wellcare eob explanation codes wellcare eob explanation codes

Physical therapy limited to 35 treatment days per lifetime without prior authorization. Consent Form Is Missing, Incomplete, Or Contains Invalid Information. This claim must contain at least one specified Surgical Procedure Code. Quantity Billed is not equally divisible by the number of Dates of Service on the detail. These codes provide additional explanation for an adjustment already described by a Claim Adjustment Reason Code (CARC) or convey information about remittance processing. One or more Occurrence Span Code(s) is invalid in positions three through 24. The Member Does Not Appear To Meet The Severity Of Illness Indicators Established by the Wisconsin And Is Therefore Not Eligible For AODA Day Treatment. Claim Detail Is Pended For 60 Days. WellCare Known Issues List EOP Denial Code or Rejection Reason Code Issue Description Impacted Provider Specialty . If laboratory costs exceed reimbursement, submit a claim adjustment request with lab bills for reconsideration. Do Not Use Informational Code(s) When Submitting Billing Claim(s). Valid Numbers Are Important For DUR Purposes. Modifier Submitted Is Invalid For The Member Age. Do Not Bill Intraoral Complete Series Components Separately. Independent Laboratory Provider Number Required. This Is A Manual Decrease To Your Accounts Receivable Balance. Admission Date does not match the Header From Date Of Service(DOS). The Tooth Is Not Essential To Maintain An Adequate Occlusion. The Services Requested Do Not Meet Criteria For An Acute Episode. Edentulous Alveoloplasty Requires Prior Authotization. Member enrolled in QMB-Only Benefit plan. The Procedure Requested Is Not On s Files. Please Refer To The Original R&S. Prior authorization is required for Maxalt when Maxalt or sumatriptan productshave not been reimbursed within 365 days. Payment Recouped. Use This Claim Number If You Resubmit. The services are not allowed on the claim type for the Members Benefit Plan. This National Drug Code is not covered under the Core Plan or Basic Plan for the diagnosis submitted. Total billed amount is less than the sum of the detail billed amounts. RN And LPN Subsequent Care Visits Limited To 6 Hrs Per Day/per Member/per Provider. 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. Supervising Nurse Name Or License Number Required. Pregnancy Indicator must be "Y" for this aid code. Service billed is bundled with another service and cannot be reimbursed separately. Consultation or surgical procedures are not reimbursable in conjuctions with Emergency Room services. CPT Or CPT/modifier Combination Is Not Valid On This Date Of Service(DOS). Referring Provider ID is not required for this service. The quantity billed of the NDC is not equally divisible by the NDC package size. Do not insert a period in the ICD-9-CM or ICD-10-CM codes. Other Insurance Disclaimer Code Used Is Inappropriate For This Members Insurance Coverage. Please Do Not Resubmit Your Claim, And Disregard Additional Informational Messages for this claim. Denied due to Add Dates Not In Ascending Order Or DD/DD/DD Format. There is no action required. Denied. Effective September 1, 2021: Benefit Changes to Total Disc Arthroplasty for Medicaid and CHIP. Due To Non-covered Services Billed, The Claim Does Not Meet The Outlier Trim Point. Result of Service submitted indicates the prescription was not filled. Denied/Cutback. Claims may deny for the initial inpatient admission E&M if a provider from the same provider group and same specialty bills any other inpatient E&M visit, i.e. Each month you fill a prescription, your Medicare Prescription Drug Plan mails you an "Explanation of Benefits" (EOB). The Fifth Diagnosis Code (dx) is invalid. Supplemental Payment Authorized By Department of Health Services (DHS) Due to an Interim Rate Settlement. wellcare eob explanation codes. Condition code 20, 21 or 32 is required when billing non-covered services. Invalid modifier removed from primary procedure code billed. Repackaging allowance is not allowed for unit dose NDCs. Please Furnish A Breakdown Of Your Procedure Code And Charge In Question GivenOn The Adjustment/reconsideration Request. A National Provider Identifier (NPI) is required for the Rendering Provider listed in the header. Routine Foot Care Procedures Must Be Billed With Valid Routine Foot Care Diagnosis. The HCPCS procedure code listed for revenue code 0624 is either invalid or non-reimburseable. Training CompletionDate Exceeds The Current Eligibility Timeline. Please Correct And Submit. Details Include Revenue/surgical/HCPCS/CPT Codes. Questionable Long-term Prognosis Due To Poor Oral Hygiene. A number is required in the Covered Days field. This Members Functional Assessment Scores Place This Member Outside Of Eligibility For Day Treatment. The Comprehensive Community Support Program reimbursement limitations have been exceeded. There Is Evidence That The Member Is Not Detoxified From Alcohol And/or Other Drugs and is Therefore Not Currently Eligible For AODA Day Treatment. An ICD-9-CM Diagnosis Code of greater specificity must be used for the Second Diagnosis Code. Adjustment Requested Member ID Change. Referring Physician With Credential Other Than Md Is Not Applicable To Type Of Service Provided. Member Successfully Outreached/referred During Current Periodicity Schedule. Complex Care Services Are Limited To One Per Date Of Service(DOS) Per Member. Denied. 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 . Etiology Diagnosis Code(s) (E-Codes) are invalid as the Admitting/Principal Diagnosis 1. This notice gives you a summary of your prescription drug claims and costs. Denied. Procedure code 00942 is allowed only when provided on the same date ofservice as procedure code 57520. Claims may be denied if an advanced imaging procedure is billed with a diagnosis of syncope and there is no history of a 12-lead EKG being performed/billed the same date or in the previous 90 days. Please verify billing. Routine foot care is limited to no more than once every 61days per member. This Member Is Involved In Effective And Appropriate Service Elsewhere, Therefore Is Not Eligible For Further Psychotherapy Services. A Total Charge Was Added To Your Claim. Denied/Cutback. Resubmit Claim Once Election Form Requirements Are Met Per The Hospice Provider Handbook. According to the American College of Emergency Physicians, the American Heart Association and the American College of Cardiology Foundation, CT, CTA, MRA, MRI should not be performed routinely for evaluation of syncope in the absence of related neurologic signs and symptoms. Our Records Indicate This Provider Is Not Certified For AODA Day Treatment. This Member Has Prior Authorization For Therapy Services. Resubmit Claim With Corrected Tooth Number/letter Or With X-ray Documenting Tooth Placement. Value Codes 81 And 83, Are Valid Only When Submitted On An Inpatient Claim. Denied due to Member Not Eligibile For All/partial Dates. Service Provided Before Prior Authorization Was Obtained Is Not Allowable. Speech Therapy Evaluations Are Limited To 4 Hours Per 6 Months. 0001 01/01/1900 NOT USED - MEMBER'S DMAP I.D. By continuing to use our site, you agree to our Privacy Policy and Terms of Use. No payment allowed for Incidental Surgical Procedure(s). If Required Information Is not received within 60 days, the claim detail will be denied. The billing provider number is not on file. Denied. Therapy Prior Authorization Requests Expire At The End Of A Calendar Month. Other Insurance/TPL Indicator On Claim Was Incorrect. Please Request A Corrected EOMB Through The Medicare Carrier And Adjust With The Corrected EOMB. This is a duplicate claim. wellcare explanation of payment codes and comments. LTC hospital bedhold quantity must be equal to or less than occurrence code 75span date range(s). The Reimbursement Code Assigned To This Certification Segment Does Not Authorize a Training Payment. THE WELLCARE GROUP OF COMPANIES . Seventh Occurrence Code Date is required. Denied/Cutback. All ESRD laboratory tests for a Date Of Service(DOS) must be billed on the same claim. Please Re-submit This Claim With The Insurance EOB Showing A Denial OrPartial Payment. Denied due to Medicare Allowed Amount Required. Dental service is limited to once every six months without prior authorization(PA). A HCPCS code is required when condition code A6 is included on the claim. Service Paid At The Maximum Amount Allowed By ReimbursementPolicies. Phone: 800-723-4337. Capitation Payment Recouped Due To Member Disenrollment. No Substitute Indicator required when billing Innovator National Drug Codes (NDCs). 2434. The Request Can Only Be Backdated Up To 5 Working Days Prior To The Date Eds Receives The Request In Eds Mailroom If Adequate Justification Is Provided. Please Check The Adjustment Icn For The Reprocessed Claim. Member is not enrolled in /BadgerCare Plus for the Date(s) of Service. Denied. Denied. The National Drug Code (NDC) is not on file for the Dispense Date Of Service(DOS). Psychotherapy Provided In The Members Home Is Not A Covered Benefit Of . Denied. Procedure Code Used Is Not Applicable To Your Provider Type. Eyeglasses limited to original plus 1 replacement pair, lens or frame in 12 wit hout Prior Authorization. Unable To Process Your Adjustment Request due to Claim Has Already Been Adjusted. Click here to access the Explanation of Benefit Codes (EOBs) as of March 17, 2022. This list was formerly published as Part 6 of the administrative and billing instructions in Subchapter 5 of your MassHealth provider manual. An xray or diagnostic urinalysis is reimbursable only when performed on the same Date Of Service(DOS) and billed on the same claim as the initial office visit. Annual Physical Exam Limited To Once Per Year By The Same Provider. Invalid Service Facility Address. Please Resubmit Corr. Information inadequate to establish medical necessity of procedure performed.Please resubmit with additional supporting documentation. WCDP member enrolled in Medicare Part D. Claim is excluded from Drug Rebate Invoicing. Service Denied. Claim paid at the program allowed amount. Documentation Does Not Justify Medically Needy Override. Pharmaceutical Care Codes Are Billable On Non-compound Drug Claims Only. Claim paid according to Medicares reimbursement methodology. All Home Health Services Exceeding 8 Hours Per Day Or 40 Or More Hours Per Week Require Prior Authorization. Denied due to Detail Add Dates Not In MM/DD Format. Description. EOB Codes List|Explanation of Benefit Reason Codes (2023) February 7, 2022 by medicalbillingrcm. ACTION TYPE LEGEND: NFs Eligibility For Reimbursement Has Expired. Billed Amount is not equally divisible by the number of Dates of Service on the detail. HMO Extraordinary Claim Denied. Adjustment/reconsideration Denied, Provider Signature/date Was Not Provided OnThe Adjustment/reconsideration Request. One or more To Date(s) of Service is invalid for Occurrence Span Codes in positions three through 24. For over 40 years, Washington Publishing Company (WPC) has specialized in managing and distributing data integration information through publications, training, and consulting services. Multiple Prescriptions For Same Drug/ Same Fill Date, Not Allowed. A split claim is required when the service dates on your claim overlaps your Federal fiscal year end (FYE) date. Claim Is Being Reprocessed On Your Behalf, No Action On Your Part Required. Money Will Be Recouped From Your Account. Modification Of The Request Is Necessitated By The Members Minimal Progress. Schedule 3, 4 or 5 drugs are limited to the original dispensing plus 5 refillsor 6 months. (Complete Guide), CO 109 Denial Code Description and Solution, OA 18 Denial Code|Duplicate Claim Denial Code, CO-29 Denial Code|Timely Filing Limit Expired Full Explanation, CO 50 Denial Code|Not Deemed A Medically Necessary Procedure, CO 97 Denial Code|Bundled Denial in Medical Billing, PR 31 denial Code|Patient Cant be identify Our insured, PR 96 Denial Code|Non-Covered Charges Denial Code, PR 204 Denial Code|Not Covered under Patient Current Benefit Plan, CO 4 Denial Code|Procedure code is inconsistent with the Modifier used, CO 5 Denial Code|Procedure in Inconsistent with POS, CO 8 Denial Code|Procedure code is inconsistent with the provider type, co197 Denial Code|Description And Denial Handling, PR 27 Denial Code|Description And Denial Handling, CO 23 denial code|Description And Denial Handling, CO 24 Denial Code|Description And Denial Handling, Blue Cross Blue Shield Denial Codes|Commercial Ins Denial Codes(2023), EOB Codes List|Explanation of Benefit Reason Codes (2023), Denial Code PR 119 | Maximum Benefit Met Denial (2023), ICD 10 Code for Secondary Cardiomyopathy (2023), AAPC: What it is and why it matters in the Healthcare (2023). This Claim Cannot Be Processed. Denied. Only One Ventilator Allowed As Per Stated Condition Of The Member. Do Not Indicate A Hcpcs Or Cpt Procedure Code On An Inpatient Claim. NFs Eligibility For Reimbursement Has Expired. Once Therapy Is Prior Authorized, All Therapy Must Be Billed With A Valid Prior Authorization Number. Reduction To Maintenance Hours. Remittance Advice Remark Codes (RARCs) are used to provide additional explanation for an adjustment already described by a CARC or to convey information about remittance processing; Search for a Reason or Remark Code. A more specific Diagnosis Code(s) is required. Dates Of Service Must Be Itemized. Services billed exceed prior authorized amount. Denials with solutions in Medical Billing; Denials Management - Causes of denials and solution in medical billing; Medical Coding denials with solutions FACIAL. Prescription Drug Plan (PDP) payment/denial information is required on the claim to SeniorCare. The initial rental of a negative pressure wound therapy pump is limited to 90 days; member lifetime. Principal Diagnosis 8 Not Applicable To Members Sex. Nine Digit DEA Number Is Missing Or Incorrect. Benefit code These codes are submitted by the provider to identify state programs. For additional information on HIPAA EOB codes, visit the Code List section of the WPC website at www.wpc-edi.com. Service Denied. The Documentation Submitted Indicates The Tasks Specified Can Be Completed During The Visits Approved. Pricing Adjustment/ Maximum Flat Fee Level 2 pricing applied. Description & Use Of Day RX Procedure Codes Based On Members Status-not the place Of Service Where Day Rx Service Performed. No Action On Your Part Required. Denied due to Quantity Billed Missing Or Zero. The header total billed amount is required and must be greater than zero. Prior Authorization Is Required For Payment Of This Service With This Modifier. Service Denied. Header To Date Of Service(DOS) is required. Date Of Service/procedure/charges Billed On The Adjustment/reconsideration Request Do Not Match The Original Claim. Service Denied. Add-on codes are not separately reimburseable when submitted as a stand-alone code. Admission Date is on or after date of receipt of claim. It is a duplicate of another detail on the same claim. The Medical Necessity For Psychotherapy Services Has Not Been Documented, ThusMaking This Member Ineligible For The Requested Service. 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. Case Planning And/or On-going Monitoring For Both Targeted Case Managementand Child Care Coordination Are Not Allowed In The Same Month. Recoding/adjusting claim may result in a different DRG code assignmentand reimbursement. The Request Does Not Meet Generally Accepted Conditions Requiring Fluoride Treatments. The header total billed amount is invalid. ACode With No Modifier Billed On The Same Day As A Code With Modifier 11 Are Viewed as the same trip. The Procedure Code Indicated Is For Informational Purposes Only. Claim Denied. The Pharmaceutical Care Code (PCC) does not have a rate on file for the Date Of Service(DOS). Denied due to Provider Signature Is Missing. The From Date Of Service(DOS) for the Second Occurrence Span Code is invalid. Billing/performing Provider Indicated On Claim Is Not Allowable. Claim Detail Denied As Duplicate. A Hospital Stay Has Been Paid For DOS Indicated. Claim Denied For No Client Enrollment Form On File. Please Disregard Additional Messages For This Claim. Inpatient mental health services performed by masters level psychotherapists or substance abuse counselors are not covered. Time Spent In AODA Day Treatment By Affected Family Members Is Not Covered. An approved PA was not found matching the provider, member, and service information on the claim. Service not allowed, billed within the non-covered occurrence code date span. Please Clarify. 10 Important Billing Tips for FQHC and RHC Providers. Summarize Claim To A One Page Billing And Resubmit. Medically Unbelievable Error. Only non-innovator drugs are covered for the members program. Valid NCPDP Other Payer Reject Code(s) required. . No Action Required on your part. Reimbursement For This Detail Does Not Include Unit DoseDispensing Fee. A Qualified Provider Application Is Being Mailed To You. Only Healthcheck Modifiers Can Be Billed With Healthcheck Services. Denied. The Sixth Diagnosis Code (dx) is invalid. WellCare 2022 schedule; NOFEE: Code is not a covered service on your fee schedule modifiers, Part 2 for CR, GT and blank modifiers IH033: Exceeds clinical guidelines; IH038: Pricing Adjustment/ Payment amount decreased based on Pay for Performance policies. Denied/cutback. Drug(s) Billed Are Not Refillable. This obstetrical service was previously paid for this Date Of Service(DOS) for thismember. Paid In Accordance With Dental Policy Guide Determined By DHS. Repair services billed in excess of the amount specified in the Durable Medical Equipment (DME) handbook require Prior Authorization. Duplicate Item Of A Claim Being Processed. All services should be coordinated with the Hospice provider. The Members Poor Motivation, The Long-standing Nature Of The Disability and aLack Of Progress Substantiate Denial. Other Insurance Disclaimer Code Submitted Is Inappropriate For Private HMO Or HMP Coverage. Rqst For An Acute Episode Is Denied. Supplemental Payment Authorized By Department of Health Services (DHS) Due to a Department Of Justice Settlement. Total Rental Payments For This Item Have Exceeded The Maximum Allowable Forthe Purchase Of This Item. Next step verify the application to see any authorization number available or not for the services rendered. The disposable medical supply Procedure Code has a quantity limit as indicated in the DMS Index. Initial Visit/Exam limited to once per lifetime per provider. MLN Matters Number: MM6229 Related . Pricing Adjustment/ Pharmacy dispensing fee applied. Pricing Adjustment/ Anesthesia pricing applied. With Payspan's eEOB member-friendly functionality, members can log into the payer's secure portal and . 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. Medicare Deductible Is Paid In Full. The Competency Test Date On The Request Does Not Match The CNAs Test Date OnThe WI Nurse Aide Registry. The first position of the attending UPIN must be alphabetic. A Third Occurrence Code Date is required. Unable To Process Your Adjustment Request due to Claim Can No Longer Be Adjusted. When billing multiple diagnosis codes, the recoding is based on the highest level of service associated to one or more of the diagnosis codes billed. According to CMS Medicare Claims Processing Manual, Place of Service codes (POS) are used to identify where, i.e., physician office, inpatient hospital, a procedure or service is furnished to a patient. Outside Lab,element 20 On CMS 1500 Claim Form Must Be Checked Yes When Handling Charges Are Billed. Header To Date Of Service(DOS) is after the ICN Date. Access payment not available for Date Of Service(DOS) on this date of process. Service(s) Denied/cutback. The training Completion Date On This Request Is After The CNAs CertificationTest Date. The Medical Necessity For The Hours Requested Is Not Supported By The Information Submitted In The Personal Care Assessment Tool. Please Do Not File A Duplicate Claim. Pricing Adjustment/ SeniorCare claim cutback because of Patient Liability and/or other insurace paid amounts. Denied due to Detail Dates Are Not Within Statement Covered Period. Second Other Surgical Code Date is required. Learns to use professional . Billing Provider is not certified for Substance Abuse Day Treatment for the Date(s) of Service. Service Denied. This Revenue Code has Encounter Indicator restrictions. All three DUR fields must indicate a valid value for prospective DUR. 690 Canon Eb R-FRAME-EB Claim Detail from Date Of Service(DOS) And to Date Of Service(DOS) Are Required And Must Be Within The Same Calendar Month. Amount Indicated In Current Processed Line On R&S Report Is The Manual Check You Recently Received. Referring Provider is not currently certified. 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. No policy override available for BadgerCare Plus Benchmark Plan, Core Plan or Basic Plan. Admit Diagnosis Code is invalid for the Date(s) of Service. Per Information From Insurer, Claim(s) Was (were) Not Submitted. Procedure Code and modifiers billed must match approved PA. Prior authorization requests for this drug are not accepted. Fourth Diagnosis Code (dx) is not on file. Denied due to Greater Than Four Dates Of Service Billed On One Detail. Do not leave blank fields between the multiple occurance codes. We Have Determined There Were (are) Several Home Health Agencies Willing To Provide Medically Necessary Skilled Nursing Services To This Member. A Second Occurrence Code Date is required. An Alert willbe posted to the portal on how to resubmit. The Secondary Diagnosis Code is inappropriate for the Procedure Code. Prior Authorization (PA) is required for payment of this service.