wellcare eob explanation codes wellcare eob explanation codes

Billing Provider is not certified for Substance Abuse Day Treatment for the Date(s) of Service. Separate reimbursement for drugs included in the composite rate is not allowed. ACTION DESCRIPTION. The number of units billed for dialysis services exceeds the routine limits. Complete Refusal Detail Is Not Payable Without Referral/treatment Details. One or more To Date(s) of Service is invalid for Occurrence Span Codes in positions three through 24. Therefore itIs Not Necessary To Wait The Full 6 Weeks After Extractions Before Taking Denture Impressions. Please Correct And Resubmit. This level not only validates the code sets , but also ensures the usage is appropriate for any This Unbundled Procedure Code And Billed Charge Were Rebundled To Another Code, Which Was Either Billed By The Provider On This Claim Or Added By Claimcheck. Denied due to Detail Fill Date Is A Future Date. Claim Is Being Reprocessed Through The System. Individual Audiology Procedures Included In Basic Comprehensive Audiometry. The Performing Or Billing Provider On The Claim Does Not Match The Billing Provider On Theprior Authorization File. EOB EOB DESCRIPTION. Please note that the submission of medical records is not a guarantee of payment. Service(s) Denied/cutback. Request Denied. Questionable Long-term Prognosis Due To Poor Oral Hygiene. Day Treatment Services For Members With Inpatient Status Limited To 20 Hours. All services should be coordinated with the Inpatient Hospital provider. ambulatory surgical center, outpatient hospital) exists for the same member, same date of service and the same procedure or service. The Resident Or CNAs Name Is Missing. 0300-0319 (Laboratory/Pathology). Previously Paid Individual Test May Be Adjusted Under a Panel Code. Claim or Adjustment received beyond 730-day filing deadline. Compound Ingredient Quantity must be greater than zero. NDC was reimbursed at AWP (Average Wholesale Price) (Average Wholesale Price) rate. Contactmembers hospice for payment of services or resubmit with documentation of unrelated Nature of Care. A number is required in the Covered Days field. Please Refer To Your Hearing Services Provider Handbook. Once Therapy Is Prior Authorized, All Therapy Must Be Billed With A Valid Prior Authorization Number. Admit Date and From Date Of Service(DOS) must match. The From Date Of Service(DOS) for the First Occurrence Span Code is required. Auditory Screening with Preventive Medicine Visits. Pricing Adjustment/ Usual & Customary Charge (UCC) rate pricing applied. Rental Only Allowed; Medical Need For Purchase Has Not Been Documented. Panel And Individual Test Not Payable For Same Member/Provider/ Date Of Service(DOS). Occurance code or occurance date is invalid. The Modifier For The Proc Code Is Invalid. The Evaluation Was Received By Fiscal Agent More Than Two Weeks After The Evaluation Date. Please Resubmit. Fourth Other Surgical Code Date is required. Medically Unbelievable Error. Denied. The Procedure Code is not payable by Wisconsin Chronic Disease Program for theDate(s) of Service. NCTracks AVRS. Please Resubmit A New Adjustment/reconsideration Request Form And Indicate TheMost Recent Cclaim Number Where Payment Was Made Or Allowed. Services Beyond The Six Week Postpartum Period Are Not Covered, Per DHS. Maximum Reimbursement Amount Has Been Determined By Professional Consultant. Combine Like Details And Resubmit. Denied. If this is your first visit, be sure to check out the FAQ & read the forum rules.To view all forums, post or create a new thread, you must be an AAPC Member.If you are a member and have already registered for member area and forum access, you can log in by clicking here.If you've forgotten your username or password use our . Restorative Nursing Can Provide Follow-through, Based On Diagnosis Of Long-standing Nature, And The Amount Of Therapy. Please Verify That Physician Has No DEA Number. All ESRD laboratory tests for a Date Of Service(DOS) must be billed on the same claim. 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). This National Drug Code (NDC) is only payable as part of a compound drug. The detail From Date Of Service(DOS) is after the detail To Date Of Service(DOS). This Claim Cannot Be Processed. Claim Paid Under DRG Reimbursement, Except For Transplants Billed Using Suffixes 05 Through 09. Detail To Date Of Service(DOS) is invalid. Tooth surface is invalid or not indicated. Charges For Anesthetics Are Included In Charge For All Surgical Procedures. Admission Denied In Accordance With Pre-admission Review Criteria. The total billed amount is missing or is less than the sum of the detail billed amounts. Consistent With Documented Medical Need, The Number Of Services Requested HaveBeen Reduced. An ICD-9-CM Diagnosis Code of greater specificity must be used for the Diagnosis Code in posistion 10 through 24. By continuing to use our site, you agree to our Privacy Policy and Terms of Use. Please Resubmit Using Newborns Name And Number. 1 PC Dispensing Fee Allowed Per Date Of Service(DOS). Denied. Schedule 3, 4 or 5 drugs are limited to the original dispensing plus 5 refillsor 6 months. One Visit Allowed Per Day, Service Denied As Duplicate. Single Bitewing X-rays Limited To Once Per Day And No More Than Two InA Six Month Period. The From Date Of Service(DOS) for the Second Occurrence Span Code is required. Annual Physical Exam Limited To Once Per Year By The Same Provider. Consent Form Is Missing, Incomplete, Or Contains Invalid Information. Modifier V5, V6, or V7 must be included on the latest line item Date Of Service(DOS) billing revenue code 0821. Units Billed Are Inconsistent With The Billed Amount. Denials with solutions in Medical Billing; Denials Management - Causes of denials and solution in medical billing; Medical Coding denials with solutions Use The ICN which Is In An Allowed Or Paid Status When Filing An Adjustment/ReconsiderationRequest. Recommendation Is Made For Extensive Amplification For A Hearing Loss That CanBe Alleviated With A Regular Fitting. 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). Member has Medicare Managed Care for the Date(s) of Service. Please Itemize Services Including Date And Charges For Each Procedure Performed. Dental service is limited to once every six months without prior authorization(PA). A Primary Occurrence Code Date is required. Submitted rendering provider NPI in the detail is invalid. Home Health services for CORE plan members are covered only following an inpatient hospital stay. Services have been determined by DHCAA to be non-emergency. Other Insurance/TPL Indicator On Claim Was Incorrect. The Medical Necessity For Psychotherapy Services Has Not Been Documented, ThusMaking This Member Ineligible For The Requested Service. Multiple Service Location Found For the Billing Provider NPI. The Rendering Providers taxonomy code in the detail is not valid. Resubmit Using Valid Rn/lpn Procedure Codes And A Valid PA Number. Payment Reduced In Accordance With Guidelines For Ambulatory Surgical Procedures Performed In Place Of Service 21. Denied/Cutback. This Claim HasBeen Manually Priced Using The Medicare Coinsurance, Deductible, And Psyche RedUction Amounts As Basis For Reimbursement. Diagnosis Indicated Is Not Allowable For Procedures Designated As Mycotic Procedures. According to the American Society of Anesthesiologists and the International Spine Intervention Society, minor pain procedures such as epidural steroid injections, epidural blood patch, trigger point injections, sacroiliac joint injection, bursal injections, occipital nerve block and facet injections under most routine circumstances, require only local anesthesia. Claim Is For A Member With Retro Ma Eligibility. Correction Made Per Medical Consultant Review. The Revenue/HCPCS Code combination is invalid. Home Health visits (Nursing and therapy) in excess of 30 visits per calendar year per member require Prior Authorization. Service Denied. Earn Money by doing small online tasks and surveys, What is Denials Management in Medical Billing? 10 Important Billing Tips for FQHC and RHC Providers. Routine Foot Care Procedures Must Be Billed With Valid Routine Foot Care Diagnosis. An exception will apply for anesthesia services billed with modifiers indicating severe systemic disease (Physical status modifiers P3, P4 or monitored anesthesia care modifier G9). Strong knowledge of adjustment and denial reason codes from Electronic Remittance Advices (ERA/835 files) and from paper Explanation of benefits (EOB's) / Explanation of payments (EOP's), CPT and ICD10 codes; Excellent interpersonal and communication skills with professional demeanor and positive attitude Anesthesia Modifying Services Must Be Billed Separately From The Charge For Anesthesia Base And Time Units. Timely Filing Deadline Exceeded. According to CMS policy and the American College of Radiology, a chest X-ray (CPT codes 71045, 71046) should not be performed for screening purposes in the absence of pertinent signs, symptoms or diseases. Admission Date does not match the Header From Date Of Service(DOS). Prior authorization is required for Advair or Symbicort if no other Glucocorticoid Inhaled product has been reimbursed within 90 days. Claim Is Being Reprocessed, No Action On Your Part Required. Pregnancy Indicator must be "Y" for this aid code. Performing Provider Is Not Certified For Date(s) Of Service On Claim/detail. Unable To Process Your Adjustment Request due to Member ID Number On The Claim And On The Adjustment Request Do Not Match. Ninth Diagnosis Code (dx) is not on file. . The Fifth Diagnosis Code (dx) is invalid. An ICD-9-CM Diagnosis Code of greater specificity must be used for the Fourth Diagnosis Code. Admit Diagnosis Code is invalid for the Date(s) of Service. When diagnoses 800.00 through 999.9 are present, an etiology (E-code) diagnosis must be submitted in the E-code field. Service Denied. Please Rebill Inpatient Dialysis Only. Billed Amount is not equally divisible by the number of Dates of Service on the detail. Denied due to Some Charges Billed Are Non-covered. Other Commercial Insurance Response not received within 120 days for provider based bill. Date Of Service Must Fall Between The Prior Authorization Grant Date And Expiration Date. Supervising Nurse Name Or License Number Required. Prior Authorization (PA) is required for payment of this service. Denied. The Request Has Been Approved To The Maximum Allowable Level. Purchase Of A DME/DMS Item Exceeding One Per Month Requires Prior Authorization. Resubmit Claim With Corrected Tooth Number/letter Or With X-ray Documenting Tooth Placement. Providers should submit adequate medical record documentation that supports the claim (services) billed. Claim Detail Denied For Invalid CPT, Invalid CPT/modifier Combination, Or Invalid Type Of Quantity Billed. The Third Occurrence Code Date is invalid. Homecare Services W/o PA Are Not Payable When Prior Authorized HomecAre Services Have Been Provided To The Same Member. This drug/service is included in the Nursing Facility daily rate. Handwritten Changes/corrections On The Medicare EOMB Are Not Acceptable. This dental service limited to once per five years.Prior Authorization is needed to exceed this limit. Denied. NUMBER IS MISSING OR INCORRECT 0002 01/01/1900 COULD NOT PROCESS CLAIM. Claim or Adjustment received beyond 365-day filing deadline. DME rental is limited to 90 days without Prior Authorization. Intraoral Complete Series/comprehensive Oral Exam Limited To Once Every Three Years, Unless Prior Authorized. The condition code is not allowed for the revenue code. SMV Or Prescribing Provider Description Code(s) Missing OrInvalid. These services are not allowed for members enrolled in Tuberculosis-Related Services Only Benefit Plan. HMO Extraordinary Claim Denied. No Action Required on your part. Remark Codes: N20. The maximum number of details is exceeded. Additional services mustbe billed as treatment services and count towards the Mental Health and/or substance abuse treatment policy for prior authorization. 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. Healthcheck Screening Limited To Two Per Year From Birth To Age 3 And One Per Year For Age3 Or Older. Type of Bill is invalid for the claim type. Denied due to Procedure/Revenue Code Is Not Allowable. The Service Requested Does Not Correspond With Age Criteria. Quantity Billed is invalid for the Revenue Code. Billing Provider is restricted from submitting electronic claims. Complex care of 17-plus hours and complex care of less than 17 hours are not allowed on the same Date Of Service(DOS). Adjustment To Eyeglasses Not Payable As A Repair Service. This claim has been adjusted due to a change in the members enrollment. Correct Claim Or Submi Paper Claim Noting That Verification Has Occurred. Service not payable with other service rendered on the same date. Hearing Aid Batteries Are Limited To 12 Monaural/24 Binaural Batteries Per 30-day Period, Per Provider, Per Hearing Aid. The Revenue Code is not payable by Wisconsin Well Woman Program for the Date(s) of Service. General Assistance Payments Should Not Be Indicated On Claims. Only One Outpatient Claim Per Date Of Service(DOS) Allowed. Denied. 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. Rendering Provider is not a certified provider for Wisconsin Chronic Disease Program. Level, Intensity Or Extent Of Service(s) Requested Has Been Modified Consistent With Medical Need As Defined In The Plan Of Care. The Change In The Lens Formula Does Not Warrant Multiple Replacements. Denied. Claim Denied In Order To Reprocess WithNew ID. The submitted claim contains value code 68 and 48 or 49 but does not contain revenue code 0634 or 0635 and HCPCS Q4055. Per Information From Insurer, Claim(s) Was (were) Not Submitted. Req For Acute Episode Is Denied. 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. Services Requested Do Not Meet The Criteria for an Acute Episode. The Billing Providers taxonomy code is invalid. Original Payment/denial Processed Correctly. The Request Does Not Meet Generally Accepted Conditions Requiring Fluoride Treatments. Please Correct And Resubmit. A Payment For The CNAs Competency Test Has Already Been Issued. Non-covered Charges Are Missing Or Incorrect. Election Form Is Not On File For This Member. Allowance For Coinsurance Is Limited To Allowable Amount Less Medicares Payment. Medicare Disclaimer Code invalid. The Medicare Claims Processing Manual and the UB-04 Data Specifications Manual outlines requirements for billing outpatient claims including that (HCPCS) codes are required on outpatient claims (UB-04) with related revenue codes. For over 40 years, Washington Publishing Company (WPC) has specialized in managing and distributing data integration information through publications, training, and consulting services. X . More Than 5 Consecutive Calendar Days Of Continuous Care Are Not Payable. Reimbursement For This Certification, Test, Segment Has Already Been Issued ToYour NF. Review Billing Instructions. wellcare eob explanation codes. Dispensing replacement parts and complete appliance on same Date Of Service(DOS) not Allowed. Denied/Cutback. A Second Occurrence Code Date is required. One or more Occurrence Code(s) is invalid in positions nine through 24. Reading your EOB. The Surgical Procedure Code is not payable for /BadgerCare Plus for the Date Of Service(DOS). Fifth Diagnosis Code (dx) is not on file. Rendering Provider Type and/or Specialty is not allowable for the service billed. A National Provider Identifier (NPI) is required for the Rendering Provider listed in the header. According to the AMA CPT Manual and our policy, an initial inpatient admission (CPT 99221-99223) is allowed once every seven days. Prescription Drug Plan (PDP) payment/denial information is required on the claim to SeniorCare. Rendering Provider is not a certified provider for . Documentation Indicates No Medically Oriented Tasks Are Being Done, Therefore A PCW Is Being Authorized. NFs Eligibility For Reimbursement Has Expired. Member Name Missing. Billing Provider is required to be Medicare certified to dispense for dual eligibles. NDC was reimbursed at State Maximum Allowable Cost (SMAC) rate. Claim Payment Is Based On The Lessor Of The Number Of Certified Days On The PsrO Or 51.42 Board Stamp Or Admitting Calendar Month Days In Specialty Hospital. Printable . 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. Please Refer To The PDL For Preferred Drugs In This Therapeutic Class. Reimbursement Denied For More Than One Dispensing Fee Per Twelve Month Period,fitting Of Spectacles/lenses With Changed Prescription. 51.42 Board Stamp Required On All Outpatient Specialty Hospital Claims For Dates Of Service On Or After January 1, 1986. The Pharmaceutical Care Code (PCC) does not have a rate on file for the Date Of Service(DOS). Denied as duplicate claim. Condition Code is missing/invalid or incorrect for the Revenue Code submitted. Denied. Denied/cutback. Reimbursement For HCPCS Procedure Code 58300 Includes IUD Cost. Based on these reimbursement guidelines, claims may deny when the following revenue codes are billed without the appropriate HCPCS code: The diagnosis code on the claim requires Condition code A6 be present on the Type of Bill. Denied/Cutback. Claim Detail Denied Due To Required Information Missing On The Claim. Restorative Nursing Involvement Should Be Increased. Diag Restriction On ICD9 Coverage Rule edit. Denied. The Service Requested Was Performed Less Than 5 Years Ago. Additional servcies may be billed with H0046 and will count toward mental health and/or substance abuse treatment policy limits for prior authorization. Drug(s) Billed Are Not Refillable. Denied by Claimcheck based on program policies. The Clinical Profile And Narrative History Indicate Day Treatment Is Neither Appropriate Nor A Medical Necessity For This Member. Service Denied. This Payment Is To Satisfy The Amount Owed For OBRA Level 1. Eyeglasses limited to original plus 1 replacement pair, lens or frame in 12 wit hout Prior Authorization. Please Disregard Additional Informational Messages For This Claim. The To Date Of Service(DOS) for the Second Occurrence Span Code is invalid. A split claim is required when the service dates on your claim overlaps your Federal fiscal year end (FYE) date. Newborn Care Must Be Billed Under Newborn Name And Number; Occurrence Codes 50& 51 Cannotbe Present if Billing Under Newborn Name.