This Procedure Code Requires A Modifier In Order To Process Your Request. This is a same-day claim for bill types 13X, 14X, 71X, or 83X and there are multiple units or combination of chemistry/hemotology tests. HTTP Status Code Connect Time (ms) Result; 2023-03-01 04:10:52: 200: 255: Page Active: Drug(s) Billed Are Not Refillable. Valid Numbers AreImportant For DUR Purposes. Unable To Process This Request Because The Competency Test Date And TrainingCompletion Date Fields Are Blank. Procedure Code Changed To Permit Appropriate Claims Processing. Diagnosis V25.2 May Only Be Used When Billing For Sterilization Procedures. Denied. Claim Previously/partially Paid. 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. Non-Reimbursable Service. Subsequent Aide Visits Limited To 7 Hrs Per Day/per Member/per Provider. This claim is a duplicate of a claim currently in process. Billed Amount On Detail Paid By WWWP. Member is assigned to a Hospice provider. Purchase Of A DME/DMS Item Exceeding One Per Month Requires Prior Authorization. ambulatory surgical center, outpatient hospital) exists for the same member, same date of service and the same procedure or service. An ICD-9-CM Diagnosis Code of greater specificity must be used for the Third Diagnosis Code. Services restricted to EPSDT clients valid only with a Full Scope, EPSDT-eligible Aid Code. The first position of the attending UPIN must be alphabetic. This claim has been adjusted due to Medicare Part D coverage. The Member Is Enrolled In An HMO. Reimbursement of this service is included in the reimbursement of the most complex/complete procedure performed. CNAs Eligibility For Training Reimbursement Has Expired. . This Surgical Code Has Encounter Indicator restrictions. 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. Claim Denied For No Provider Agreement On File Or Not Certified For Date Of Service(DOS). Payment Recovered For Claim Previously Processed Under Wrong Member ID Number. Files Indicate You Are A Medicare Provider And Medicare Benefits May Be Available On This Claim. The Diagnosis Does Not Indicate A Significant Change In the Members Condition. Rendering Provider is not a certified provider for Wisconsin Well Woman Program. An approved PA was not found matching the provider, member, and service information on the claim. The Primary Occurrence Code Date is invalid. Pricing Adjustment/ Anesthesia pricing applied. The number of tooth surfaces indicated is insufficient for the procedure code billed. 0001 01/01/1900 NOT USED - MEMBER'S DMAP I.D. Explanation . These services are not allowed for members enrolled in Tuberculosis-Related Services Only Benefit Plan. Department of Health Services (DHS) Authorized Payment Is Being Withheld Due toa Department Of Justice Settlement. 51.42 Board Directors Or Designees Statement & Signature Required OnThe Claim Form For Payment Of Functional Assessment. The Member Has Received A 93 Day Supply Within The Past Twelve Months. Only Healthcheck Modifiers Can Be Billed With Healthcheck Services. wellcare eob explanation codes. Services Requiring Prior Authorization Cannot Be Submitted For Payment On A Claim In Conjunction With Non Prior Authorized Services. Amount Paid Reduced By Amount Of Other Insurance Payment. Claim Denied/Cutback. Please Indicate One Prior Authorization Number Per Claim. Limited to once per quadrant per day. Pricing Adjustment/ Maximum Flat Fee pricing applied. If it is medically necessary to exceed the limitation, submit an Adjustment/Reconsideration request with supporting documentation. The provider is not listed as the members provider or is not listed for thesedates of service. Reimbursement also may be subject to the application of Dates of Service reflected by the Quantity Billed for dialysis exceeds the Statement Covers Period. Quick Tip: In Microsoft Excel, use the " Ctrl + F " search function to look up specific denial codes. Billing provider number was used to adjudicate the service(s). Only One Ventilator Allowed As Per Stated Condition Of The Member. 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. Part C Explanation of Benefits (EOB) Materials. This CNAs Social Security Number, SSN, Is Not On The EDS Nurse Aide Registry File. Recasing Or Replacement Of Hearing Aid Case Is Limited To Once Per 2 Year Period Per Member Per Provider. 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. Please Refer To The Original R&S. NUMBER IS MISSING OR INCORRECT 0002 01/01/1900 COULD NOT PROCESS CLAIM. LTC hospital bedhold quantity must be equal to or less than occurrence code 75span date range(s). The Information Provided Indicates This Member Is Not Willing Or Able To Participate Inaftercare/continuing Care Services And Is Therefore Not Eligible For AODA Day Treatment. Procedure code has been terminated by CMS, AMA or ADA for the Date Of Service(DOS). Procedure code 00942 is allowed only when provided on the same date ofservice as procedure code 57520. Claim Reduced Due To Member Income Available Toward Cost Of Care (Nursing Home Liability). The Procedure Code Indicated Is For Informational Purposes Only. Only One Date For EachService Must Be Used. Inicio Quines somos? Please submit claim to HIRSP or BadgerRX Gold. Non-covered Charges Are Missing Or Incorrect. Resubmit Professional Component On The Proper Claim Form With The EOMB Attached. Please Select A Procedure Code In The 58980-58988 Range That Best Describes The Procedure Being Performed. Claim Denied. Drugs Prescribed and Filled on the Same Day, Cannot have a Refill Greater thanZero. Denied due to Procedure Is Not Allowable For Diagnosis Indicated. Referral/treatment Procedures Are Not Payable When Billed With A Complete Refusal Detail. Please Indicate The Dollar Amount Requested For The Service(s) Requested. Denied. Intraoral Complete Series/comprehensive Oral Exam Limited To Once Every Three Years, Unless Prior Authorized. Please familiarize yourself with these new explanation codes and update your accounts receivable as indicated. The submitted claim contains value code 68 and 48 or 49 but does not contain revenue code 0634 or 0635 and HCPCS Q4055. Please Resubmit With The Costs For Sterilization Related Charges Identified As Non-covered Charges On The Claim. We Have Determined There Were (are) Several Home Health Agencies Willing To Provide Medically Necessary Skilled Nursing Services To This Member. Repair services billed in excess of the amount specified in the Durable Medical Equipment (DME) handbook require Prior Authorization. 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. Permanent Tooth Restoration/sealant, Limited To Once Every 3 Years Unless Narrative Documents Medical Necessity. Reimbursement For This Service Has Been Approved. By continuing to use our site, you agree to our Privacy Policy and Terms of Use. Pricing Adjustment/ Repackaging dispensing fee applied. Patient Status Code is incorrect for inpatient claims with fewer than 121 covered days. A Reimbursement Request For A Level I Screen Must Be Received At Within A Year Of The Screen Date. All services should be coordinated with the primary provider. Critical care performed in air ambulance requires medical necessity documentation with the claim. subsequent hospital care (CPT 99231-99233) or inpatient consultations (CPT 99251-99255) in the previous week. Incorrect or invalid NDC/Procedure Code/Revenue Code billed. Medicare Part A Or B Charges Are Missing Or Incorrect. Services are not payable. Determinations as to whether services are reasonable and necessary for an individual patient should be made on the same basis as all other such determinations: with reference to accepted standards of medical practice and the medical circumstances of the individual case. Service Denied. Effective With Claims Received On And After 10/01/03 , Occurrence Codes 50 And 51 Are Invalid. Revenue code billed with modifier GL must contain non-covered charges. Assessment Is Not A Covered Service Unless All Four Components Of Skilled Nursing Are Present: Assessment, Planning, Intervention And Evaluation. 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. Benefit Payment Determined By DHS Medical Consultant Review. Only two dispensing fees per month, per member are allowed. Denied due to Claim Exceeds Detail Limit. Note: The Group, Reason and Remark Codes are HIPAA EOB codes and are cross-walked to L&I's EOB codes. 0; Case Plan and/or assessment reimbursment is limited to one per calendar year.Calendar Year. Reimb Is Limited to the Average Monthly NH Cost and Services Above that Amount Are Considered non-Covered Services. Claim Detail from Date Of Service(DOS) And to Date Of Service(DOS) Are Required And Must Be Within The Same Calendar Month. Header Rendering Provider number is not found. Healthcheck Screening Limited To Two Per Year From Birth To Age 3 And One Per Year For Age3 Or Older. The Medicare Paid Amount is missing or incorrect. Department of Health Services (DHS) Authorized Payment Is Being Withheld Due toan Interim Rate Settlement. Payment Subject To Pharmacy Consultant Review. These are EOB codes, revised for NewMMIS, that may appear on your PDF remittance advice. The Lens Formula Does Not Justify Replacement. A Second Surgical Opinion Is Required For This Service. Default Prescribing Physician Number XX5555555 Was Indicated. Previously Denied Claims Are To Be Resubmitted As New Day Claims. A National Provider Identifier (NPI) is required for the Rendering Provider listed in the header. EOB Codes List|Explanation of Benefit Reason Codes (2023) February 7, 2022 by medicalbillingrcm. Procedure Not Payable for the Wisconsin Well Woman Program. Homecare Services W/o PA Are Not Payable When Prior Authorized Homecare Services have Been Provided To The Same Member. Service(s) Must Be Submitted On Paper Claim Form Along With Preoperative History And Physical Report And Operation Report. This National Drug Code (NDC) requires a whole number for the Quantity Billed. Birth to 3 enhancement is not reimbursable for place of service billed. This Service Is Not Payable Without A Modifier/referral Code. Modifier Invalid: Modifiers Are No Longer Allowed For Procedure Code Billed. Refer To Your Pharmacy Handbook For Policy Limitations. A Less Than 6 Week Healing Period Has Been Specified For This PA. Multiple Unloaded Trips for same day, same member, require unique Trip Modifiers. Medication checks by a Psychiatrist and/or Registered Nurse are limited to four services per calendar month. More Than 5 Consecutive Calendar Days Of Continuous Care Are Not Payable.
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