ACTION DESCRIPTION. Incidental modifier is required for secondary Procedure Code. The Medical Need For Some Requested Services Is Not Supported By Documentation. Please Do Not Resubmit Your Claim, And Disregard Additional Informational Messages for this claim. Timely Filing Deadline Exceeded. Value code 48 exceeds 13.0 or value code 49 exceeds 39.0 and HCPCS codes Q4081or J0882 are present but either modifer ED or EE are not present. Inpatient mental health services performed by masters level psychotherapists or substance abuse counselors are not covered. Escalations. Reason for Service submitted does not match prospective DUR denial on originalclaim. Additional Psychotherapy Is Not Considered Appropriate Or Inline With More Effective, Available Services. $150.00 Reimbursement Limit Has Been Reached For Individual And Group Pncc Health Education/nutritional Counseling. A Rendering Provider is not required but was submitted on the claim. Claim Denied. Documentation Does Not Justify Fee For ServiceProcessing . Providers should submit adequate medical record documentation that supports the claim (services) billed. Will Not Authorize New Dentures Under Such Circumstances. Claim/adjustment Received Beyond The 455 Day Resubmission Deadline. Type of Bill indicates services not reimbursable or frequency indicated is notvalid for the claim type. 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). Rinoplastia; Blefaroplastia Denied due to NDC Is Not Allowable Or NDC Is Not On File. This drug has been paid under an equivalent code within seven days of this Date Of Service(DOS). Only preferred drugs are covered for the member?s program, Only generic drugs are covered for the member?s program. Denied. Claim Denied. Documentation You Have Submitted Does Not Meet The Requirements Of HSS 107.09(4)(k). Prescriber ID and Prescriber ID Qualifier do not match. An ICD-9-CM Diagnosis Code of greater specificity must be used for the First Diagnosis Code. Prescriber ID is invalid.e. Birth to 3 enhancement is not reimbursable for place of service billed. Claim Is Pended For 60 Days. Subsequent Aide Visits Limited To 7 Hrs Per Day/per Member/per Provider. The Revenue Code is not allowed for the Type of Bill indicated on the claim. If it is medical necessary for more than 13 or 14 services per calendar month, submit an adjustment request with supporting documentation. Professional Service code is invalid. Member enrolled in Medicare Part D for the Dispense Date Of Service(DOS). Healthcheck screenings or outreach limited to three per year for members between the age of one and two years. Claim Denied Due To Incorrect Accommodation. Please Review The Cover Letter Attached To Your Claim, Any Informational Messages, And Provide The Requested Information BeforeResubmitting the Claim. Requires A Unique Modifier. Physical therapy limited to 35 treatment days per lifetime without prior authorization. A National Provider Identifier (NPI) is required for the Performing Provider listed in the header. The condition code is not allowed for the revenue code. Your latest EOB will be under Claims on the top menu. This Dental Service Limited To Once Every Six Months, Unless Prior Authorized. A Reimbursement Request For A Level I Screen Must Be Received At Within A Year Of The Screen Date. Members age does not fall within the approved age range. Discharge Date is before the Admission Date. Member Name Missing. Tooth surface is invalid or not indicated. Claim Reduced Due To Member Income Available Toward Cost Of Care (Nursing Home Liability). Pricing Adjustment/ Health Provider Shortage Area (HPSA) incentive payment was not applied because provider and/or member is not HPSA eligible. -OR- The claim contains value code 48, 49, or 68 but does not contain revenue codes 0634 or 0635. Policy override must be granted by the Drug Authorization and Policy Override Center to dispense less than a 100 day supply. Men. Restorative Nursing Can Provide Follow-through, Based On Diagnosis Of Long-standing Nature, And The Amount Of Therapy. Serviced Denied. Submitted referring provider NPI in the detail is invalid. Rendering Provider is not certified for the Date(s) of Service. Denied due to Provider Is Not Certified To Bill WCDP Claims. Ulcerations Of The Skin Do Not Warrant A New Spell Of Illness. Psych Evaluation And/or Functional Assessment Ser. Please Correct And Resubmit. Limited to once per quadrant per day. Admission Denied In Accordance With Pre-admission Review Criteria. Diagnosis Treatment Indicator is invalid. Please Correct And Submit. Claim Denied Due To Incorrect Billed Amount. Resubmit Claim With Copyof A Temporary ID Card, EVS Printed Response Or Indicate The AVR Transaction Log Number. Please submit claim to BadgerRX Gold. Amount Recouped For Duplicate Payment on a Previous Claim. This National Drug Code Has Diagnosis Restrictions. Please Review The Covered Services Appendices Of The Dental Handbook. Adjustment To Eyeglasses Not Payable As A Repair Service. Health (3 days ago) Webwellcare explanation of payment codes and comments. The Service Requested Does Not Correspond With Age Criteria. Pricing Adjustment/ Ambulatory Payment Classification (APC) pricing applied. Recd Beyond 90 Days Special Filing Deadline FOr System Generated Adjmts/Medicare X-overs/Other Insurance Reconsideration/Cou rt Order/Fair Hearing. Header To Date Of Service(DOS) is required. The Eighth Diagnosis Code (dx) is invalid. This National Drug Code is not covered under the Core Plan or Basic Plan for the diagnosis submitted. Denied due to From Date Of Service(DOS)/date Filled Is Missing/invalid. Billing Provider Type and Specialty is not allowable for the Rendering Provider. The Surgical Procedure Code is not payable for the Date Of Service(DOS). Claim Is Pended For 60 Days. NCTracks AVRS. These services are not allowed for members enrolled in Tuberculosis-Related Services Only Benefit Plan. Benefit code These codes are submitted by the provider to identify state programs. Please Correct And Resubmit. Additional Reimbursement Is Denied. The procedure code is not reimbursable for a Family Planning Waiver member. Intraoral Complete Series/comprehensive Oral Exam Limited To Once Every Three Years, Unless Prior Authorized. Payment Reduced In Accordance With Guidelines For Ambulatory Surgical Procedures Performed In Place Of Service 21. The Functional Assessment And/or Progress Status Report Does Not Indicate Any Change, and/or Positive Rehabilitation Potential. Member In TB Benefit Plan. The content shared in this website is for education and training purpose only. Member is enrolled in Medicare Part A on the Date(s) of Service. If laboratory costs exceed reimbursement, submit a claim adjustment request with lab bills for reconsideration. Submitclaim to the appropriate Medicare Part D plan. If required information is not received within 60 days, the claim will be. Claimchecks Editing And Your Supporting Documentation Was Reviewed By The DHS Medical Consultant. NCTracks Contact Center. Service(s) Denied/cutback. Training Completion Date Must Be Within A Year Of The CNAs Certification, Test, Date. The relationship between the Billed and Allowed Amounts exceeds a variance threshold. Care Does Not Meet Criteria For Complex Case Reimbursement. Services Beyond The Six Week Postpartum Period Are Not Covered, Per DHS. Denied. Child Care Coordination services are reimbursable only if both the member and provider are located in Milwaukee County. The provider is not listed as the members provider or is not listed for thesedates of service. Resubmit charges for covered service(s) denied by Medicare on a claim. Routine Foot Care Procedures Must Be Billed With Valid Routine Foot Care Diagnosis. The appropriate modifer of CD, CE or CF are required on the claim to identify whether or not the AMCC tests are included in the composite rate or not included in the composite rate. Personal Care In Excess Of 250 Hrs Per Calendar Year Requires Prior Authorization. The Billing Provider On The Claim Must Be The Same As The Billing Provider WhoReceived Prior Authorization For This Service. (National Drug Code). The Request Has Been Approved To The Maximum Allowable Level. CPT is registered trademark of American Medical Association. Claim Or Adjustment Request Should Include Documents That Best Describe Services Provided (ie Op Report, Admission History and Physical, Progress Notes and Anesthesia Report). Denied due to Diagnosis Not Allowable For Claim Type. Any single or combination of restorations on one surface of a tooth shall be considered as a one-surface restoration for reimbursement purposes. The changes in the brain that happen during a migraine cannot be seen by the imaging studies since a migraine is caused by a complicated interaction between the brain and the blood vessels in the face and head. Payment Recovered For Claim Previously Processed Under Wrong Member ID Number. Diagnosis of malignancies and inflammatory conditions frequently requires numerous biopsies of a particular organ or suspicious site. Head imaging in the form of CT scans, MRI or MRA is allowed only when the service is medically reasonable and necessary. 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. 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. Denied. Service(s) Denied. Denied/Cutback. Payment has been reduced or denied because the maximum allowance of this ESRD service has been reached. Medicare Deductible Is Paid In Full. Other Payer Date can not be after claim receipt date. The header total billed amount is invalid. Your 1099 Liability Has Been Credited. Denied due to Diagnosis Code Is Not Allowable. Medicare RA/EOMB And Claim Dates And/or Charges Do Not Match. Service Billed Exceeds Restoration Policy Limitation. Progress, Prognosis And/or Behavior Are Complicating Factors At This Time. Drugs Prescribed and Filled on the Same Day, Cannot have a Refill Greater thanZero. Documentation Does Not Justify Reconsideration For Payment. Billing Provider is not certified for the Date(s) of Service. Per Information From Insurer, Claim(s) Was (were) Not Submitted. To better assist you, please first select your state. Dispensing fee denied. 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. According to the American Association of Neuromuscular & Electro-Diagnostic Medicine and CMS Policy, nerve conduction studies and a needle electromyography (EMG) must both be performed in order to diagnose radiculopathy (pinched nerve in back or neck). Unrelated Procedure/Service by the Same Physician During the Post-op Period, Modifier 79. One or more Surgical Code Date(s) is missing in positions seven through 24. Amount Recouped For Mother Baby Payment (newborn). Member must receive this service from the state contractor if this is for incontinence or urological supplies. Watch FutureRemittance And Status Reports For Its Finalization Before Resubmitting. Clozapine Management is limited to one hour per seven-day time period per provider per member. Good Faith Claim Denied. This service is not covered under the ESRD benefit. Condition Code is missing/invalid or incorrect for the Revenue Code submitted. The Documentation Submitted Does Not Substantiate Additional Care. Claims may deny for a CT head or brain, CTA head, MRA head, MRI brain or CT follow-up when the only diagnosis on the claim is a migraine. Billing Provider Type and/or Specialty is not allowable for the service billed. Restorative Nursing Involvement Should Be Increased. Member Has Already Been Granted Actute Episode for 3 Months In This Cal Yr. Reimb Is Limited To Average Monthy NH Cost And Services Above That Are Consider Non-covered Services. Reimbursement For This Service Is Included In The Transportation Base Rate. This procedure is limited to once per day. Services on this claim were previously partially paid or paid in full. Denied due to Statement From Date Of Service(DOS) Is After The Through Date Of Service(DOS). 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 . This Member Is Receiving Concurrent AODA/Psychotherapy Services And Is Therefore Only Eligible For Maintenance Hours. Only one initial visit of each discipline (Nursing) is allowedper day per member. EDI TRANSACTION SET 837P X12 HEALTH CARE . ESRD claims are not allowed when submitted with value code of A8 (weight) and a weight of more than 500 kilograms and/or the value code of A9 (height) and the height of more than 900 centimeters. This Request Can Only Be Backdated To The Date EDS First Receives The Request In The Mailroom. Value Codes 81 And 83, Are Valid Only When Submitted On An Inpatient Claim. Timely Filing Deadline Exceeded. Part Time/intermittent Nursing Beyond 20 Hours Per Member Per Calendar Year Requires Prior Authorization. Payment Subject To Pharmacy Consultant Review. It Must Be In MM/DD/YY FormatAnd Can Not Be A Future Date. A SeniorCare drug rebate agreement is not on file for this drug for the Date Of Service(DOS). Training Completion Date Must Be Prior To And Within A Year Of The CNAs Certification Date. Detail Denied. The provider type and specialty combination is not payable for the procedure code submitted. Dispensing Two Lens Replacements On Same Date Of Service(DOS) Not Allowed. A more specific Diagnosis Code(s) is required. Medicare Id Number Missing Or Incorrect. Contingency Plan for CORE and HIRSP Kids Suspend all non-pharmacy claims. Only One Federally Required Annual Therapy Evaluation Per Calendar Year, Per Member, Per Provider. RN Home Health visits and Supervisory visits are not reimbursable on the same Date Of Service(DOS) for same provider. Home care ongoing assessments are allowed once every sixty days per member.nt, But Arepayable Every Fifty-fourth Day For Flexibility In Scheduling. Prescription limit of five Opioid analgesics per month. Lab Procedures Billed In Conjunction With Family Planning Pharmacy Visit Denied as not a Benefit. This claim/service is pending for program review. Pap Smears, Hematocrit, Urinalysis Are Not Reimbursable Separately In Conjunction With Family Planning Medical Visits. CRNAs, AAs, And Anesthesiologists Supervising CRNAs/AAs Must Bill AnesthesiA Services Using The Appropriate Modifier. Service Denied. Claims may deny for procedures billed with modifier 79 when the same or different 0-, 10- or 90-day procedure code has not been billed on the same date of service. Service paid in accordance with program requirements. 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. Schedule 3, 4 or 5 drugs are limited to the original dispensing plus 5 refillsor 6 months. Claim Denied. Claim paid at the program allowed amount. Members I.d. PATIENT PAID PORTION USED TOWARDS DEDUCTIBLE. The Member Has Received A 93 Day Supply Within The Past Twelve Months. SeniorCare member enrolled in Medicare Part D. Claim is excluded from Drug Rebate Invoicing. Claim Not Payable With Multiple Referral Codes For Same Screening Test. 2. Reimbursement For Panel Test Only- Individual Tests In Addition To Panel Test Disallowed. New Prescription Required. Repackaged National Drug Codes (NDCs) are not covered. Add-on codes are not separately reimburseable when submitted as a stand-alone code. Eyeglasses limited to original plus 1 replacement pair, lens or frame in 12 wit hout Prior Authorization. No Matching, Complete Reporting Form Is On File For This Client. This Procedure Is Denied Per Medical Consultant Review. Quantity submitted matches original claim. Research Has Determined That The Member Does Not Qualify For Retroactive Eligibility According To Hfs 106.03(3)(b) Of The Wisconsin Administrative Code. Patient Status Code is incorrect for Long Term Care claims. One or more From Date Of Service(DOS) (DOS) is invalid for Occurrence Span Codes in positions three through 24. Claim Denied. Ninth Diagnosis Code (dx) is not on file. The Documentation Submitted Does Not Indicate Medically Oriented Tasks Are Medically Necessary, Therefore Personal Care Services Have Been Approved. Billing Provider Name Does Not Match The Billing Provider Number. CPT Or CPT/modifier Combination Is Not Valid On This Date Of Service(DOS). 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. Medicare Disclaimer Code Used Inappropriately. Please Review Remittance And Status Report. One or more Condition Code(s) is invalid in positions eight through 24. Fourth Diagnosis Code (dx) is not on file. As a result, providers experience more continuity and claim denials are easier to understand. wellcare eob explanation codes. Only non-innovator drugs are covered for the members program. The Medical Need For This Service Is Not Supported By The Submitted Documentation. No Interim Billing Allowed On Or After 01-01-86. Pricing Adjustment/ The submitted charge exceeds the allowed charge. Denied/Cutback. Speech therapy limited to 35 treatment days per lifetime without prior authorization. Member is assigned to an Inpatient Hospital provider. Reason Code 234 | Remark Codes N20. A Second Occurrence Code Date is required. Copyright 2023 Wellcare Health Plans, Inc. New Coding Integrity Reimbursement Guidelines. For FQHCs, place of service is 50. This Mutually Exclusive Procedure Code Remains Denied. Date Of Service/procedure/charges Billed On The Adjustment/reconsideration Request Do Not Match The Original Claim. PDN Codes W9045/w9046 Are Not Payable On The Same Date As PDN Codes W9030/W9031 For The Same Provider And Member. Diagnosis Code indicated is not valid as a primary diagnosis. Please Provide The Type Of Drug Or Method Used To Stop Labor. Please Correct And Resubmit. There is no action required. The total of amounts billed for the DOS on the claim exceeds the allowed dailylimit for PDN services. Physical Therapy Limited To 35 Treatment Days Per Spell Of Illness W/o Prior Authorization. The Request Does Not Meet Generally Accepted Conditions Requiring Fluoride Treatments. The Billing Providers taxonomy code is missing. Claim Denied/Cutback. Prospective DUR denial on original claim can not be overridden. No Separate Payment For IUD. Individual Test Paid. Previously Denied Claims Are To Be Resubmitted As New-day Claims. Indicated Diagnosis Is Not Applicable To Members Sex. Comprehension And Language Production Are Age-appropriate. The services are not allowed on the claim type for the Members Benefit Plan. 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. Reimb Is Limited To The Average Montly NH Cost And Services Above that Amount Are Considered non-Covered Services. 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. Header To Date Of Service(DOS) is after the ICN Date. No Action Required. Services Can Only Be Authorized Through One Year From The Prescription Date. Principal Diagnosis 6 Not Applicable To Members Sex. Compound drugs require a minimum of two components with at least one payable FowardHealth covered drug. It Corrects A Mispayment FoundDuring Claims Processing Or Resulting From Retroactive File Changes. Second Rental Of Dme Requires Prior Authorization For Payment. Claims may deny when reported and not meeting the ICD-10-CM Laterality policy for Diagnosis-to-Diagnosis comparison. Denied due to Claim Contains Future Dates Of Service. Charges Paid At Reduced Rate Based Upon Your Usual And Customary Pricing Profile. Procedure not payable for Place of Service. The Duration Of Treatment Sessions Exceed Current Guidelines. Effective 04/01/09, the BadgerCare Plus Core Plan will limit coverage for Hypoglycemics-Insulin to Humalog and Lantus. Pharmaceutical Care Codes Are Billable On Non-compound Drug Claims Only. Effective 5/31/2019, we will introduce new Coding Integrity Reimbursement Guidelines. Member has Medicare Managed Care for the Date(s) of Service. Claim Denied For No Consent And/or PA. Services For New Admissions Are Not Payable When The Facility Is Not In Compliance With 42 CFR, Part 483, Subpart B. Complete Refusal Detail Is Not Payable Without Referral/treatment Details. Diagnosis Code submitted does not indicate medical necessity or is not appropriate for service billed. Documentation Provided Indicates A Less Elaborate Procedure Should Be Considered. Second Surgical Opinion Guidelines Not Met. Learns to use professional . Rebill Using Correct Claim Form As Instructed In Your Handbook. Provider signature and/or date is required. Reason Code 162: Referral absent or exceeded. One or more To Date(s) of Service is missing for Occurrence Span Codes in positions three through 24. Please Resubmit As A Regular Claim If Payment Desired. Documentation Does Not Justify Medically Needy Override. Ability to proficiently use Microsoft Excel, Outlook and Word. Result of Service submitted indicates the prescription was not filled. The sum of the Accommodation Days is not equal to the sum of Covered plus Non-Covered Days, or the From and To Dates of Service cannot be the same. An ICD-9-CM Diagnosis Code of greater specificity must be used for the Eighth Diagnosis Code. Insufficient Documentation To Support The Request. Adjustment Requested Member ID Change. Second Other Surgical Code Date is invalid. Day Treatment Services For Members With Inpatient Status Limited To 20 Hours. Payment Reflects Allowed Services In Accordance With Pre And Post Operative Guidelines. A code with no Trip Modifier billed on same day as a code with Modifier U1 are considered the same trip. Please Bill Appropriate PDP. Department of Health Services (DHS) Authorized Payment Is Being Withheld Due toa Final Rate Settlement. 12/06/2022 . Denial Codes. Pharmaceutical Care Code must be billed with a payable drug detail or if a prescription was not filled, the quantity dispensed must be zero. Claim Previously/partially Paid. Once medical records are received, medical review professionals will review the documentation to determine whether the claim is supported as submitted and pay or deny accordingly.