wellcare eob explanation codes

NFs Eligibility For Reimbursement Has Expired. The header total billed amount is invalid. Reason Code 160: Attachment referenced on the claim was not received. Denied. Prescriber ID Qualifier must equal 01. The Service/procedure Proposed Is Not Supported By Submitted Documentation. Claims may deny when reported with incompatible ICD-10-CM Laterality policy for Diagnosis-to-Modifier comparison. Healthcheck Screening Limited To Two Per Year From Birth To Age 3 And One Per Year For Age3 Or Older. The Screen Date Is Either Missing Or Invalid. Claim Denied. If you haven't created an account yet, register now. Paid In Accordance With Dental Policy Guide Determined By DHS. Fourth Other Surgical Code Date is invalid. Please Resubmit A New Adjustment/reconsideration Request Form And Indicate TheMost Recent Cclaim Number Where Payment Was Made Or Allowed. Our Records Indicate This Provider Is Not Certified For AODA Day Treatment. Please Indicate Separately On Each Detail. Inpatient mental health services performed by masters level psychotherapists or substance abuse counselors are not covered. Members I.d. Surgical Procedure Code billed is not appropriate for members gender. Please Clarify. Use The New Prior Authorization Number When Submitting Billing Claim. Rendering Provider Type and/or Specialty is not allowable for the service billed. Supply The Place Of Service Code On The Request Form (the Place Of Service Where The Service/procedure Would Be Performed). CO/96/N216. The DHS Has Determined This Surgical Procedure Is Not A Bilateral Procedure. CPT Code 88305 (Level IV Surgical pathology, gross and microscopic examination) includes different types of biopsies. Denied. Additional rental of a negative pressure wound therapy pump is limited to 90 days in a 12 month period. NDC was reimbursed at Employer Medical Assistance Contribution (EMAC) rate. Consent Form Is Missing, Incomplete, Or Contains Invalid Information. The Requested Transplant Is Not Covered By . Use the most current year's ICD-9-CM or ICD-10-CM codes, depending on the date(s) of service. The detail From or To Date Of Service(DOS) is missing or incorrect. Payment Recouped. For example, F80.2 (Mixed receptive-expressive language disorder) cannot be billed on the same claim as F84.0 (Autism Disorder) since ICD-10's Coding Manual views them as mutually exclusive dx codes. Out-of-State non-emergency services require Prior Authorization. The Non-contracted Frame Is Not Medically Justified. Indicator for Present on Admission (POA) is not a valid value. Auditory Screening with Preventive Medicine Visits. Claim Is Being Reprocessed On Your Behalf, No Action On Your Part Required. The Surgical Procedure Code is not payable for Wisconsin Chronic Disease Program for the Date Of Service(DOS). The Sixth Diagnosis Code (dx) is invalid. A Qualified Provider Application Is Being Mailed To You. Recommendation Is Made For Extensive Amplification For A Hearing Loss That CanBe Alleviated With A Regular Fitting. 2434. 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. Explanation of Benefits (EOB) The four-digit explanation of benefits (EOB) codes and the corresponding narratives indicate that the submitted claim paid as billed or describe the reason the claim suspended, was denied, or did not pay in full. Pricing Adjustment/ Medicare Pricing information. EOB Any EOB code that applies to the entire claim (header level) prints here. Authorizations. Has Recouped Payment For Service(s) Per Providers Request. They are used to provide information about the current status of . Indicated Diagnosis Is Not Applicable To Members Sex. Denied due to NDC Is Not Allowable Or NDC Is Not On File. Insufficient Info On Unlisted Med Proc; Submit Claim Or Attachment With A Complete Description Of The Procedure As Described In History and Physical Exam Report, Med Progress, anesthesia or Op Report. SeniorCare member enrolled in Medicare Part D. Claim is excluded from Drug Rebate Invoicing. Subsequent surgical procedures are reimbursed at reduced rate. Denied due to Greater Than Four Dates Of Service Billed On One Detail. A Fourth Occurrence Code Date is required. Discharge Diagnosis 4 Is Not Applicable To Members Sex. Revenue code 082X is present on an ESRD claim which also contains revenue code088X (X frequency non equal to 9). You Must Adjust The Nursing Home Coinsurance Claim. Benefit code These codes are submitted by the provider to identify state programs. Therapy visits in excess of one per day per discipline per member are not reimbursable. Please Do Not File A Duplicate Claim. Earn Money by doing small online tasks and surveys, What is Denials Management in Medical Billing? Prior authorization is required for Maxalt when Maxalt or sumatriptan productshave not been reimbursed within 365 days. Please Clarify. Adjustment and original claim do not have the same finanical payer, 6355 replacing 635R diagnosis (For use of Category of Service only), 6360 replacing 635S diagnosis (For use of Category of Service only), 6365 replacing 635T diagnosis (For use of Category of Service only). WellCare Known Issues List Please be advised: Claims that have either rejected or denied . Please Resubmit. Only One Panel Code Within Same Category (CBC Or Chemistry) Maybe Performed Per Member/Provider/Date Of Service. Remark Codes: N20. Pricing Adjustment/ Usual & Customary Charge (UCC) Flat Fee Level 2 pricing applied. Please Contact The Surgeon Prior To Resubmitting this Claim. CO/96/N216. Pricing Adjustment/ Pharmacy pricing applied. These codes provide additional explanation for an adjustment already described by a Claim Adjustment Reason Code (CARC) or convey information about remittance processing. Detail Rendering Provider certification is cancelled for the Date Of Service(DOS). Denied due to Member Not Eligibile For All/partial Dates. Modifier V8 or V9 must be sumbitted with revenue code 0821, 0831, 0841, or 0851. The Member Has At Least 4 Posterior Teeth, Including Bicuspids On Each Side, which Can Be Used For Chewing. WellCare_Consult_ManagedProcedureCodeList_2023_20221222 Page 2 of 7 Remote afterloading high dose rate radionuclide interstitial or intracavitary brachytherapy, includes codes are provided per day by the same individual physician or other health care professional. Independent Laboratory Provider Number Required. Watch FutureRemittance And Status Reports For Its Finalization Before Resubmitting. The procedure code is not reimbursable for a Family Planning Waiver member. Referral Codes Must Be Indicated For W7001, W7002, W7003, W7006, W7008 And W7013. Please Provide The Type Of Drug Or Method Used To Stop Labor. Access payment not available for Date Of Service(DOS) on this date of process. Dispense as Written indicator is not accepted by . Medicare Paid The Total Allowable For The Service. Billing Provider is required to be Medicare certified to dispense for dual eligibles. Prescriber Number Supplied Is Not On Current Provider File. No payment allowed for Incidental Surgical Procedure(s). Referring Provider is not currently certified. HTTP Status Code Connect Time (ms) Result; 2023-03-01 04:10:52: 200: 255: Page Active: To allow for multiple biopsies for investigation and diagnosis of certain disease entities, WellCare applies max units editing for CPT code 88305 based on gastrointestinal (GI) and prostate-related diagnoses. Part C Explanation of Benefits (EOB) Materials. Denied due to Procedure Billed Not A Covered Service For Dates Indicated. Take care to review your EOB to ensure you understand recent charges and they all are accurate. Other Medicare Managed Care Response not received within 120 days for providerbased bill. Personal Care In Excess Of 250 Hrs Per Calendar Year Requires Prior Authorization. Denied. Procedure Code is allowed once per member per lifetime. Surgical Procedures May Only Be Billed With A Whole Number Quantity. Number Is Missing Or Incorrect. The Submission Clarification Code is missing or invalid. Service(s) exceeds four hour per day prolonged/critical care policy. Please Correct And Resubmit. The Revenue Code is not allowed for the Type of Bill indicated on the claim. Pricing Adjustment/ Claim has pricing cutback amount applied. A valid procedure code is required on WWWP institutional claims. According to CMS policy and the American College of Radiology, a chest X-ray (CPT codes 71045, 71046) should not be performed for screening purposes in the absence of pertinent signs, symptoms or diseases. Questionable Long Term Prognosis Due To Gum And Bone Disease. Activities To Promote Diversion Or General Motivation Are Non-covered Services. Reimbursement For This Detail Does Not Include Unit DoseDispensing Fee. Your Adjustment/reconsideration Request For Additional Payment Has Been Denied, Request Was Received Beyond The 90 Day Requirement For Payment Reconsideration. Two Informational Modifiers Required When Billing This Procedure Code. The member has no Level of Care (LOC) authorization on file or the LOC on filedoes not match the LOC on the claim. Invalid Service Facility Address. HIPAA EOB codes are returned on the 835 Remittance Advice file and are maintained by the Washington Publishing Company. Billed amount exceeds prior authorized amount. One or more Condition Code(s) is invalid in positions eight through 24. A more specific Diagnosis Code(s) is required. The Rendering Providers taxonomy code is missing in the header. This obstetrical service was previously paid for this Date Of Service(DOS) for thismember. Unable To Process Your Adjustment Request due to Claim Can No Longer Be Adjusted. A Reimbursement Request For A Level I Screen Must Be Received At Within A Year Of The Screen Date. The Diagnosis Code Is Not Valid On This Date Of Service(DOS). Care Does Not Meet Criteria For Complex Case Reimbursement. Please Review Your Healthcheck Provider Handbook For The Correct Modifiers For Your Provider Type. This claim has been adjusted due to Medicare Part D coverage. The Members Clinical Profile/diagnosis Is Not Within Diagnostic Limitations for Psychotherapy Services. Please Rebill Only CoveredDates. Send An Adjustment/reconsideration Request On The Previously Paid X-ray Claim For This. The diagnosis codes must be coded to the highest level of specificity. This Revenue Code has Encounter Indicator restrictions. This Is An Adjustment of a Previous Claim. These Supplies/items Are Included In The Purchase Of The Dme Item Billed On The Same Date Of Service(DOS). trevor lawrence 225 bench press; new internal . This procedure is limited to once per day. Billing Provider ID is missing or unidentifiable. Wellcare uses cookies. A discrepancy exists between the Other Coverage Indicator and the Other Paid Amount. Denied. Revenue codes 082X, 083X, 084X, 085X, 0800 or 0881 (X frequency not equal to 5) exist on an ESRD claim for a member who has selected method 1 or no method and the claim does not contain condition codes 71, 72, 73 ,74, 75, or 76. According to the American College of Radiology and the American Academy of Neurology, a CT of the head or brain, CTA of the head, MRA of the head or MRI of the brain should not be performed routinely for patients with a migraine in the absence of related neurologic signs and symptoms. Supervisory visits for Unskilled Cases allowed once per 60-day period. qatar to toronto flight status. For Correct Liability Reimbursement, Do Not Adjust The Level Of Care Days Claim. Submit Claim To For Reimbursement. Please Disregard Additional Information Messages For This Claim. Please Furnish A UB92 Revenue Code And Corresponding Description. Service Denied. Ancillary Billing Not Authorized By State. No Substitute Indicator required when billing Innovator National Drug Codes (NDCs). Header To Date Of Service(DOS) is after the ICN Date. Please Verify The Units And Dollars Billed. Claim Denied. Principal Diagnosis 9 Not Applicable To Members Sex. Acute Care General And Specialty Hospitals Are Subject To Pre-admission Requirements Or The Pre-admission Review Number Indicated Is Invalid. Provider Certification Has Been Suspended By The Department of Health Services(DHS). Member does not have commercial insurance for the Date(s) of Service. The Dispense As Written (DAW) indicator is not allowed for the National Drug Code. The statement coverage FROM date on a hemodialysis ESRD claim (revenue code 0821, 0880, or 0881) was greater than the hemodialysis termination date in the provider file. The condition code is not allowed for the revenue code. Service(s) paid in accordance with program policy limitation. This National Drug Code (NDC) is only payable as part of a compound drug. The total billed amount is missing or is less than the sum of the detail billed amounts. Has Already Issued A Payment To Your NF For A Level I Screen With The Same Admission Date. Denied. This drug is limited to a quantity for 34 days or less. Incorrect Or Invalid National Drug Code Billed. Reimbursement for this procedure and a related procedure is limited to once per Date Of Service(DOS). Anesthesia Modifying Services Must Be Billed Separately From The Charge For Anesthesia Base And Time Units. WellCare Known Issues List EOP Denial Code or Rejection Reason Code Issue Description Impacted Provider Specialty . Diagnosis 635-635.92 May Only Be Used When Billing For Abortion Procedures. This service or a related service performed on this date has already been billed by another provider and paid. This Service Is Not Payable Without A Modifier/referral Code. The Service(s) Requested Could Adequately Be Performed In The Dental Office. Requires A Unique Modifier. Denied. One or more Occurrence Code(s) is invalid in positions nine through 24. Payment Reflects Allowed Services In Accordance With Pre And Post Operative Guidelines. This Service Is A Resubmission Of A Service Previously Denied For Prior Authorization. The Fourth Occurrence Code Date is invalid. Hospital discharge must be within 30 days of from Date Of Service(DOS). Denied. Other Coverage Code is missing or invalid. Questionable Long-term Prognosis Due To Decay History. Denied/Cutback. Reimbursement For This Service Is Included In The Transportation Base Rate. Denied due to Detail Dates Are Not Within Statement Covered Period. Denied. 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 Denied. The Member Has Received A 93 Day Supply Within The Past Twelve Months. DN017 Medicare EOB Denials BH N/A 10/15/2017 9/26/2017 6815, 321095 CE034 99213 99214 in Place of Service 52 Disposable medical supplies are payable only once per trip, per member, per provider. A valid Level of Effort is also required for pharmacuetical care reimbursement. Please Correct Claim And Resubmit. Please Indicate The Revenue Code/procedure Code/NDC Code For Which The Credit is To Be Applied. 10 Important Billing Tips for FQHC and RHC Providers. Supplement Payment Authorized By Department of Health Services (DHS) Due to a Final Rate Settlement. Home Health Services In Excess Of 60 Visits Per Calendar Month Per Member Required Prior Authorization. According To Our Records, The Surgeon For This Sterilization Procedure Has NotSubmitted The Members Consent Form. External Cause Diagnosis May Not Be The Single Or Primary Diagnosis. For more information on which codes are considered "Mutually Exclusive", see the "ICD-10 2019 The Complete Official Codebook. Supplemental Payment Authorized By Department of Health Services (DHS) Due to a Department Of Justice Settlement. A: This denial is received when Medicare records indicate that Medicare is the beneficiary's secondary payer. $150.00 Reimbursement Limit Has Been Reached For Individual And Group Pncc Health Education/nutritional Counseling. Denied/Cutback. HMO Payment Equals Or Exceeds Hospital Rate Per Discharge. This drug/service is included in the Nursing Facility daily rate. The Reimbursement Code Assigned To This CNA Does Not Authorize A NAT Payment. Please Correct And Resubmit. Preventive Medicine Code Billed Is Allowed For Health Check Agencies Only With The Appropriate Healthcheck Modifier. Amount Recouped For Duplicate Payment on a Previous Claim. The Competency Test Date On The Request Does Not Match The CNAs Test Date OnThe WI Nurse Aide Registry. No action required. Claim Denied Due To Absent Or Incorrect Discharge (to) Date. Denied due to The Members Last Name Is Incorrect. Please Furnish A NDC Code And Corresponding Description. Live-agent chat is the easiest and fastest way to get real-time support for an array of topics, including: Member Eligibility. HTTP Status Code Connect Time (ms) Result; 2023-03-01 04:10:52: 200: 255: Page Active: Please Furnish An ICD-9 Surgical Code And Corresponding Description. Medicare Disclaimer Code Used Inappropriately. Revenue code 0850 thru 0859 is not allowed when billed with revenue codes 0820thru 0829, 0830 thru 0839, or 0840 thru 0849. Member ID has changed. Quantity submitted matches original claim. Reason Code 162: Referral absent or exceeded. An ICD-9-CM Diagnosis Code of greater specificity must be used for the Third Diagnosis Code. Abortion Dx Code Inappropriate To This Procedure. Claim or Adjustment received beyond 365-day filing deadline. Prospective DUR denial on original claim can not be overridden. This drug is not covered for Core Plan members. If laboratory costs exceed reimbursement, submit a claim adjustment request with lab bills for reconsideration. Department of Health Services (DHS) Authorized Payment Is Being Withheld Due toan Audit. Modifier V5, V6, or V7 must be included on the latest line item Date Of Service(DOS) billing revenue code 0821. Header To Date Of Service(DOS) is invalid. Incorrect Liability Start/end DatesOr Dollar Amounts Must Be Corrected Through County Social Services Agency. Date Of Service/procedure/charges Billed On The Adjustment/reconsideration Request Do Not Match The Original Claim. Service Denied. Pricing Adjustment/ Medicare pricing cutbacks applied. Procedure Dates Do Not Fall Within Statement Covers Period. Endurance Activities Do Not Require The Skills Of A Therapist. This Service Is Included In The Hospital Ancillary Reimbursement. This Adjustment Was Initiated By . Allowed Amount On Detail Paid By WWWP. The information on the claim isinvalid or not specific enough to assign a DRG. Condition code must be blank or alpha numeric A0-Z9. Denied. Continuous home care and routine home care may not be billed for the same member on the same Date Of Service(DOS). Gastrointestinal Surgery For The Purpose Of Weight Control Is Covered Only As An Emergency Procedure. Training CompletionDate Exceeds The Current Eligibility Timeline. Please Refer To The All Provider Handbook For Instructions. The HCPCS procedure code listed for revenue code 0624 is either invalid or non-reimburseable. Multiple Providers Of Treatment Are Not Indicated For This Member. Submitted rendering provider NPI in the header is invalid. For 2020, WellCare is adding 68 new Medicare Advantage plans for a total of 261 plans with $0 or low monthly plan premiums. Services Not Provided Under Primary Provider Program. Denied. Condition code 80 is present without condition code 74. The Service(s) Requested Could Be Adequately Performed With Local Anesthesia In The Dental Office. Adjustment Requested Member ID Change. The Value Code(s) submitted require a revenue and HCPCS Code. Services billed are included in the nursing home rate structure. Avoiding denial reason code CO 22 FAQ Q: We received a denial with claim adjustment reason code (CARC) CO 22. Pricing Adjustment/ Usual & Customary Charge (UCC) rate pricing applied. Drug Dispensed Under Another Prescription Number. Header From Date Of Service(DOS) is after the header To Date Of Service(DOS). Denied. Effective September 1, 2021: Benefit Changes to Total Disc Arthroplasty for Medicaid and CHIP. The Member Was Not Eligible For On The Date Received the Request. Speech Therapy Evaluations Are Limited To 4 Hours Per 6 Months. This Is A Manual Decrease To Your Accounts Receivable Balance. Unable To Process Your Adjustment Request due to Provider Not Found. Denied. Service Denied. Prior Authorization is required for service(s) exceeding mental health and/or substance abuse benefit guidelines. Claim Denied. Please Refer To The Original R&S. Procedure Code is not payable for SeniorCare participants. Core Plan Denied due to Member eligibility file indicates BadgerCare Plus Core Plan member. Valid group codes for use on Medicare remittance advice are:. Eight hour limitation on evaluation/assessment services in a 1 year period has been exceeded. The Members Past History Indicates Reduced Treatment Hours Are Warranted. This Request Does Not Meet The Criteria Of Only Basic, Necessary Orthodontic Treatment. Services on this claim have been split to facilitate processing.on On Your Part Is Required. Two different providers cannot be reimbursed for the same procedure for the same member on the same Date Of Service(DOS). . Out of State Billing Provider not certified on the Dispense Date. Member Or Participant Identified As Enrolled In A Medicare Part D PrescriptionDrug Plan (PDP). The Member Has Been Totally Without Teeth And An Appliance For 5 Years. Provider signature and/or date is required. The Procedure Requested Is Not Appropriate To The Members Sex. Payment Recovered For Claim Previously Processed Under Wrong Member ID Number. Other payer patient responsibility grouping submitted incorrectly. Denied. Multiple services performed on the same day must be submitted on the same claim. The Timeframe Between Certification, Test, Date And Hire Date Exceeds A Year. Adequate Justification For Starting Member In AODA Day Treatment Prior To Authorization being Obtained Has Not Been Provided. Quantity Billed is restricted for this Procedure Code. HCPCS Procedure Code is required if Condition Code A6 is present. Revenue Code 0001 Can Only Be Indicated Once. WWWP Does Not Process Interim Bills. Member is assigned to an Inpatient Hospital provider. Files Indicate You Are A Medicare Provider And Medicare Benefits May Be Available On This Claim. Do Not Indicate NS On The Claim When The NDC Billed Is For A Generic Drug. Value Code 48 And 49 Must Have A Zero In The Far Right Position. Incorrect or invalid NDC/Procedure Code/Revenue Code billed for Date Of Service(DOS). Denied due to Medicare Allowed, Deductible, Coinsurance And Paid Amounts Do Not Balance. Missing Or Invalid Level Of Effort And/or Reason For Service Code, Professional Service Code, Result Of Service Code Billed In Error. Detail From Date Of Service(DOS) is after the ICN Date. Please Submit With Completed timely Filing Form In The All Provider Handbook And Supporting Documentation. Claim count of Present on Admission (POA) indicators does not match count of non-admitting and non-emergency diagnosis codes. Case Planning And/or On-going Monitoring For Both Targeted Case Managementand Child Care Coordination Are Not Allowed In The Same Month. The training Completion Date On This Request Is After The CNAs CertificationTest Date. Service is not reimbursable for Date(s) of Service. Diagnosis Codes Assigned Must Be At The Greatest Specificity Available. RN And LPN Subsequent Care Visits Limited To 6 Hrs Per Day/per Member/per Provider. Unable To Process Your Adjustment Request due to Member ID Number On The Claim And On The Adjustment Request Do Not Match. No matching Reporting Form on file for the detail Date Of Service(DOS). Procedure Code Modifier(s) Invalid For Date Of Service(DOS) Or For Prior Authorization Date Of Receipt. Learns to use professional . Strong knowledge of adjustment and denial reason codes from Electronic Remittance Advices (ERA/835 files) and from paper Explanation of benefits (EOB's) / Explanation of payments (EOP's), CPT and ICD10 codes; Excellent interpersonal and communication skills with professional demeanor and positive attitude The detail From Date Of Service(DOS) is after the detail To Date Of Service(DOS). NDC was reimbursed at generic WAC (Wholesale Acquisition Cost) rate. Do not leave blank fields between the multiple occurance codes. Revenue code submitted is no longer valid. Please Supply Modifier Code(s) Corresponding To The Procedure Code Description. 2004-79 For Instructions. Denied. This Is A Duplicate Request. Payment Authorized By Department of Health Services (DHS) To Be Recouped at a Later Date. Provider Is Responsible For Averaging Costs During Cal Year Not To Exceed YrlyTotal (12 x $2325.00). The canister, dressings and related supplies are included as part of the reimbursement for the negative pressure wound therapy pump. The Service Requested Was Performed Less Than 5 Years Ago. Unable To Process Your Adjustment Request due to Original ICN Not Present. This Dms Item Is Limited To 12 Per 30 Days, Per Provider, Without Prior Authorization. This National Drug Code (NDC) is not covered. The Existing Appliance Has Not Been Worn For Three Years. Another PNCC Has Billed For This Member In The Last Six Months. Please Review All Provider Handbook For Allowable Exception. Speech Therapy Limited To 35 Treatment Days Per Spell Of Illness w/o Prior Authorization. The revenue code has Family Planning restrictions. Explanation of Benefit Codes (EOBs) Mar 14, 2022 4. Hospital And Nursing Home Stays Are Not Payable For The Same DOS Unless The Nursing Home Claim Indicated Hospital Bedhold Days. Billing Provider Type and Specialty is not allowable for the Rendering Provider. Training Reimbursement DeniedDue To late Billing. The three key components when selecting the appropriate level of E&M services provided are history, examination, and medical decision-making. Services Must Be Submitted On Proper Claim/adjustment/reconsiderationRequest Form. Physical Therapy, Occupational Therapy Or Speech Therapy Limited To 90 Min PerDay. Prior Authorization (PA) is required for payment of this service.

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