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Services Beyond The Six Week Postpartum Period Are Not Covered, Per DHS. Review Of Adjustment/reconsideration Request Shows Original Claim Payment Was Max Allowed For Medical Service/Item/NDC. Denied. Authorizations. Claim reduced to fifteen Hospital Bedhold Days for stays exceeding fifteen days. Denied. The header total billed amount is required and must be greater than zero. A Total Charge Was Added To Your Claim. Amount Paid On Detail By WWWP Is Less Than Billed Or Reimbursement Rate Due ToPrior Payment By Other Insurance. Speech Therapy Limited To 45 Treatment Days Per Spell Of Illness W/o Prior Authorization. The Service Requested Is Included In The Nursing Home Rate Structure. Reason Code Remark Code(s) Denial Denial Description; 16: M51 | N56: The Surgical Procedure Code is not payable for /BadgerCare Plus for the Date Of Service(DOS). The Competency Test Date On The Request Does Not Match The CNAs Test Date OnThe WI Nurse Aide Registry. Prescription Date is after Dispense Date Of Service(DOS). Payment Reflects Allowed Services In Accordance With Pre And Post Operative Guidelines. Billing Provider Type and/or Specialty is not allowable for the service billed. Non-Reimbursable Service. Denied. This Surgical Code Has Encounter Indicator restrictions. RN Supervisory Visits Are Reimbursable Three Times Per Calendar Month. The Materials/services Requested Are Principally Cosmetic In Nature. The Medical Necessity For Psychotherapy Services Has Not Been Documented, ThusMaking This Member Ineligible For The Requested Service. Denied. Service is not reimbursable for Date(s) of Service. Other Payer Date can not be after claim receipt date. Denied. CSHCN number The client's CSHCN Services Program number. Please Correct and Resubmit. An ICD-9-CM Diagnosis Code of greater specificity must be used for the Second Diagnosis Code. Medically Unbelievable Error. Payment reduced. Service Billed Exceeds Restoration Policy Limitation. Denied. Resubmit Claim Once Election Form Requirements Are Met Per The Hospice Provider Handbook. One or more Occurrence Code Date(s) is invalid in positions nine through 24. Service(s) paid at the maximum daily amount per provider per member. Ninth Diagnosis Code (dx) is not on file. Denied due to Provider Signature Is Missing. The canister, dressings and related supplies are included as part of the reimbursement for the negative pressure wound therapy pump. The Request Does Not Meet Generally Accepted Conditions Requiring Fluoride Treatments. Dental service limited to twice in a six month period. Modification Of The Request Is Necessitated By The Members Minimal Progress. Medicaid Remittance Advice Remark Code:M86 MMIS EOB Code:100. Denied. Detail Quantity Billed must be greater than zero. The revenue accomodation billing code on the claim does not match the revenue accomodation billing code on the member file or does not match for these dates of service. Denied. Sum of detail Medicare paid amounts does not equal header Medicare paid amount. Please note that the submission of medical records is not a guarantee of payment. This procedure is limited to once per day. Maximum Reimbursement Amount Has Been Determined By Professional Consultant. Adjustment Requested Member ID Change. 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. If required information is not received within 60 days, the claim will be. Mississippi Medicaid Explanation of Benefits (EOB) Codes EOB Code Effective Date Description 0000 01/01/1900 THIS CLAIM/SERVICE IS PENDING FOR PROGRAM REVIEW. Please familiarize yourself with these new explanation codes and update your accounts receivable as indicated. The From Date Of Service(DOS) for the Second Occurrence Span Code is required. The Number Of Weeks Has Been Reduced Consistent With Goals And Progress Documented. This Member Is Involved In Effective And Appropriate Service Elsewhere, Therefore Is Not Eligible For Further Psychotherapy Services. Denied due to Procedure Is Not Allowable For Diagnosis Indicated. Contactmembers hospice for payment of services or resubmit with documentation of unrelated Nature of Care. Provider Is Responsible For Averaging Costs During Cal Year Not To Exceed YrlyTotal (12 x $2325.00). Denied. Dialysis/EPO treatment is limited to 13 or 14 services per calendar month. We update the Code List to conform to the most recent publications of CPT and HCPCS . Not A WCDP Benefit. Training CompletionDate Exceeds The Current Eligibility Timeline. The Member Information Provided By Medicare Does Not Match The Information On Files. Claim Denied. Billing Provider indicated is not certified as a billing provider. Outside Lab Indicator Must Be Y For The Procedure Code Billed. Language Comprehension And Language Production Are Equivalent To Cognition, Thus Formal Speech Therapy Is Not Needed. Anesthesia and Moderate Sedation Services CPTs 00300, 00400, 00600, 01935-01936, 01991-01992, 99152-99153, 99156-99157, Pain Management Services CPTs 20552, 20553, 27096, 62273, 62320-62323, 64405, 64479, 64480, 64483, 64484, 64490-64495, 0228T, 0229T, 0230T, 0231T, G0260, Nerve Conduction Studies CPT 95907-95913, Needle electromyography (EMG)-CPT 95885, 95886. RN And LPN Subsequent Care Visits Limited To 6 Hrs Per Day/per Member/per Provider. Your latest EOB will be under Claims on the top menu. The Maximum Allowable Was Previously Approved/authorized. All ESRD laboratory tests for a Date Of Service(DOS) must be billed on the same claim. Once 50 Initial Visits/year Has Been Reached Within Any One Discipline All Home Health Services Require Pa. A: This denial is received when Medicare records indicate that Medicare is the beneficiary's secondary payer. One or more Date(s) of Service is missing for Occurrence Span Codes in positions 9 through 24. Member enrolled in Tuberculosis-Related Services Only Benefit Plan. Program guidelines or coverage were exceeded. Do Not Submit Claims With Zero Or Negative Net Billed. Claims may deny when a procedure defined as requiring an anatomical modifier is billed without an associated anatomical modifier. Good Faith Claim Has Previously Been Denied By Certifying Agency. Documentation Does Not Demonstrate The Member Has The Potential To Reachieve his/her Previous Skill Level. Information Required For Claim Processing Is Missing. Documentation Does Not Justify Medically Needy Override. Claims may deny when reported with incompatible ICD-10-CM Laterality policy for Diagnosis-to-Modifier comparison. Occupational Therapy Limited To 35 Treatment Days Per Spell Of Illness W/o Prior Authorization. One or more Diagnosis Codes has a gender restriction. For more information on which codes are considered "Mutually Exclusive", see the "ICD-10 2019 The Complete Official Codebook. Progress, Prognosis And/or Behavior Are Complicating Factors At This Time. This Individual Is Either Not On The Registry Or The SSN On The Request D oesnt Match The SSN Thats Been Inputted On The Registry. If Required Information Is Not Received Within 60 Days,the claim will be denied. Charges Paid At Reduced Rate Based Upon Your Usual And Customary Pricing Profile. The Member Does Not Meet The Criteria For Binaural Amplification; One Hearing Aid Is Authorized. This service or a related service performed on this date has already been billed by another provider and paid. (8 days ago) WebMassHealth List of EOB Codes Appearing on the Remittance Advice. Claim/adjustment Received Beyond The 455 Day Resubmission Deadline. Claim or line denied. Please Clarify. Reimbursement For Training Is One Time Only. The Rendering Providers taxonomy code in the detail is not valid. We Have Determined There Were (are) Several Home Health Agencies Willing To Provide Medically Necessary Skilled Nursing Services To This Member. Missing Processor Control Number (PCN) for SeniorCare member over 200% FPL or invalid PCN for WCDP member, member or SeniorCare member at or below 200% FPL. At least one Remark Code must be provided (may be comprised of either the Remittance Advice Remark Code or NCPDP Reject Reason Code.) This Service Is Covered Only In Emergency Situations. The Skills Of A Therapist Are Not Required To Maintain The Member. Procedure Code billed is not appropriate for members gender. AODA Day Treatment Is Not A Covered Service For Members Who Are Residents Of Nursing Homes or Who Are Hospital Inpatients. The first position of the attending UPIN must be alphabetic. Claim Denied Due To Incorrect Billed Amount. Member last name does not match Member ID. Refill Indicator Missing Or Invalid. Denied due to The Members First Name Is Missing Or Incorrect. The diagnosis code is not reimbursable for the claim type submitted. A Separate Notification Letter Is Being Sent. No Complete Program Enrollment Form Is On File For This Client Or The Client Is Not Eligible For The Date Of Service(DOS) On The Clai im. Please Correct And Resubmit. Established in 1975 and incorporated in 1987, WPC is widely recognized as a leading expert in supporting the development, publishing, and licensing of complex . Claim Detail Denied. Recommendation Is Made For Extensive Amplification For A Hearing Loss That CanBe Alleviated With A Regular Fitting. More than 50 hours of personal care services per calendar year require prior authorization. They are used to provide information about the current status of . Occurrence Code is required when an Occurrence Date is present. One or more Occurrence Span Code(s) is invalid in positions three through 24. Default Prescribing Physician Number XX5555555 Was Indicated. Please Request A Corrected EOMB Through The Medicare Carrier And Adjust With The Corrected EOMB. Do not insert a period in the ICD-9-CM or ICD-10-CM codes. The Other Payer ID qualifier is invalid for . Summarize Claim To A One Page Billing And Resubmit. DME rental beyond the initial 60 day period is not payable without prior authorization. Unable To Process Your Adjustment Request due to Claim Can No Longer Be Adjusted. Laboratory Is Not Certified To Perform The Procedure Billed. Payment Subject To Pharmacy Consultant Review. This procedure is age restricted. LTC hospital bedhold quantity must be equal to or less than occurrence code 75span date range(s). Incorrect Liability Start/end DatesOr Dollar Amounts Must Be Corrected Through County Social Services Agency. When diagnoses 800.00 through 999.9 are present, an etiology (E-code) diagnosis must be submitted in the E-code field. DRG cannotbe determined. The Member Is Also Involved In A Structured Living And/or Working Arrangement.A Reduction In Day Treatment Hours Is Indicated. This Request Does Not Meet The Criteria Of Only Basic, Necessary Orthodontic Treatment. Denied. Healthcheck screenings or outreach limited to three per year for members between the age of one and two years. Denied due to The Members Last Name Is Missing. Denied. 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. The Member Is Involved In group Physical Therapy Treatment. Indicator for Present on Admission (POA) is not a valid value. Services Denied In Accordance With Hearing Aid Policies. Services restricted to EPSDT clients valid only with a Full Scope, EPSDT-eligible Aid Code. Based on these reimbursement guidelines, claims may deny when the following revenue codes are billed without the appropriate HCPCS code: The Quantity Allowed Was Reduced To A Multiple Of The Products Package Size. This claim/service is pending for program review. A Valid Level Of Effort Is Required For Billing Compound Drugs Or Pharmaceutical Care. The topic of Requirements for Compression Garments can be found in the Claims Section, Submission Chapter. Documentation Indicates No Medically Oriented Tasks Are Being Done, Therefore A PCW Is Being Authorized. Denied. Scope Aid Code and an EPSDT Aid Code. Reimbursement limit for all adjunctive emergency services is exceeded. Service Denied. Unrelated Procedure/Service by the Same Physician During the Post-op Period, Modifier 79. Services Not Payable When Rendered To An Individual Aged 21-64 Who Is A Resident Of A Nursing Home Imd. Nursing Home Visits Limited To One Per Calendar Month Per Provider. All services should be coordinated with the Inpatient Hospital provider. Procedure Code Used Is Not Applicable To Your Provider Type. Rn Visit Every Other Week Is Sufficient For Med Set-up. Research Has Determined That The Member Does Not Qualify For Retroactive Eligibility According To Hfs 106.03(3)(b) Of The Wisconsin Administrative Code. Reimb Is Limited To The Average Montly NH Cost And Services Above that Amount Are Considered non-Covered Services. Claim Detail Denied As Duplicate. Please Supply Modifier Code(s) Corresponding To The Procedure Code Description. A dispense as written indicator is not allowed for this generic drug. The From Date Of Service(DOS) for the Second Occurrence Span Code is invalid. Previously Denied Claims Are To Be Resubmitted As New-day Claims. Fourth Other Surgical Code Date is invalid. Professional Service code is invalid. If it is medical necessary for more than 13 or 14 services per calendar month, submit an adjustment request with supporting documentation. Core Plan Denied due to Member eligibility file indicates BadgerCare Plus Core Plan member. Member eligibility file indicates that BadgerCare Plus Benchmark, CorePlan or Basic Plan member. A Previously Submitted Adjustment Request Is Currently In Process. Service Denied. Individual Replacements Reimbursed As Dispensing A Complete Appliance. Transplant services not payable without a transplant aquisition revenue code. 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. Hospital And Nursing Home Stays Are Not Payable For The Same DOS Unless The Nursing Home Claim Indicated Hospital Bedhold Days. Type of Bill indicates services not reimbursable or frequency indicated is notvalid for the claim type. Per Information From Insurer, Prior Authorization Was Not Requested/approved Prior To Providing Services. The Clinical Profile/Diagnosis Makes This Member Ineligible For AODA Services. Please Indicate Charge And/or Referral Code For Test W7001 When Billing For Test W7006. Home Health, Personal Care And Private Duty Nursing Services Are Subject To A Monthly Cap. Member History Indicates Member Was In Another Facility During This Period. The diagnosis code on the claim requires Condition code A6 be present on the Type of Bill. Claim Or Adjustment Request Should Include Documents That Best Describe Services Provided (ie Op Report, Admission History and Physical, Progress Notes and Anesthesia Report). Header Bill Date is before the Header From Date Of Service(DOS). Per Information From Insurer, Claims(s) Was (were) Paid. Claims With Dollar Amounts Greater Than 9 Digits. Unable To Process Your Adjustment Request due to Original Claim ICN Not Found. Number Is Missing Or Incorrect. A Training Payment Has Already Been Issued For This Cna. Do not resubmit. Reimb Is Limited to the Average Monthly NH Cost and Services Above that Amount Are Considered non-Covered Services. Requests For Training Reimbursement Denied Due To Late Billing. 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. No Private HMO Or HMP On File. A Less Than 6 Week Healing Period Has Been Specified For This PA. NDC was reimbursed at Employer Medical Assistance Contribution (EMAC) rate. A SeniorCare drug rebate agreement is not on file for this drug for the Date Of Service(DOS). Supervisory visits for Unskilled Cases allowed once per 60-day period. Correct Claim Or Resubmit With X-ray. This drug has been paid under an equivalent code within seven days of this Date Of Service(DOS). A Second Surgical Opinion Is Required For This Service. Request Denied Due To Late Billing. Compound Ingredient Quantity must be greater than zero. Healthcheck screenings or outreach is limited to six per year for members up to one year of age. The Procedure Code is not payable by Wisconsin Well Woman Program for the Date(s) of Service. To better assist you, please first select your state. Services Not Allowed For Your Provider T. The Procedure Code has Place of Service restrictions. Service Allowed Once Per Lifetime, Per Tooth. Services on this claim were previously partially paid or paid in full. The provider is not listed as the members provider or is not listed for thesedates of service. Revenue Codes 0110 (N6) And 0946 (N7) Are Not Payable When Billed On The Same Dateof Service As Bedhold Days. Documentation Does Not Justify Reconsideration For Payment. A more specific Diagnosis Code(s) is required. Lab Procedures Billed In Conjunction With Family Planning Pharmacy Visit Denied as not a Benefit. The Tooth Is Not Essential For Support Of A Partial Denture. Please Correct And Resubmit. Detail From Date Of Service(DOS) is after the ICN Date. Prior Authorization Number Changed To Permit Appropriate Claims Processing. The disposable medical supply Procedure Code has a quantity limit as indicated in the DMS Index. Claim Denied Due To Invalid Pre-admission Review Number. Reimbursement for this procedure and a related procedure is limited to once per Date Of Service(DOS). The Value Code(s) submitted require a revenue and HCPCS Code. Claim Denied Due To Absent Or Incorrect Discharge (to) Date. The Provider Type/specialty Is Not Recognized For These Date(s) Of Service. Only One Federally Required Annual Therapy Evaluation Per Calendar Year, Per Member, Per Provider. The service is not reimbursable for the members benefit plan. Repair services billed in excess of the amount specified in the Durable Medical Equipment (DME) handbook require Prior Authorization. Payment(s) For Capital Or Medical Education Are Generated By EDS And May Not Be Billed By The Provider. Pricing Adjustment/ Third party liability deducible amount applied. Denied. Denied. Prescription limit of five Opioid analgesics per month. A covered DRG cannot be assigned to the claim. This Claim Has Been Denied Due To A POS Reversal Transaction. Good Faith Claim Denied For Timely Filing. BY . Vision Diagnostic Services Limited To 1 Of These: Vision Exam, Diagnostic Review, Supplemental Test Or Contact Lens Therapy. 51.42 Board Directors Or Designees Statement & Signature Required OnThe Claim Form For Payment Of Functional Assessment. Denied. Medicare RA/EOMB And Claim Dates And/or Charges Do Not Match. The following are the most common reasons HCFA/CMS-1500 and UB/CMS-1450 paper claims for Veteran care are rejected: Requires the 17 alpha-numeric internal control number (ICN) [format: 10 digits + "V" + 6 digits] or 9-digit social security number (SSN) with no special characters. Please Review Remittance AndStatus Reports For More Recent Adjustment Claim Number, Correct And Resubmit. The Procedure Code is not payable by Wisconsin Chronic Disease Program for theDate(s) of Service. Please Reference Payment Report Mailed Separately. Please Resubmit. The To Date Of Service(DOS) for the First Occurrence Span Code is required. Claim Is Pended For 60 Days. Service not payable with other service rendered on the same date. . Request Denied Because The Screen Was Done More Than 90 Days Prior To The Admission Date. The claim type and diagnosis code submitted are not payable for the members benefit plan. Handwritten Changes/corrections On The Medicare EOMB Are Not Acceptable. Reimbursement determination has been made under DRG 981, 982, or 983. Denied by Claimcheck based on program policies. Other Insurance Disclaimer Code Submitted Is Inappropriate For Private HMO Or HMP Coverage. Your 1099 Liability Has Been Credited. As a provider, you have access to a portal that streamlines your work, keeps you up-to-date more than ever before and provides critical information. Effective 04/01/09, the BadgerCare Plus Core Plan will limit coverage for Hypoglycemics-Insulin to Humalog and Lantus. Member has Medicare Managed Care for the Date(s) of Service. Prescription Drug Plan (PDP) payment/denial information required on the claim to WCDP. 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. This Claim Is Being Reprocessed As An Adjustment On This R&s Report. Contact Wisconsin s Billing And Policy Correspondence Unit. Quick Tip: In Microsoft Excel, use the " Ctrl + F " search function to look up specific denial codes. This procedure is duplicative of a service already billed for same Date Of Service(DOS). Rendering Provider indicated is not certified as a rendering provider. There are many different remittance adjustment reason codes (RARCs) established for Medicare and we understand their explanations may be "generic" and confusing, so we have provided a listing in the table below of the most commonly used denial messages and RARCs utilized by Medical Review Part B during medical record review. Service is reimbursable only once per calendar month. All Home Health Services Exceeding 8 Hours Per Day Or 40 Or More Hours Per Week Require Prior Authorization. Billed Procedure Not Covered By WWWP. Pricing Adjustment/ Provider Level of Care (LOC) pricing applied. 0; More than one PPV or Influenza vaccine billed on the same Date Of Service(DOS) for the same member is not allowed. Prescribing Provider UPIN Or Provider Number Missing From Claim And Attachment. This claim must contain at least one specified Surgical Procedure Code. Multiple Unloaded Trips For Same Day/same Recip. NDC- National Drug Code is not covered on a pharmacy claim. Condition Code is missing/invalid or incorrect for the Revenue Code submitted. These are EOB codes, revised for NewMMIS, that may appear on your PDF remittance advice. Denied. This Claim Has Been Manually Priced Based On Family Deductible. The Clinical Status Of The Member Does Not Meet Standards Accepted By The Department Of Health And Family Services For Transplant. Please Indicate The Revenue Code/procedure Code/NDC Code For Which The Credit is To Be Applied. Prior Authorization is required for manipulations/adjustments exceeding 20 perspell of illness. The drug code has Family Planning restrictions. A Third Occurrence Code Date is required. Request was not submitted Within A Year Of The CNAs Hire Date. Discrepancy Between The Other Insurance Indicator And OI Paid Amount. Rural Health Clinics May Only Bill Revenue Codes On Medicare Crossover Claims. The Service Performed Was Not The Same As That Authorized By . Split Decision Was Rendered On Expansion Of Units. For example, F80.2 (Mixed receptive-expressive language disorder) cannot be billed on the same claim as F84.0 (Autism Disorder) since ICD-10's Coding Manual views them as mutually exclusive dx codes. Day Treatment exceeding 120 hours per month is not payable regardless of PriorAuthorzation. Denied. Resubmit charges for covered service(s) denied by Medicare on a claim. Always bill the correct place of service. General Exercise To Promote Overall Fitness And Flexibility Are Non-covered Services. NDC- National Drug Code billed is not appropriate for members gender. Requested Documentation Has Not Been Submitted. WellCare Known Issues List EOP Denial Code or Rejection Reason Code Issue Description Impacted Provider Specialty . Denied as duplicate claim. Other payer patient responsibility grouping submitted incorrectly. 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). Claim count of Present on Admission (POA) indicators does not match count of non-admitting and non-emergency diagnosis codes. Payment Is Limited To One Unit Dose Service Per Calendar Month, Per Legend Drug, Per Member. Denied. Paid In Accordance With Dental Policy Guide Determined By DHS. Claim Previously/partially Paid. CO/204. NFs Eligibility For Reimbursement Has Expired. The Member Has At Least 4 Posterior Teeth, Including Bicuspids On Each Side, which Can Be Used For Chewing. Compound drugs require a minimum of two components with at least one payable FowardHealth covered drug. Ancillary Billing Not Authorized By State. Performed After Therapy/dayTreatment Have Begun Must Be Billed As Therapy Or Limit-exceed Psych/aoda/func. Billed Amount On Detail Paid By WWWP. When a provider submits an E&M level of service that exceeds the maximum level of E&M service level based on the diagnosis submitted, the E&M code is recoded (and allowed to pay) to match the maximum level of E&M service allowed based on the severity of the medical diagnosis submitted. A new set of Generic Reason codes and statements for Part A, Part B and DME have been added and approved for use across all Prior Authorization (PA), Claim reviews . Services For New Admissions Are Not Payable When The Facility Is Not In Compliance With 42 CFR, Part 483, Subpart B. This drug/service is included in the Nursing Facility daily rate. The value code 48 (Hemoglobin reading) or 49 (Hematocrit) is required for the revenue code/HCPCS code combination. If you are still unable to resolve the login problem, read the troubleshooting steps or report your issue. Next step verify the application to see any authorization number available or not for the services rendered. The Resident Or CNAs Name Is Missing. Phone: 800-723-4337. The Hearing Aid Recommended Is Not Necessary; The Member Could Be Adequately Fitted With A Conventional Aid. Service Denied. Denied due to Per Division Review Of NDC. We thank you for your continued partnership in servicing the Wellcare By Fidelis Care membership. Amount Recouped For Mother Baby Payment (newborn). Dispense as Written indicator is not accepted by . Please correct and resubmit. This service is not payable for the same Date Of Service(DOS) as another service included on the same claim, according to the National Correct Coding Initiative. Denied. Drug Dispensed Under Another Prescription Number. Home Health services for CORE plan members are covered only following an inpatient hospital stay.