The amount in the Other Insurance field is invalid. The Revenue Code is not payable by Wisconsin Chronic Disease Program for the Date Of Service(DOS). Valid group codes for use on Medicare remittance advice are:. Prior authorization is required for Maxalt when Maxalt or sumatriptan productshave not been reimbursed within 365 days. Review Reason Codes and Statements | CMS For Newly Certified CNAs, Date Of Inclusion Is T heir Test Date. Services Billed On This Claim/adjustment Have Been Split to Facilitate Processing. No Complete WWWP Participation Agreement Is On File For This Provider. Claims may deny when a procedure defined as requiring an anatomical modifier is billed without an associated anatomical modifier. Complete Medicare Denial Codes List - Billing Executive Independent RHCs Must Bill Codes W6251, W6252, W6253, W6254 Or W6255. These coding rules are published within the Medicare Claims Processing Manual, Current Procedural Terminology (CPT) by the American Medical Association (AMA) and ICD-10-CM guidelines governed by Medicare and Medicaid Services (CMS) and the National Center for Health Statistics (NCHS). Denied due to The Members First Name Is Missing Or Incorrect. A National Drug Code (NDC) is required for this HCPCS code. Please Rebill Inpatient Dialysis Only. Procedure May Not Be Billed With A Quantity Of Less Than One. Individual Test Paid. codes are provided per day by the same individual physician or other health care professional. Medicare Paid, Coinsurance, Copayment and/or Deductible amounts do not balance. This Member Is Receiving Concurrent AODA/Psychotherapy Services And Is Therefore Only Eligible For Maintenance Hours. To access the training video's in the portal, please register for an account and request access to your contract or medical group. Prescription limit of five Opioid analgesics per month. BMN prior authorization may be submitted for Mental Health drugs for which a Core Plan transitioned member has been previously grandfathered. Modifier invalid for Procedure Code billed. An ICD-9-CM Diagnosis Code of greater specificity must be used for the Diagnosis Code in posistion 10 through 24. The Request May Only Be Back-dated Two Weeks Prior To Receipt By EDS. The Type Of Psychotherapy Service Requested For This Member Is Considered To be Professionally Unacceptable, Unproven And/or Experimental. 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. Speech Therapy Limited To 45 Treatment Days Per Spell Of Illness W/o Prior Authorization. Please Clarify Services Rendered/provide A Complete Description Of Service. Member is enrolled in Medicare Part D for the Dispense Date Of Service(DOS). NDC- National Drug Code is not covered on a pharmacy claim. WWWP Does Not Process Interim Bills. Member must receive this service from the state contractor if this is for incontinence or urological supplies. Prescription Date is after Dispense Date Of Service(DOS). This Is Not A Preadmission Screen And Is Not Reimbursable. Duplicate ingredient billed on same compound claim. DX Of Aphakia Is Required For Payment Of This Service. Pharmacy Clm Submitted Exceeds The Number Of Clms Allowed Per Cal. RN And LPN Subsequent Care Visits Limited To 6 Hrs Per Day/per Member/per Provider. Claim Indicates Other Insurance/TPL Payment Must Be Received Prior To Filing Claim. Revenue code submitted with the total charge not equal to the rate times number of units. Please Request Prior Authorization For Additional Days. Denied due to Detail Add Dates Not In MM/DD Format. If correct, special billing instructions apply. This service is not covered under the ESRD benefit. HMO Capitation Claim Greater Than 120 Days. Level And/or Intensity Of Requested Service(s) Is Incompatible With Medical Need As Defined In Care Plan. Admission Date does not match the Header From Date Of Service(DOS). Submit copy of the dated and signed evaluation and indicate if this is an initial Evaluation. 51.42 Board Directors Or Designees Statement & Signature Required OnThe Claim Form For Payment Of Functional Assessment. Formal Speech Therapy Is Not Needed. HealthDrive Corporation Senior Reimbursement Specialist - Medical As a result, providers experience more continuity and claim denials are easier to understand. Denied. HIPAA EOB codes are returned on the 835 Remittance Advice file and are maintained by the Washington Publishing Company. Newborn Care Must Be Billed Under Newborn Name And Number; Occurrence Codes 50& 51 Cannotbe Present if Billing Under Newborn Name. PDF Wellcare Known Issue List You can view these EOBs online by following these steps: Log in to your bcbsm.com account to view your prescriptions coverage. Members do not have to wait for the post office to deliver their EOB in a paper format. Certifying Agency Did Not Verify Member Eligibility within 70 Day Period. Reimbursement for this procedure and a related procedure is limited to once per Date Of Service(DOS). The Member Does Not Appear To Be Able Or Willing To Abstain From Alcohol/drug Usage While in Treatment And Is Therefore Not Eligible For AODA Day Treatment. Claim Is For A Member With Retro Ma Eligibility. 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). Area of the Oral Cavity is required for Procedure Code. No Action Required. Condition codes 71, 72, 73, 74, 75, and 76 cannot be present on the same ESRD claim at the same time. Service Denied. Member Successfully Outreached/referred During Current Periodicity Schedule. Benefit Payment Determined By DHS Medical Consultant Review. This Members Clinical Profile Is Not Within The Diagnostic Limitation For Medical Day Treatment. Billing Provider Type and Specialty is not allowable for the Place of Service. A New Prior Authorization Number Has Been Assigned To This Request In Order ToProcess. Third modifier code is invalid for Date Of Service(DOS). Drugs Prescribed and Filled on the Same Day, Cannot have a Refill Greater thanZero. The first occurrence span from Date Of Service(DOS) is after the to Date Of Service(DOS). The Other Payer ID qualifier is invalid for . AODA Day Treatment Is Not A Covered Service For Members Who Are Residents Of Nursing Homes or Who Are Hospital Inpatients. Login - WellCare The Quantity Allowed Was Reduced To A Multiple Of The Products Package Size. CPT is registered trademark of American Medical Association. Third Other Surgical Code Date is invalid. Adjustment To Crossover Paid Prior To Aim Implementation Date. Pricing Adjustment/ Maximum Flat Fee pricing applied. Missing Or Invalid Level Of Effort And/or Reason For Service Code, Professional Service Code, Result Of Service Code Billed In Error. The Member Is Enrolled In An HMO. Value codes 48 Homoglobin Reading and 49 Hematocrit Reading, must have a zero in the far right position. Referral Codes Must Be Indicated For W7001, W7002, W7003, W7006, W7008 And W7013. The Diagnosis Does Not Indicate A Significant Change In the Members Condition. This National Drug Code is not covered under the Core Plan or Basic Plan for the diagnosis submitted. Only One Federally Required Annual Therapy Evaluation Per Calendar Year, Per Member, Per Provider. Due To Miscellaneous Or Unspecified Reason, Adjustment/Resubmission was initiated by Provider, Adjustment/Resubmission was initiated by DHS, Adjustment/Resubmission was initiated by EDS, Adjustment Generated Due To Change In Patient Liability, Payout Processed Due To Disproportionate Share. The detail From Date Of Service(DOS) is invalid. One or more Diagnosis Code(s) is not payable by Wisconsin Chronic Disease Program for the Date Of Service(DOS). Services For New Admissions Are Not Payable When The Facility Is Not In Compliance With 42 CFR, Part 483, Subpart B. Rebill On Pharmacy Claim Form. Abortion Dx Code Inappropriate To This Procedure. Outside Lab Indicator Must Be Y For The Procedure Code Billed. Pricing Adjustment/ Payment reduced due to the inpatient or outpatient deductible. Payment Authorized By Department of Health Services (DHS) To Be Recouped at a Later Date. An explanation of benefits is a document from your insurance company outlining the services you received and how much they cost. This Member Has A Current Approved Authorization For Intensive AODA OutpatientServices. Medicare Coinsurance Amount Was Not Provided On Crossover Claim. Multiple Providers Of Treatment Are Not Indicated For This Member. Complex care of 17-plus hours and complex care of less than 17 hours are not allowed on the same Date Of Service(DOS). This Is A Duplicate Request. Procedure Dates Do Not Fall Within Statement Covers Period. Crossover Claims/adjustments Must Be Received Within 180 Days Of The Medicare Paid Date. Please Do Not File A Duplicate Claim. NUMBER IS MISSING OR INCORRECT 0002 01/01/1900 COULD NOT PROCESS CLAIM. Billing Provider does not have required Certification Addendum on file. Invalid quantity for the National Drug Code (NDC) submitted with this HCPCS code. Quantity submitted matches original claim. If the KT/V reading was not performed, then the value code D5 with 9.99 must be present without the occurrence code 51. 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. Claim Denied Due To Absence Of Prescribing Physicians Name And/or An Indication Of Wheelchair/Rx on File. A valid Level of Effort is also required for pharmacuetical care reimbursement. Money Will Be Recouped From Your Account. Denied. 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. Member is enrolled in Medicare Part A on the Date(s) of Service. Only non-innovator drugs are covered for the members program. Claim Denied. Resubmit Claim With Corrected Tooth Number/letter Or With X-ray Documenting Tooth Placement. Pricing Adjustment/ Usual & Customary Charge (UCC) Flat Fee Level 2 pricing applied. A Second Occurrence Code Date is required. Please Do Not Resubmit Your Claim, And Disregard Additional Informational Messages for this claim. Claim cannot contain both Condition Codes A5 and X0 on the same claim. (National Drug Code). The medical record request is coordinated with a third-party vendor. Only One Date For EachService Must Be Used. Claims adjustments. The Treatment Request Is Not Consistent With The Members Diagnosis. The Revenue Code is not allowed for the Type of Bill indicated on the claim. Denied. Good Faith Claim Correctly Denied. Dollar Amount Of Claim Was Adjusted To Correct Mathematical Error. Marketing Models, Standard Documents, and Educational Material Procedure Code Used Is Not Applicable To Your Provider Type. Admission Denied In Accordance With Pre-admission Review Criteria. Because a claim can have edits and audits at both the header and detail levels, EOB codes are listed . subsequent hospital care (CPT 99231-99233) or inpatient consultations (CPT 99251-99255) in the previous week. Has Already Issued A Payment To Your NF For This Level L Screen. Denied due to Statement Covered Period Is Missing Or Invalid. Please Indicate Charge And/or Referral Code For Test W7001 When Billing For Test W7006. NCTracks AVRS. Denied due to Procedure Is Not Allowable For Diagnosis Indicated. As A Reminder, This Procedure Requires SSOP. Please Indicate The Dollar Amount Requested For The Service(s) Requested. Duplicate/second Procedure Deemed Medically Necessary And Payable. Good Faith Claim Denied. Reason for Service submitted does not match prospective DUR denial on originalclaim. Incorrect Or Invalid National Drug Code Billed. Policy override must be granted by the Drug Authorization and Policy Override Center to dispense less than a 100 day supply. The content shared in this website is for education and training purpose only. Immunization Questions A And B Are Required For Federal Reporting. Reimbursement of this service is included in the reimbursement of the most complex/complete procedure performed. Principle Surgical Procedure Code Date is missing. More Than 5 Consecutive Calendar Days Of Continuous Care Are Not Payable. Please Correct And Resubmit. Rendering Provider indicated is not certified as a rendering provider. Claim contains an unclassified drug HCPCS procedure code or a drug HCPCS procedure code included in the composite rate. Pharmacuetical care limitation exceeded. Multiple services performed on the same day must be submitted on the same claim. NDC- National Drug Code is not allowed for the member on the Date Of Service(DOS). Verify billed amount and quantity billed. Claim Is Pended For 60 Days. Claim Denied For No Client Enrollment Form On File. Member Expired Prior To Date Of Service(DOS) On Claim. Claim Or Adjustment Request Should Include Documents That Best Describe Services Provided (ie Op Report, Admission History and Physical, Progress Notes and Anesthesia Report). 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. Denied/Cutback. Normal delivery payment includes the induction of labor. Revenue Code 0001 Can Only Be Indicated Once. The CNA Is Only Eligible For Testing Reimbursement. One or more Surgical Code(s) is invalid in positions six through 23. Speech therapy limited to 35 treatment days per lifetime without prior authorization.
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