wellcare eob explanation codes wellcare eob explanation codes

CRNAs, AAs, And Anesthesiologists Supervising CRNAs/AAs Must Bill AnesthesiA Services Using The Appropriate Modifier. The Services Requested Do Not Meet Criteria For An Acute Episode. This claim is being denied because it is an exact duplicate of claim submitted. Quantity Would Always Be 00010 If Number Of Pounds Not Indicated. Type of Bill indicates services not reimbursable or frequency indicated is notvalid for the claim type. Healthcheck screenings or outreach limited to two per year for members betweenthe ages of two and three years. EDI TRANSACTION SET 837P X12 HEALTH CARE . The submitted claim contains value code 68 and 48 or 49 but does not contain revenue code 0634 or 0635 and HCPCS Q4055. Billing Provider is restricted from submitting electronic claims. Allowance For Coinsurance Is Limited To Allowable Amount Less Medicares Payment. Member Expired Prior To Date Of Service(DOS) On Claim. CPT Code 88305 (Level IV - Surgical pathology, gross and microscopic examination) includes different types of biopsies. Two different providers cannot be reimbursed for the same procedure for the same member on the same Date Of Service(DOS). Billing Provider Name Does Not Match The Billing Provider Number. The Procedure Code billed not payable according to DEFRA. Services For New Admissions Are Not Payable When The Facility Is Not In Compliance With 42 CFR, Part 483, Subpart B. Only one initial visit of each discipline (Nursing) is allowedper day per member. Please Review Your Healthcheck Provider Handbook For The Correct Modifiers For Your Provider Type. The second occurrence span from Date Of Service(DOS) is after to to Date Of Service(DOS). You can even print your chat history to reference later! BY . To Continue Treatment With Two Anti-ulcer Drugs Beyond Authorized Limit Please Submit Request On Paper With Clinical Documentation Clearly Indicating medical necessity. SMV Mileage Exceeding 40 Miles In Urban Counties Or 70 Miles In Rural CountiesRequires Prior Authorization. Case Plan and/or assessment reimbursment is limited to one per calendar year.Calendar Year. A National Provider Identifier (NPI) is required for the Billing Provider. Denied/Cutback. Amount Recouped For Mother Baby Payment (newborn). Part C Explanation of Benefits (EOB) Materials. Admission Denied In Accordance With Pre-admission Review Criteria. Medicaid Remittance Advice Remark Code:M86 MMIS EOB Code:100. Acknowledgement Of Receipt Of Hysterectomy Info Form Is Missing, Incomplete, Or Contains Invalid Information. Member is enrolled in Medicare Part A and/or Part B on the on the Dispense Dateof Service. Detail To Date Of Service(DOS) is required. Competency Test Date Is Not A Valid Date. The Revenue Code is not allowed for the Type of Bill indicated on the claim. Incorrect Liability Start/end DatesOr Dollar Amounts Must Be Corrected Through County Social Services Agency. Effective 1/1: Electronic Prescribing of Controlled Substances Required. A1 This claim was refused as the billing service provider submitted is: . PleaseReference Payment Report Mailed Separately. Denied/cutback. Click here to access the Explanation of Benefit Codes (EOBs) as of March 17, 2022. Pricing Adjustment. Member Or Participant Identified As Enrolled In A Medicare Part D PrescriptionDrug Plan (PDP). CO/204/N182 . Each month you fill a prescription, your Medicare Prescription Drug Plan mails you an "Explanation of Benefits" (EOB). A National Drug Code (NDC) is required for this HCPCS code. Rendering Provider is not a certified provider for Wisconsin Chronic Disease Program. We Are Recouping The Payment. wellcare eob explanation codes. Claim Denied. Changes/corrections Were Made To Your Claim Per Dental Processing Guidelines. Denied due to The Member WCDP Id Number Is Incorrect Or Not On Our Current Eligibility File. (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). Denied. Pricing AdjustmentUB92 Hospice LTC Pricing. EOB. Invalid Admission Date. This Dental Service Limited To Once A Year. TPA Certification Required For Reimbursement For This Procedure. The medical record request is coordinated with a third-party vendor. This Service Is A Resubmission Of A Service Previously Denied For Prior Authorization. Seventh Occurrence Code Date is required. The member is locked-in to a pharmacy provider or enrolled in hospice. Denied. The Medical Records Submitted With The Current Request Conflict Or Disagree With Our Medical Records On This Member. The Value Code and/or value code amount is missing, invalid or incorrect. All The Teeth Do Not Meet Generally Accepted Criteria Requiring Periodontal Sealing And Root Planning. Good Faith Claim Denied For Timely Filing. Claim paid at program allowed rate. This Service Is Not Payable Without A Modifier/referral Code. Incorrect Liability Start/end Dates Or Dollar Amounts Must Be Corrected Through County Social Services Agency Before Claim/Adjustment/Reconsideration RequestCan be Processed. The Rendering Providers taxonomy code is missing in the detail. Requests For Training Reimbursement Denied Due To Late Billing. This drug is a Brand Medically Necessary (BMN) drug. Do not resubmit. Dates Of Service Must Be Itemized. This is a duplicate claim. Pricing Adjustment/ Medicare Pricing information. A valid header Medicare Paid Date is required. The amount in the Other Insurance field is invalid. This Member Is Receiving Concurrent AODA/Psychotherapy Services And Is Therefore Only Eligible For Maintenance Hours. Pharmaceutical care code must be billed with a valid Level of Effort. Valid Numbers Are Important For DUR Purposes. Denied. Only Healthcheck Modifiers Can Be Billed With Healthcheck Services. Do Not Submit Claims With Zero Or Negative Net Billed. Alternatively, CPT XXXXX has been billed in the previous 10 days for a CPT code with a 10-day post-operative period, or in the previous 90 days for a code with a 90-day post-operative period by the same provider. A valid Prior Authorization is required. Denied. Questionable Long-term Prognosis Due To Poor Oral Hygiene. Denied. The Clinical Profile, Narrative History, And Treatment History Indicate The Recipient Is Only Eligible For Maintenance Hours. An ICD-9-CM Diagnosis Code of greater specificity must be used for the Fourth Diagnosis Code. It is a duplicate of another detail on the same claim. One or more Condition Code(s) is invalid in positions eight through 24. Missing Or Invalid Level Of Effort And/or Reason For Service Code, Professional Service Code, Result Of Service Code Billed In Error. The Header and Detail Date(s) of Service conflict. Services Must Be Submitted On Proper Claim/adjustment/reconsiderationRequest Form. Denied. Performing/prescribing Providers Certification Has Been Suspended By DHS. Contact. One or more Diagnosis Codes are not applicable to the members gender. Risk Assessment/Care Plan is limited to one per member per pregnancy. Non-Reimbursable Service. You Must Adjust The Nursing Home Coinsurance Claim. Bilateral Procedures Must Be Billed On One Detail With Modifier 50, Quantity Of 1.detail With Modifier 50 May Be Adjusted If Necessary. Only one antipsychotic drug is allowed without an Attestation to Prescribe More Than One Antipsychotic Drug for a Member 16 Years of Age or Younger. This Member Has Received Primary AODA Treatment In The Last Year And Is Therefore Not Eligible For Primary Intensive AODA Treatment At This Time. Claim Denied. Split Decision Was Rendered On Expansion Of Units. Service Denied, refer to Medicares Billing and/or Policy Guidelines. The Rendering Providers taxonomy code is missing in the header. Denied due to Quantity Billed Missing Or Zero. Hearing Aid Batteries Are Limited To 12 Monaural/24 Binaural Batteries Per 30-day Period, Per Provider, Per Hearing Aid. Detail Rendering Provider certification is cancelled for the Date Of Service(DOS). The Primary Diagnosis Code is inappropriate for the Procedure Code. The Total Billed Amount is missing or incorrect. Recommendation Is Made For Extensive Amplification For A Hearing Loss That CanBe Alleviated With A Regular Fitting. 2434. Resubmit Claim Once Election Form Requirements Are Met Per The Hospice Provider Handbook. Disposable medical supplies are payable only once per trip, per member, per provider. Pricing Adjustment/ Revenue code flat rate pricing applied. Adequate Justification For Starting Member In AODA Day Treatment Prior To Authorization being Obtained Has Not Been Provided. Medicare Id Number Missing Or Incorrect. . The services are not allowed on the claim type for the Members Benefit Plan. Therefore, physician provider claim would deny. Medical Necessity For Food Supplements Has Not Been Documented. An amount in the Gross Amount Due field and/or Usual and Customary Charge field is required. Training Completion Date Must Be Within A Year Of The CNAs Certification, Test, Date. To access the training video's in the portal, please register for an account and request access to your contract or medical group. Rendering Provider is not certified for the Date(s) of Service. Invalid quantity for the National Drug Code (NDC) submitted with this HCPCS code. 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). Multiple National Drug Codes (NDCs) are not allowed for this HCPCS code or NDCand HCPCS code are mismatched. ACTION DESCRIPTION. Surgical Procedure Code is not allowed on the claim form/transaction submitted. Provider is not eligible for reimbursement for this service. No Supporting Documentation. Pricing Adjustment/ SeniorCare claim cutback because of Patient Liability and/or other insurace paid amounts. Only two dispensing fees per month, per member are allowed. Discharge Diagnosis 5 Is Not Applicable To Members Sex. Department of Health Services (DHS) Authorized Payment Is Being Withheld Due toan Interim Rate Settlement. If The Proc Code Does Not Require A Modifier, Please Remove The Modifier. Please Resubmit. SeniorCare member enrolled in Medicare Part D. Claim is excluded from Drug Rebate Invoicing. Contactmembers hospice for payment of services or resubmit with documentation of unrelated Nature of Care. Services are not payable. Pharmaceutical Care Code must be billed with a payable drug detail or if a prescription was not filled, the quantity dispensed must be zero. Denied due to Add Dates Not In Ascending Order Or DD/DD/DD Format. Invalid Service Facility Address. CORE Plan Members are limited to 25 non-emergency outpatient hospital visits per enrollment year. The billing provider number is not on file. . This Procedure Code Not Approved For Billing. Member has commercial dental insurance for the Date(s) of Service. A code with no Trip Modifier billed on same day as a code with Modifier U1 are considered the same trip. Diagnosis Code indicated is not valid as a primary diagnosis. Refill Indicator Missing Or Invalid. A valid Prior Authorization is required for Brand Medically Necessary Drugs. Second Other Surgical Code Date is required. This revenue code requires value code 68 to be present on the claim. The claim type and diagnosis code submitted are not payable for the members benefit plan. NDC was reimbursed at brand WAC (Wholesale Acquisition Cost) (Wholesale Acquisition Cost) rate. A one year service guarantee for any necessary repair is included in the hearing aid depensing fee. Reimbursement For This Certification, Test, Segment Has Been Issued To AnotherNF. Denied. Denied. Claim Denied. Please Furnish An ICD-9 Surgical Code And Corresponding Description. NFs Eligibility For Reimbursement Has Expired. Prior Authorization Is Required For Payment Of This Service With This Modifier.