Second And Subsequent Cerebral Evoked Response Tests Paid At A Reduced Rate Per Guidelines. Reimbursement For This Detail Does Not Include Unit DoseDispensing Fee. These services are not allowed for members enrolled in Tuberculosis-Related Services Only Benefit Plan. Denied. Denied. Dosings for Narcotic Treatment Service program are limited to six per Sunday thru Saturday calendar week. Claim Denied. Procedure Code is restricted by member age. Normal delivery payment includes the induction of labor. The Dispense As Written (DAW) indicator is not allowed for the National Drug Code. One or more To Date(s) of Service is missing for Occurrence Span Codes in positions three through 24. A: This denial is received when Medicare records indicate that Medicare is the beneficiary's secondary payer. Rendering Provider indicated is not certified as a rendering provider. 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). Duplicate Item Of A Claim Being Processed. CPT Code And Service Date For Memberis Identical To Another Claim Detail On File For Another WWWP Provider. Claim Denied/cutback. The Screen Date Must Be In MM/DD/CCYY Format. Prior Authorization is required to exceed this limit. 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. 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. This claim must contain at least one specified Surgical Procedure Code. Payment Recouped. Submit Claim To Other Insurance Carrier. Denied. Four X-rays are allowed per spell of illness per provider. Correct And Resubmit. Medicare Providers | Wellcare PDN Codes W9045/w9046 Are Not Payable On The Same Date As PDN Codes W9030/W9031 For The Same Provider And Member. No Matching, Complete Reporting Form Is On File For This Client. Verify billed amount and quantity billed. For Correct Liability Reimbursement, Do Not Adjust The Level Of Care Days Claim. Payment may be reduced due to submitted Present on Admission (POA) indicator. Please Verify The Units And Dollars Billed. An ICD-9-CM Diagnosis Code of greater specificity must be used for the Diagnosis Code in posistion 10 through 24. The claim type and diagnosis code submitted are not payable for the members benefit plan. Because a claim can have edits and audits at both the header and detail levels, EOB codes are listed . 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 Corrected. Time Spent In AODA Day Treatment By Affected Family Members Is Not Covered. All Requests Must Have A 9 Digit Social Security Number. The Service Requested Is Considered To Be Professionally Unacceptable, Unproven and/or Experimental. Denied. Claim Denied. Purchase of additional DME/DMS item exceeding life expectancy rRequires Prior Authorization. If the KT/V reading was not performed, then the value code D5 with 9.99 must be present without the occurrence code 51. If correct, special billing instructions apply. For RHCs, place of service is 72, however, you can bill lab services with a place of service 11. Condition code 20, 21 or 32 is required when billing non-covered services. Individual Test Paid. The Fourth Occurrence Code Date is invalid. The quantity billed of the NDC is not equally divisible by the NDC package size. A code with no Trip Modifier billed on same day as a code with Modifier U1 are considered the same trip. Adjustment/reconsideration Request Denied Due To Incorrect/insufficient Information. . Cannot Be Reprocessed Unless There Is Change In Eligibility Status. Detail Quantity Billed must be greater than zero. CO/204. A Second Occurrence Code Date is required. We thank you for your continued partnership in servicing the Wellcare By Fidelis Care membership. Claim Detail Denied As Duplicate. Denied due to Per Division Review Of NDC. MedicalBillingRCM.com is a participant in the Amazon Services LLC Associates Program, an affiliate advertising program designed to provide a means for sites to earn advertising fees by advertising and linking to Amazon.com. The Rendering Providers taxonomy code in the header is not valid. Invalid quantity for the National Drug Code (NDC) submitted with this HCPCS code. Designated codes for conditions such as fractures, burns, ulcers and certain neoplasms require documentation of the side/region of the body where the condition occurs. PDF Remittance Advice Remark Code (RARC) and Claim Adjustment Reason Code - CMS Request Denied. Members age does not fall within the approved age range. Use The New Prior Authorization Number When Submitting Billing Claim. The Comprehensive Community Support Program reimbursement limitations have been exceeded. Claims may deny when tympanometry/impedance testing (CPT 92567) is billed with a preventive medicine service (CPT 99381-99397) or wellness visit (CPT G0438-G0439) without appropriate modifier appended to the E&M service to identify a separately identifiable procedure; tympanometry/impedance testing will be considered part of the office visit. Wellcare Cvs Caremark Login - bwdkg.bluejeanblues.net Claim or line denied. Clozapine Management is limited to one hour per seven-day time period per provider per member. Per Information From Insurer, Prior Authorization Was Not Requested/approved Prior To Providing Services. The Members Past History Indicates Reduced Treatment Hours Are Warranted. Discharge Diagnosis 2 Is Not Applicable To Members Sex. Login - WellCare Anesthesia and moderate sedation services billed with pain management services for a patient age 18 or older may deny unless a surgical procedure CPT code range 10021-69990 (other than pain management procedures) is also billed on the claim. Timeframe Between The CNAs Training Date And Test Date Exceeds 365 Days. Denied. Remittance Advice Remark Codes (RARCs) are used to provide additional explanation for an adjustment already described by a Claim Adjustment Reason Code (CARC) or to convey information about remittance processing. You Must Either Be The Designated Provider Or Have A Refer. Healthcheck screenings or outreach is limited to six per year for members up to one year of age. Payment Authorized By Department of Health Services (DHS) To Be Recouped at a Later Date. The Request Does Not Meet Generally Accepted Conditions Requiring Fluoride Treatments. Denied by Claimcheck based on program policies. Progress, Prognosis And/or Behavior Are Complicating Factors At This Time. Quick Tip: In Microsoft Excel, use the " Ctrl + F " search function to look up specific denial codes. Claim Denied Due To Incorrect Billed Amount. This drug is not covered for Core Plan members. Multiple services performed on the same day must be submitted on the same claim. All services should be coordinated with the Hospice provider. . Claim Denied For Future Date Of Service(DOS). Speech Therapy Limited To 45 Treatment Days Per Spell Of Illness W/o Prior Authorization. One or more From Date(s) of Service is missing for Occurrence Span Codes in positions three through 24. Information inadequate to establish medical necessity of procedure performed.Please resubmit with additional supporting documentation. This Mutually Exclusive Procedure Code Remains Denied. Supervisory visits for Unskilled Cases allowed once per 60-day period. Approved. Reimbursement Based On Members County Of Residence. HCPCS Procedure Code is required if Condition Code A6 is present. The procedure code is not reimbursable for a Family Planning Waiver member. Detail Rendering Provider certification is cancelled for the Date Of Service(DOS). Auditory Screening with Preventive Medicine Visits. Occupational Therapy Limited To 35 Treatment Days Per Spell Of Illness W/o Prior Authorization. Services Submitted On Improper Claim Form. Resubmit charges for covered service(s) denied by Medicare on a claim. A quantity dispensed is required. Compound drugs require a minimum of two components with at least one payable FowardHealth covered drug. Laboratory Is Not Certified To Perform The Procedure Billed. This Claim Is A Reissue of a Previous Claim. Denied due to Quantity Billed Missing Or Zero. The Procedure Code has Diagnosis restrictions. Multiple Unloaded Trips For Same Day/same Recip. Printable . Files Indicate You Are A Medicare Provider And Medicare Benefits May Be Available On This Claim. These Services Paid In Same Group on a Previous Claim. Earn Money by doing small online tasks and surveys, What is Denials Management in Medical Billing? For Revenue Code 0820, 0821, 0825 or 0829, HCPCS Code 90999 or Modifier G1-G6 must be present. Personal Care Services Exceeding 30 Hours Per 12 Month Period Per Member Require Prior Authorization. The Other Payer ID qualifier is invalid for . This drug has been paid under an equivalent code within seven days of this Date Of Service(DOS). This Is Not A Reimbursable Level I Screen. Please Supply The Appropriate Modifier. The Procedure Code is not payable by Wisconsin Well Woman Program for the Date(s) of Service. To allow for Medicare Pricing correct detail denials and resubmit. Revenue Code 0001 Can Only Be Indicated Once. Header Rendering Provider number is not found. Professional Components Are Not Payable On A Ub-92 Claim Form. Reason Code 159: State-mandated Requirement for Property and Casualty, see Claim Payment Remarks Code for specific explanation. Denied due to Prescription Number Is Missing Or Invalid. Please Do Not File A Duplicate Claim. Revenue Codes 0110 (N6) And 0946 (N7) Are Not Payable When Billed On The Same Dateof Service As Bedhold Days. A federal drug rebate agreement for this drug is not on file for the Date Of Service(DOS)(DOS). As a result, providers experience more continuity and claim denials are easier to understand. Pricing Adjustment/ Claim has pricing cutback amount applied. This National Drug Code (NDC) requires a whole number for the Quantity Billed. Procedure Added Due To Alt Code Replacement (age), Procedure Added Due To Alt Code Replacement (sex), Denied Duplicate- Includes Unilateral Or Bilat, Denied Duplicate/ Only Done XX Times In Lifetime, Denied Duplicate/ Only Done XX Times In A Day, Procedure Added Due To Duplicate Rebundling. Unable To Process Your Adjustment Request due to Original Claim ICN Not Found. Contact Wisconsin s Billing And Policy Correspondence Unit. The Sixth Diagnosis Code (dx) is invalid. Scope Aid Code and an EPSDT Aid Code. Pharmacuetical care limitation exceeded. Documentation Does Not Justify Reconsideration For Payment. Records Indicate This Tooth Has Previously Been Extracted. Wk. Once you register and have access to the provider portal, you will find a variety of video training available in the Resources section of the portal. Reconsideration With Documentation Warranting More X-rays. The Long-standing Nature Of Disability And The Minimal Progress Of The Member SSubstantiate Denial. Recouped. The sum of the Medicare paid, deductible(s), coinsurance, copayment and psychiatric reduction amounts does not equal the Medicare allowed amount. Reason Code: 234. Billing Provider is not certified for the Date(s) of Service. Claim Explanation Codes | Providers | Excellus BlueCross BlueShield Provider is not eligible for reimbursement for this service. Effective July 15, 2021 through December 31, 2021: Temporary Relaxation of Prior Authorization . Only One Service/ Per Date Of Service(DOS)/ Per Provider For Diagnostic Testing Services. This limitation may only exceeded for x-rays when an emergency is indicated. Member has Medicare Supplemental coverage for the Date(s) of Service. For FQHCs, place of service is 50. Claim Denied Due To Incorrect Accommodation. Drugs Prescribed and Filled on the Same Day, Cannot have a Refill Greater thanZero. The Second Other Provider ID is missing or invalid. Denied. The Diagnosis Code Is Not Valid On This Date Of Service(DOS). Service(s) exceeds four hour per day prolonged/critical care policy. NDC was reimbursed at State Maximum Allowable Cost (SMAC) rate. Rendering Provider is not certified for the Date(s) of Service. Member Is Eligible For Champus. It Must Be In MM/DD/YY FormatAnd Can Not Be A Future Date. Disposable medical supplies are payable only once per trip, per member, per provider. Member must receive this service from the state contractor if this is for incontinence or urological supplies. Valid Numbers Are Important For DUR Purposes. OA 13 The date of death precedes the date of service. Part B Frequently Used Denial Reasons - Novitas Solutions Pricing Adjustment/ Resource Based Relative Value Scale (RBRVS) pricing applied. DME rental beyond the initial 180 day period is not payable without prior authorization. Prescription limit of five Opioid analgesics per month. Assistant Surgery Must Be Billed Separately By The Assistant Surgeon With Modifier 80. Medicare paid amount(s) have been incorrectly applied to both the claim headerand details. These same rules are used by most healthcare claims payers and enforced by the Centers for Medicare and Medicaid Services. If A CNA Obtains his/her Certification After Theyve Been Hired By A NF, A NF Has A Year From Their Certification, Test, Date To Submit A Reimbursement Request To . These Individual Vaccines Must Be Billed Under The Appropriate Combination Injection Code. Resubmit Claim Once Election Form Requirements Are Met Per The Hospice Provider Handbook. This Incidental/integral Procedure Code Remains Denied. Code. Missing or invalid level of effort submitted and/or reason for service, professional service, or result of service code billed in error. NCTracks AVRS. Unable To Process Your Adjustment Request due to Provider ID Not Present. A Second Surgical Opinion Is Required For This Service. 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. An antipsychotic drug has recently been dispensed for this member. Denied. Day Treatment exceeding 120 hours per month is not payable regardless of PriorAuthorzation. This is a duplicate claim. Unable To Process Your Adjustment Request due to Claim ICN Not Found. You can even print your chat history to reference later! Denied/recouped. CO 197 Denial Code - Authorization or Pre-Certification missing The Existing Appliance Has Not Been Worn For Three Years. wellcare explanation of payment codes and comments. Denied. No Action Required on your part. Denied due to Provider Signature Is Missing. Please Resubmit With The Costs For Sterilization Related Charges Identified As Non-covered Charges On The Claim. Explanation . Pricing Adjustment/ Medicare benefits are exhausted. The topic of Requirements for Compression Garments can be found in the Claims Section, Submission Chapter. Pharmaceutical care code must be billed with a valid Level of Effort. Duplicate ingredient billed on same compound claim. There Is Evidence That The Member Is Not Detoxified From Alcohol And/or Other Drugs and is Therefore Not Currently Eligible For AODA Day Treatment. NUMBER IS MISSING OR INCORRECT 0002 01/01/1900 COULD NOT PROCESS CLAIM. Denied/Cutback. Please Correct Claim And Resubmit. It Must Be In MM/DD/YY Format AndCan Not Be A Future Date. This Dental Service Limited To Once Every Six Months, Unless Prior Authorized. Allowed Amount On Detail Paid By WWWP. Documentation Provided Indicates A Less Elaborate Procedure Should Be Considered. Denied. Hearing aid repairs are limited to once per six months, per provider, per hearing aid. The Members Clinical Profile/diagnosis Is Not Within Diagnostic Limitations for Psychotherapy Services. Please Refer To The Original R&S. Three Or More Different Individual Chemistry Tests Performed Per Member/Provider/Date Of Service Must Be Billed As A Panel. Timely Filing Deadline Exceeded. Member enrolled in Tuberculosis-Related Services Only Benefit Plan. Denied. The service is not reimbursable for the members benefit plan. This Report Was Mailed To You Separately. X-rays and some lab tests are not billable on a 72X claim. Service Denied. Up to a $1.10 reduction has been applied to this claim payment. Services not allowed for your Provider Type or for your Provider Type without a TB diagnosis. Claim Denied For No Provider Agreement On File Or Not Certified For Date Of Service(DOS). Services Not Payable When Rendered To An Individual Aged 21-64 Who Is A Resident Of A Nursing Home Imd. Please Contact The Hospital Prior Resubmitting This Claim. Prior authorization is required for Maxalt when Maxalt or sumatriptan productshave not been reimbursed within 365 days. Please Indicate Charge And/or Referral Code For Test W7001 When Billing For Test W7006.

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