Member Is Enrolled In A Family Care CMO. For Review, Forward Additional Information With R&S To WCDP. Denied. Only Medicare Crossover claims are reimbursed for coinsurance, copayment, and deductible. Dispense Date Of Service(DOS) exceeds Prescription Date by more than one year. One or more Occurrence Code(s) is invalid in positions nine through 24. Please Indicate The Revenue Code/procedure Code/NDC Code For Which The Credit is To Be Applied. 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. Billing Provider Received Payment From Both Medicare And For Clai m. An Adjustment/reconsideration Request Has Been Made To The Billing Providers Account. The Existing Appliance Has Not Been Worn For Three Years. Was Unable To Process This Request Due To Illegible Information. The Maximum Allowable Was Previously Approved/authorized. Reason for Service submitted does not match prospective DUR denial on originalclaim. Please Correct And Submit. If not, the procedure code is not reimbursable. A Training Payment Has Already Been Issued To Your NF For This CNA. An ICD-9-CM Diagnosis Code of greater specificity must be used for the Third Diagnosis Code. For Newly Certified CNAs, Date Of Inclusion Is T heir Test Date. An ICD-9-CM Diagnosis Code of greater specificity must be used for the First Diagnosis Code. Request was not submitted Within A Year Of The CNAs Hire Date. Description. For more information on which codes are considered "Mutually Exclusive", see the "ICD-10 2019 The Complete Official Codebook. Pricing Adjustment/ Payment reduced due to the inpatient or outpatient deductible. Denied/Cutback. ambulatory surgical center, outpatient hospital) exists for the same member, same date of service and the same procedure or service. The header total billed amount is invalid. This Claim Has Been Denied Due To A POS Reversal Transaction. Invalid Admission Date. Good Faith Claim Has Previously Been Denied By Certifying Agency. You Must Either Be The Designated Provider Or Have A Referral. You can even print your chat history to reference later! PDF Wellcare Known Issue List Edentulous Alveoloplasty Requires Prior Authotization. Discrepancy Between The Other Insurance Indicator And OI Paid Amount. Revenue Code Required. Compound drugs require a minimum of two components with at least one payable FowardHealth covered drug. Invalid Service Facility Address. Unable To Process Your Adjustment Request due to. Denied. One or more Occurrence Code Date(s) is invalid in positions nine through 24. Req For Acute Episode Is Denied. Revenue code submitted with the total charge not equal to the rate times number of units. Missing or invalid level of effort submitted and/or reason for service, professional service, or result of service code billed in error. No Financial Needs Statement On File. 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. Questionable Long-term Prognosis Due To Apparent Root Infection. All rental payments have been deducted from the purchase costsince the DME item was rented and subsequently purchased for the member. A Photocopy Of The PA Request Form Has Been Mailed Separately Identifying the Reimbursement Rate For The Procedure Codes Authorized. Use This Claim Number If You Resubmit. Claim Has Been Adjusted Due To Previous Overpayment. Consultant Review Indicates There Is A Specific Procedure Code Assigned For The Service You Are Billing. A: This denial is received when Medicare records indicate that Medicare is the beneficiary's secondary payer. Pricing Adjustment. Continue ToUse Appropriate Codes On Billing Claim(s). A New Prior Authorization Number Has Been Assigned To This Request In Order ToProcess. The sum of all Value Code amounts must be numeric and less than or equal to 999.999.999. Services Not Provided Under Primary Provider Program. Each month you fill a prescription, your Medicare Prescription Drug Plan mails you an "Explanation of Benefits" (EOB). Prior Authorization (PA) is required for this service. Denied. Training CompletionDate Exceeds The Current Eligibility Timeline. Claim Denied. Medicare accepts any National Uniform Billing Committee (NUBC) approved revenue codes. Modifier Submitted Is Invalid For The Member Age. Diagnosis Code is restricted by member age. Out Of State Billing Provider Not Enrolled For Entire Detail DOS Span. Vision Diagnostic Services Limited To 1 Of These: Vision Exam, Diagnostic Review, Supplemental Test Or Contact Lens Therapy. An NCCI-associated modifier was appended to one or both procedure codes. Per Information From Insurer, Claim(s) Was (were) Not Submitted. Different Drug Benefit Programs. Benefit Payment Determined By DHS Medical Consultant Review. Please Clarify The Number Of Allergy Tests Performed. No Action On Your Part Required. An antipsychotic drug has recently been dispensed for this member. Pricing Adjustment/ Paid according to program policy. The Service Requested Is Considered To Be Professionally Unacceptable, Unproven and/or Experimental. This obstetrical service was previously paid for this Date Of Service(DOS) for thismember. The Services Requested Do Not Meet Criteria For An Acute Episode. Prior Authorization is required for service(s) exceeding mental health and/or substance abuse benefit guidelines. Revenue code billed with modifier GL must contain non-covered charges. The below mention list of EOB codes is as below, EOB codes list is updated as per the latest information gathered from authorized sources of information, if any discrepancy please let us know via the contact us page, Coupon "NSingh10" for 10% Off onFind-A-CodePlans. Condition codes 71, 72, 73, 74, 75, and 76 cannot be present on the same ESRD claim at the same time. One or more From Date Of Service(DOS) (DOS) is invalid for Occurrence Span Codes in positions three through 24. One or more Diagnosis Code(s) in positions 10 through 25 is not on file. Denied. Concurrent Services Are Not Appropriate. HMO Payment Equals Or Exceeds Hospital Rate Per Discharge. Medicare RA/EOMB And Claim Dates And/or Charges Do Not Match. Supervising Nurse Name Or License Number Required. This Procedure Is Denied Per Medical Consultant Review. If you haven't created an account yet, register now. Denied. Continuous home care must be billed in an hourly quantity equal to or greater than eight hours, up to and including 24 hours. Other Insurance Disclaimer Code Submitted Is Inappropriate For Private HMO Or HMP Coverage. This level not only validates the code sets , but also ensures the usage is appropriate for any Was Unable To Process This Request. Please Review The Covered Services Appendices Of The Dental Handbook. The Documentation Submitted Indicates The Tasks Specified Can Be Completed During The Visits Approved. This Member Has Completed Intensive AODA Treatment Within The Past 12 Months and Documentation Provided Is Not Adequate To Justify Intensive Treatment at this time. 100 Days Supply Opportunity. 2. Questionable Long-term Prognosis Due To Decay History. Supervisory visits for Unskilled Cases allowed once per 60-day period. Only One Panel Code Within Same Category (CBC Or Chemistry) Maybe Performed Per Member/Provider/Date Of Service. Phone: 800-723-4337. A valid Level of Effort is also required for pharmacuetical care reimbursement. This Member Is Involved In Intensive Day Treatment, Which Is To Include Psychotherapy Services. OA 12 The diagnosis is inconsistent with the provider type. Charges For Anesthetics Are Included In Charge For All Surgical Procedures. Part C Explanation of Benefits (EOB) Materials. Revenue Code 082X is present on an ESRD claim which also contains revenue codes 083X, 084X, or 085X. Please Provide Copy Of Medicare Explanation Of Benefits/medicare Remittance Advice Attached To Claim. Denied/Cutback. Service(s) Approved By DHS Transportation Consultant. Amount Paid By Other Insurance Exceeds Amount Allowed By . Pricing Adjustment/ Medicare crossover claim cutback applied. HCPCS procedure codes G0008, G0009 or G0010 are allowed only with revenue code0771. Review Reason Codes and Statements | CMS Please Correct And Resubmit. 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. Training Completion Date Must Be Within A Year Of The CNAs Certification, Test, Date. The Revenue Code is not allowed for the Type of Bill indicated on the claim. Prescribing Provider UPIN Or Provider Number Missing From Claim And Attachment. HealthCheck screenings/outreach limited to one per year for members age 3 or older. The quantity billed of the NDC is not equally divisible by the NDC package size. Original Payment/denial Processed Correctly. Example: Diagnosis code 285.21 is entered as 28521, without a period or space. Request Denied Due To Late Billing. Hospice Member Services Related To The Terminal Illness Must Be Billed By Hospice Or Attending Physician. Please Ask Prescriber To Update DEA Number On TheProvider File. The Medical Necessity For Psychotherapy Services Has Not Been Documented, ThusMaking This Member Ineligible For The Requested Service. Normal delivery payment includes the induction of labor. Documentation Does Not Justify Fee For ServiceProcessing . Prior authorization requests for this drug are not accepted. Routine foot care Diagnoses must be billed with valid routine foot care Procedure Codes. Denied. Effective September 1, 2021: Benefit Changes to Total Disc Arthroplasty for Medicaid and CHIP. Denials with solutions in Medical Billing; Denials Management - Causes of denials and solution in medical billing; Medical Coding denials with solutions Services Are Covered For Medically Needy Members Only When Healthcheck Referral is Indicated On Claim. Total billed amount is less than the sum of the detail billed amounts. Dental service is limited to once every six months. Revenue codes 082X, 083X, 084X, 085X, 0800 or 0881 (X frequency not equal to 5) exist on an ESRD claim for a member who has selected method 1 or no method and the claim does not contain condition codes 71, 72, 73 ,74, 75, or 76. Claim Denied For Invalid Billing Type Frequency Code, Claim Type, Or SubmittedAdjustment Provider Number Does Not Match Original Claims Provider Number. The Information Provided Is Not Consistent With The Intensity Of Services Requested. TPA Certification Required For Reimbursement For This Procedure. Home Health Services In Excess Of 60 Visits Per Calendar Month Per Member Required Prior Authorization. Procedure Code and modifiers billed must match approved PA. Provider Reminders: Claims Definitions. The Revenue Code is not payable for the Date Of Service(DOS). Pricing Adjustment/ Prescription reduction applied. Reimbursement For This Certification, Test, Segment Has Already Been Issued ToYour NF. Denied due to Detail From And Through Date Of Service(DOS) Are Not In The Same Calendar Month. Number On Claim Does Not Match Number On Prior Authorization Request. Explanation of Benefit Codes (EOBs) Mar 14, 2022 1 EOB EOB DESCRIPTION. Principal Diagnosis 9 Not Applicable To Members Sex. Services For Members With Medical Status Code TR, SH, SJ, TS Or ST NotAllowed For Your Provider Type, Or For Your Provider Type without a TB Diagnosis. Please Request A Corrected EOMB Through The Medicare Carrier And Adjust With The Corrected EOMB. This claim is eligible for electronic submission. The Date Of The Screening Request Or The Date Of Screening Is Invalid Or Missing. Member ID has changed. An ICD-9-CM Diagnosis Code of greater specificity must be used for the Fourth Diagnosis Code. Claim Denied For Future Date Of Service(DOS). Service Denied. NCTracks Contact Center. Claim Denied. OA 13 The date of death precedes the date of service. Please note that the submission of medical records is not a guarantee of payment. 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. NCTracks AVRS. This claim has been adjusted because a service on this claim is not payable inconjunction with a separate paid service on the same Date Of Service(DOS) due to National Correct Coding Initiative. Member is not enrolled for the detail Date(s) of Service. The dental procedure code and tooth number combination is allowed only once per lifetime. Explanation of Benefits (EOB) Lookup - Washington State Department of Dispensing fee denied. Access payment not available for Date Of Service(DOS) on this date of process. Healthcheck screenings or outreach limited to two per year for members betweenthe ages of two and three years. Revenue code submitted is no longer valid. A Separate Notification Letter Is Being Sent. This list was formerly published as Part 6 of the administrative and billing instructions in Subchapter 5 of your MassHealth provider manual. Marketing Models, Standard Documents, and Educational Material No payment allowed for Incidental Surgical Procedure(s). Not A WCDP Benefit. This claim did not include the Plan ID, therefore we assigned TXIX as the Plan ID for this claim. Benefit code These codes are submitted by the provider to identify state programs. The Comprehensive Community Support Program reimbursement limitations have been exceeded. Watch FutureRemittance And Status Reports For Its Finalization Before Resubmitting. Individual Test Paid. This Is Not A Reimbursable Level I Screen. Transplants and transplant-related services are not covered under the Basic Plan. Copyright 2023 Wellcare Health Plans, Inc. The Skills Of A Therapist Are Not Required To Maintain The Member. To Date Of Service(DOS) Precedes From Date Of Service(DOS). The service was previously paid for this Date Of Service(DOS). CRNAs, AAs, And Anesthesiologists Supervising CRNAs/AAs Must Bill AnesthesiA Services Using The Appropriate Modifier. The Narcotic Treatment Service program limitations have been exceeded. Condition code 70-76 is required on an ESRD claim when Influenza/PPV/HEP B HCPCS codes are the only codes being billed with condition code A6. The Clinical Status Of The Member Does Not Meet Standards Accepted By The Department Of Health And Family Services For Transplant. RN Home Health visits and Supervisory visits are not reimbursable on the same Date Of Service(DOS) for same provider. This care may be covered by another payer per coordination of benefits. Case Planning And/or On-going Monitoring For Both Targeted Case Managementand Child Care Coordination Are Not Allowed In The Same Month. Program guidelines or coverage were exceeded. Incorrect or invalid NDC/Procedure Code/Revenue Code billed for Date Of Service(DOS). Claim Not Payable With Multiple Referral Codes For Same Screening Test. For RHCs, place of service is 72, however, you can bill lab services with a place of service 11. Reason Code Remark Code(s) Denial Denial Description; 16: M51 | N56: Refer To Dental HandbookOn Billing Emergency Procedures. Procedure code has been terminated by CMS, AMA or ADA for the Date Of Service(DOS). Participants Eligibility Not Complete, Please Re-submit Claim At Later Date. Take care to review your EOB to ensure you understand recent charges and they all are accurate. Dental service limited to twice in a six month period.

The Grace Year Book Summary, Articles W