Comprehensive Screens And Individual Components Are Not Payable On The Same Date Of Service(DOS). Additional servcies may be billed with H0046 and will count toward mental health and/or substance abuse treatment policy limits for prior authorization. Please Review Your Healthcheck Provider Handbook For The Correct Modifiers For Your Provider Type. If you are having difficulties registering please . Revenue code requires submission of associated HCPCS code. The Requested Procedure Is Cosmetic In Nature, Therefore Not Covered By . Additional Psychotherapy Is Not Considered Appropriate Or Inline With More Effective, Available Services. In addition, duplex scan of extracranial arteries, computed tomographic angiography (CTA) of the neck and magnetic resonance angiography (MRA) of the neck are not medically necessary for evaluation of syncope in patients with no suggestion of seizure and no report of other neurologic symptoms or signs. FACIAL. Tooth number or letter is not valid with the procedure code for the Date Of Service(DOS). Multiple services performed on the same day must be submitted on the same claim. The Tooth Is Not Essential To Maintain An Adequate Occlusion. This claim did not include the Plan ID, therefore we assigned TXIX as the Plan ID for this claim. You Must Adjust The Nursing Home Coinsurance Claim. Non-Reimbursable Service. The diagnosis code on the claim requires Condition code A6 be present on the Type of Bill. Second And Subsequent Cerebral Evoked Response Tests Paid At A Reduced Rate Per Guidelines. Submitted rendering provider NPI in the header is invalid. Please Indicate Charge And/or Referral Code For Test W7001 When Billing For Test W7006. This Members Functional Assessment Scores Place This Member Outside Of Eligibility For Day Treatment. Outside Lab,element 20 On CMS 1500 Claim Form Must Be Checked Yes When Handling Charges Are Billed. Homecare Services W/o PA Are Not Payable When Prior Authorized Homecare Services have Been Provided To The Same Member. Cutback/denied. 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. Prescribing Provider UPIN Or Provider Number Missing. Unable To Process Your Adjustment Request due to The Claim Type Of The Adjustment Does Not Match The Claim Type Of The Original Claim. . Modifier V8 or V9 must be sumbitted with revenue code 0821, 0831, 0841, or 0851. 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. This Member Is Receiving Concurrent AODA/Psychotherapy Services And Is Therefore Only Eligible For Maintenance Hours. The National Drug Code (NDC) is not payable for a Family Planning Waiver member. Denied. Only preferred drugs are covered for the member?s program, Only generic drugs are covered for the member?s program. 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. 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. Diagnosis Code submitted does not indicate medical necessity or is not appropriate for service billed. Requests For Training Reimbursement Denied Due To Late Billing. The canister, dressings and related supplies are included as part of the reimbursement for the negative pressure wound therapy pump. All Home Health Services Exceeding 8 Hours Per Day Or 40 Or More Hours Per Week Require Prior Authorization. Research Has Determined That The Member Does Not Qualify For Retroactive Eligibility According To Hfs 106.03(3)(b) Of The Wisconsin Administrative Code. This claim was processed using a program assigned provider ID number, (e.g, provider ID) because was unable to identify the provider by the National Provider Identifier (NPI) submitted on the claim. Service Not Covered For Members Medical Status Code. This procedure is duplicative of a service already billed for same Date Of Service(DOS). Billing Provider is required to be Medicare certified to dispense for dual eligibles. Denied due to Procedure Is Not Allowable For Diagnosis Indicated. Denied due to Diagnosis Not Allowable For Claim Type. Services Not Provided Under Primary Provider Program. The Medicare Claims Processing Manual and the UB-04 Data Specifications Manual outlines requirements for billing outpatient claims including that (HCPCS) codes are required on outpatient claims (UB-04) with related revenue codes. Claim Has Been Adjusted Due To Previous Overpayment. Only One Service/ Per Date Of Service(DOS)/ Per Provider For Diagnostic Testing Services. Subsequent Aide Visits Limited To 7 Hrs Per Day/per Member/per Provider. Subsequently hospital care services (CPT 99221-99223 or 99231-99233) will be denied when billed for the same date of service as observation services (CPT G0378, 99218-99220 or 99224-99226) for Bill Type 0130-013Z (hospital outpatient). Pricing AdjustmentUB92 Hospice LTC Pricing. NDC- National Drug Code is invalid for the Dispense Date Of Service(DOS). Drug Dispensed Under Another Prescription Number. Fifth Diagnosis Code (dx) is not on file. One or more Occurrence Code(s) is invalid in positions nine through 24. Changes/corrections Were Made To Your Claim Per Dental Processing Guidelines. Head imaging in the form of CT scans, MRI or MRA is allowed only when the service is medically reasonable and necessary. Claim Denied. MassHealth List of EOB Codes Appearing on the Remittance Advice. Please Resubmit As A Regular Claim If Payment Desired. The Member Was Not Eligible For On The Date Received the Request. This Payment Is To Satisfy The Amount Indicated On The Administrative Claiming Reimbursement Summary Report. Day Treatment Exceeding 5 Hours/day Not Payable Regardless Of Prior Authorization. Restorative Nursing Can Provide Follow-through, Based On Diagnosis Of Long-standing Nature, And The Amount Of Therapy. Less Expensive Alternative Services Are Available For This Member. Submitted referring provider NPI in the header is invalid. This Payment Is To Satisfy The Amount Owed For OBRA Level 1. Nursing Home Visits Limited To One Per Calendar Month Per Provider. This care may be covered by another payer per coordination of benefits. 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. Billed Amount Is Greater Than Reimbursement Rate. Prescriber ID Qualifier must equal 01. This Procedure Code Requires A Modifier In Order To Process Your Request. Denied. For Revenue Code 0820, 0821, 0825 or 0829, HCPCS Code 90999 or Modifier G1-G6 must be present. NDC- National Drug Code is restricted by member age. OA 13 The date of death precedes the date of service. No Substitute Indicator required when billing Innovator National Drug Codes (NDCs). Prescription Date is after Dispense Date Of Service(DOS). Prior Authorization Is Required For Payment Of Hospital Exceptional Claims. The Service Requested Was Performed Less Than 3 Years Ago. Single Bitewing X-rays Limited To Once Per Day And No More Than Two InA Six Month Period. These materials include the HPMS memorandum titled, "Updates Regarding Final Part C EOB Model Templates and Implementation of the Part C EOB," the final templates and instructions, and Frequently Asked Questions regarding the Part C EOB requirements for Medicare Advantage . SeniorCare member enrolled in Medicare Part D. Claim is excluded from Drug Rebate Invoicing. Please verify the accuracy of the procedure code and the presence of the appropriate procedure code modifier before cont acting ACS for assistance. Quantity Would Always Be 00010 If Number Of Pounds Not Indicated. Denied due to Medicare Allowed Amount Required. 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. Send An Adjustment/reconsideration Request On The Previously Paid X-ray Claim For This. Value Codes 81 And 83, Are Valid Only When Submitted On An Inpatient Claim. Procedure Code Modifier(s) Invalid For Date Of Service(DOS) Or For Prior Authorization Date Of Receipt. Service Denied. Services Can Only Be Authorized Through One Year From The Prescription Date. Multiple Tooth Extract On Same Date Of Service(DOS) Must Be Billed As Single And Additional Tooth Extract In Same Quadrant. Please Refer To The PDL For Preferred Drugs In This Therapeutic Class. Claim Denied. Will Not Authorize New Dentures Under Such Circumstances. EOB for services that should be paid as primary by the Health Plan EPSDT: claims billed with EP modifier 3/28/2022 03/09/2022 2636 In Process DN018 . If correct, special billing instructions apply. The Service(s) Requested Could Be Adequately Performed With Local Anesthesia In The Dental Office. Previously Denied Claims Are To Be Resubmitted As New Day Claims. The Provider Type/specialty Is Not Recognized For These Date(s) Of Service. . Denied. Drug(s) Billed Are Not Refillable. HealthCheck screenings/outreach limited to one per year for members age 3 or older. This diabetic supply has been paid under an equivalent code on this Date Of Service(DOS). Reimbursement For This Detail Does Not Include Unit DoseDispensing Fee. Pricing Adjustment/ Maximum Allowable Fee pricing used. Use The New Prior Authorization Number When Submitting Billing Claim. Supervising Nurse Name Or License Number Required. This Revenue Code has Encounter Indicator restrictions. Services Must Be Submitted On Proper Claim/adjustment/reconsiderationRequest Form. Allowed Amount On Detail Paid By WWWP. Please Contact Your District Nurse To Have This Corrected. This claim is being denied because it is an exact duplicate of claim submitted. Errors in one of the following data elements exceed their field size: Statement covered FROM Date, Admission date, Date Of Service(DOS), Revenue code. ACTION DESCRIPTION. Indicator for Present on Admission (POA) is not a valid value. Denied. Claim Reduced Due To Member/participant Spenddown. According to the American Society of Anesthesiologists and the International Spine Intervention Society, minor pain procedures such as epidural steroid injections, epidural blood patch, trigger point injections, sacroiliac joint injection, bursal injections, occipital nerve block and facet injections under most routine circumstances, require only local anesthesia. Header To Date Of Service(DOS) is invalid. HTTP Status Code Connect Time (ms) Result; 2023-03-01 04:10:52: 200: 255: Page Active: For Newly Certified CNAs, Date Of Inclusion Is T heir Test Date. Please Resubmit. One or more Date(s) of Service is missing for Occurrence Span Codes in positions 9 through 24. Claim paid at the program allowed amount. The Sixth Diagnosis Code (dx) is invalid. This claim is eligible for electronic submission. Service Denied. More than 6 hours of evaluation/assessment in a 2 year period must be billed astreatment services and count toward the MH/SA policy limits for prior authorization. Inpatient Respite Care Is Not Covered For Hospice Members Residing In Nursing Homes. POS codes are required under the provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Please Refer To The Original R&S. Documentation Does Not Justify Fee For ServiceProcessing . Routine foot care Diagnoses must be billed with valid routine foot care Procedure Codes. Please Provide The Type Of Drug Or Method Used To Stop Labor. Adjustment Requested Member ID Change. One or more To Date(s) of Service is missing for Occurrence Span Codes in positions three through 24. Training Completion Date Must Be Within A Year Of The CNAs Certification, Test, Date. The service is not reimbursable for the members benefit plan. Individual Vaccines And Combination Vaccine Code May Not Be Billed For The Same Dates Of ervice. . Please Resubmit Using Newborns Name And Number. Pricing Adjustment/ Pharmacy dispensing fee applied. Denied. Service not covered as determined by a medical consultant. The Secondary Diagnosis Code is inappropriate for the Procedure Code. Resubmit the Claim with the Appropriate Modifier for Provider Type andSpecialty. Revenue code submitted with the total charge not equal to the rate times number of units. Admission Date does not match the Header From Date Of Service(DOS). Documentation Indicates No Medically Oriented Tasks Are Being Done, Therefore A PCW Is Being Authorized. Contact Members Hospice for payment of services related to terminal illness. Wellcare uses cookies. Service Denied. Supplement Payment Authorized By Department of Health Services (DHS) Due to a Final Rate Settlement. 1. 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 Reimbursement Code Assigned To This CNA Does Not Authorize A NAT Payment. Billing Provider Type and Specialty is not allowable for the Place of Service. Other Payer Coverage Type is missing or invalid. Service Denied. Disposable medical supplies are payable only once per trip, per member, per provider. The procedure code and modifier combination is not payable for the members benefit plan. Please Indicate Mileage Traveled. Denied. Claim Denied For No Provider Agreement On File Or Not Certified For Date Of Service(DOS). Medicare RA/EOMB And Claim Dates And/or Charges Do Not Match. Reimb Is Limited To The Average Montly NH Cost And Services Above that Amount Are Considered non-Covered Services. A Payment Has Already Been Issued For This SSN. Please submit claim to HIRSP or BadgerRX Gold. The Total Number Of Hours Per Day Requested For AODA Day Treatment Exceeds Guidelines And The Request Has Been Adjusted Accordingly. Billed Amount Is Equal To The Reimbursement Rate. The Primary Diagnosis Code is inappropriate for the Surgical Procedure Code. 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. Member enrolled in Tuberculosis-Related Services Only Benefit Plan. 12/06/2022 . Denied. Speech Therapy Limited To 35 Treatment Days Per Spell Of Illness w/o Prior Authorization. Denied due to Member Not Eligibile For All/partial Dates. Seventh Occurrence Code Date is required. Please Refer To Your Hearing Services Provider Handbook. Member Expired Prior To Date Of Service(DOS) On Claim. Claims may deny when DXA bone density studies (CPT 77080 or 77081) are billed and the only diagnosis on the claim is osteoporosis screening (ICD-10 code Z13.820) for a woman who is under age 65 or for a man who is under age 70. One or more Diagnosis Code(s) in positions 10 through 25 is not on file. Payment Is Limited To One Unit Dose Service Per Calendar Month, Per Legend Drug, Per Member. 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 Resubmit. Billing Provider is not certified for the detail From Date Of Service(DOS). Professional Components Are Not Payable On A Ub-92 Claim Form. An approved PA was not found matching the provider, member, and service information on the claim. Prior authorization is required for Advair or Symbicort if no other Glucocorticoid Inhaled product has been reimbursed within 90 days. One or more Diagnosis Codes has an age restriction. Member is assigned to an Inpatient Hospital provider. No Action On Your Part Required. The Change In The Lens Formula Does Not Warrant Multiple Replacements. 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. Denied. The Header and Detail Date(s) of Service conflict. No Action On Your Part Required. Additional rental of a negative pressure wound therapy pump is limited to 90 days in a 12 month period. Recasing Or Replacement Of Hearing Aid Case Is Limited To Once Per 2 Year Period Per Member Per Provider. Supplemental Payment Authorized By Department of Health Services (DHS) Due to aAudit. Please Provide Copy Of Medicare Explanation Of Benefits/medicare Remittance Advice Attached To Claim. Date of service is on or after July 1, 2010 and TOB is 72X, value code D5 mustbe present. The Resident Or CNAs Name Is Missing. Annual Physical Exam Limited To Once Per Year By The Same Provider. Pricing Adjustment/ Patient Liability deduction applied. To access the training video's in the portal, please register for an account and request access to your contract or medical group. Purchase of a blood glucose monitor includes the first 30 days of supplies for the monitor. Denied. NCTracks AVRS. PDN services billed on this claim exceed 12 hours/day per nurse, PDN services billed on this claim exceed 60 hours/week per nurse, PDN services billed on this claim exceed 24 hours/day per member. Documentation You Have Submitted Does Not Meet The Requirements Of HSS 107.09(4)(k). This drug has been paid under an equivalent code within seven days of this Date Of Service(DOS). Service (Procedure Code/Modifier Combination) is not reimbursable for Date Of Service(DOS). Discharge Diagnosis 5 Is Not Applicable To Members Sex. A Fourth Occurrence Code Date is required. This Member, As Indicated By Narrative History, Does Not Agree To Abstinence from Alcohol Or Other Drugs And Is Ineligible For AODA Treatment. The Reimbursement Code Assigned To This Certification Segment Does Not Authorize a NAT Payment. The Member Has Been Totally Without Teeth And An Appliance For 5 Years. Member is assigned to a Hospice provider. Maximum Reimbursement Amount Has Been Determined By Professional Consultant. FFS CLAIM PROFESSIONAL ASC X12N VERSION . Well-baby visits are limited to 12 visits in the first year of life. Continue ToUse Appropriate Codes On Billing Claim(s). Denied. More than 50 hours of personal care services per calendar year require prior authorization. Will Only Pay For One. Good Faith Claim Denied For Timely Filing. Condition Code 73 for self care cannot exceed a quantity of 15. An Individual CBC Or Chemistry Test With A CBC Or Chemistry Panel, Performed Per Member/Provider/Date Of Service Must Be Billed w/ Appropriate Panel Code. Claims With Dollar Amounts Greater Than 9 Digits. Per Information From Insurer, Requested Information Was Not Supplied By The Provider. Printable . 51.42 Board Directors Or Designees Statement & Signature Required OnThe Claim Form For Payment Of Functional Assessment. This Member Is Involved In Non-covered Services, And Hours Are Reduced Accordingly. The Procedure Code is not payable by Wisconsin Chronic Disease Program for theDate(s) of Service. These case coordination services exceed the limit. Initial Visit/Exam limited to once per lifetime per provider. All services should be coordinated with the Inpatient Hospital provider. Acute Care General And Specialty Hospitals Are Subject To Pre-admission Requirements Or The Pre-admission Review Number Indicated Is Invalid. Consent Form Is Missing, Incomplete, Or Contains Invalid Information. Surgical Procedure Code billed is not appropriate for members gender. The service was previously paid for this Date Of Service(DOS). Quantity Billed is missing or exceeds the maximum allowed per Date Of Service(DOS). Contact The Nursing Home. Claim Corrected. Prior Authorization (PA) is required for payment of this service. Compound Drug Service Denied. CRNAs, AAs, And Anesthesiologists Supervising CRNAs/AAs Must Bill AnesthesiA Services Using The Appropriate Modifier. 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. Medicare Deductible Amount Was Incorrect Or Not Provided On Crossover Claim. The Existing Appliance Has Not Been Worn For Three Years. We Are Recouping The Payment. Continuous home care must be billed in an hourly quantity equal to or greater than eight hours, up to and including 24 hours. Good Faith Claim Denied Because Of Provider Billing Error. Billing Provider Type and Specialty is not allowable for the service billed. The Clinical Profile/Diagnosis Makes This Member Ineligible For AODA Services. EOB. Only one initial visit of each discipline (Nursing) is allowedper day per member. 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). Explanation of Benefit Codes (EOBs) Mar 14, 2022 1 EOB EOB DESCRIPTION. The Seventh Diagnosis Code (dx) is invalid. Prescriber Number Supplied Is Not On Current Provider File. Pricing Adjustment/ Provider Level of Care (LOC) pricing applied. Live-agent chat is the easiest and fastest way to get real-time support for an array of topics, including: Member Eligibility. Req For Acute Episode Is Denied. Denied. These Supplies/items Are Included In The Purchase Of The Dme Item Billed On The Same Date Of Service(DOS).