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Medicare Deductible Is Paid In Full. The first occurrence span from Date Of Service(DOS) is after the to Date Of Service(DOS). OA 13 The date of death precedes the date of service. Please Correct And Resubmit. Denied. CO/204/N182 . Watch FutureRemittance And Status Reports For Its Finalization Before Resubmitting. Denied. Note: The Group, Reason and Remark Codes are HIPAA EOB codes and are cross-walked to L&I's EOB codes. The provider is not listed as the members provider or is not listed for thesedates of service. Pricing Adjustment/ Maximum Flat Fee pricing applied. NFs Eligibility For Reimbursement Has Expired. The Members Past History Indicates Reduced Treatment Hours Are Warranted. Compound Ingredient Quantity must be greater than zero. Routine Foot Care Procedures Must Be Billed With Valid Routine Foot Care Diagnosis. Denied. Denied due to Medicare Allowed Amount Is Greater Than Total Billed Amount. The Tooth Is Not Essential To Maintain An Adequate Occlusion. One or more Condition Code(s) is invalid in positions eight through 24. Please Furnish A NDC Code And Corresponding Description. WCDP member enrolled in Medicare Part D. Claim is excluded from Drug Rebate Invoicing. Medical Necessity For Food Supplements Has Not Been Documented. Etiology Diagnosis Code(s) (E-Codes) are invalid as the Admitting/Principal Diagnosis 1. Critical care in non-air ambulance is not covered. 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. Medically Needy Claim Denied. Denied due to Take Home Drugs Not Billable On UB92 Claim Form. Member does not meet the age restriction for this Procedure Code. All Day Treatment Services For Members With Nursing Home Status Should Be Billed Under Procedure Code W8912(pre 10/1/03)/h2012(post 10/1/03) And Require PriorAuthorization. Continue ToUse Appropriate Codes On Billing Claim(s). Denied. THE WELLCARE GROUP OF COMPANIES . Referral Codes Must Be Indicated For W7001, W7002, W7003, W7006, W7008 And W7013. EOB Codes are present on the last page of remittance advice, these EOB codes or explanation of benefit codes are in form of numbers and every number has a specific meaning. Incorrect Or Invalid National Drug Code Billed. Denied. Homecare Services W/o PA Are Not Payable When Prior Authorized Homecare Services have Been Provided To The Same Member. Unable To Reach Provider To Correct Claim. $150.00 Reimbursement Limit Has Been Reached For Individual And Group Pncc Health Education/nutritional Counseling. Type of Bill indicates services not reimbursable or frequency indicated is notvalid for the claim type. Payment Subject To Pharmacy Consultant Review. Crosswalk - Adjustment Reason Codes and Remittance Advice (RA) Remark Codes to PHC Explanation (EX) Codes Revised 11/16/2020 Page 1 Key: If RA has . No Financial Needs Statement On File. . As a result, providers experience more continuity and claim denials are easier to understand. From Date Of Service(DOS) is before Admission Date. Reason Code: 234. Superior HealthPlan News. The Member Is Also Involved In A Structured Living And/or Working Arrangement.A Reduction In Day Treatment Hours Is Indicated. A more specific Diagnosis Code(s) is required. Duplicate/second Procedure Deemed Medically Necessary And Payable. Previously Denied Claims Are To Be Resubmitted As New Day Claims. If you are having difficulties registering please . ACode With No Modifier Billed On The Same Day As A Code With Modifier 11 Are Viewed as the same trip. This service is payable at a frequency of once per 12-month period, per provider, per hearing aid. Revenue code submitted with the total charge not equal to the rate times number of units. Recoding/adjusting claim may result in a different DRG code assignmentand reimbursement. Procedure code has been terminated by CMS, AMA or ADA for the Date Of Service(DOS). Only Medicare crossover claims are reimbursable. Reimbursement For This Certification, Test, Segment Has Been Issued To AnotherNF. 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 . Please Check The Adjustment Icn For The Reprocessed Claim. This National Drug Code Has Diagnosis Restrictions. 2434. For dates of service on or after 7/1/10 for TOB 72X an occurrence code 51 and value code D5 are required when the KT/V reading was performed. Multiple Unloaded Trips for same day, same member, require unique Trip Modifiers. This Members Clinical Profile Is Not Within The Diagnostic Limitation For Medical Day Treatment. Procedure Denied Per DHS Medical Consultant Review. For example, a claim from a physician provider with place of service 11 (Office) would be considered incorrectly coded when a claim from an outpatient facility (e.g. A National Provider Identifier (NPI) is required for the Billing Provider. The Fourth Occurrence Code Date is invalid. Member is assigned to an Inpatient Hospital provider. The Hearing Aid Recommended Is Not Necessary; The Member Could Be Adequately Fitted With A Conventional Aid. Service(s) Denied By DHS Transportation Consultant. We encourage you to take advantage of this easy-to-use feature. Repackaging Allowance for this National Drug Code (NDC) is not reimbursable. Procedure Code is not allowed on the claim form/transaction submitted. Speech Therapy Is Not Warranted. Principal Diagnosis 7 Not Applicable To Members Sex. Amount Paid On Detail By WWWP Is Less Than Billed Or Reimbursement Rate Due ToPrior Payment By Other Insurance. Next step verify the application to see any authorization number available or not for the services rendered. Reimbursement For HCPCS Procedure Code 58300 Includes IUD Cost. Pharmacy Clm Submitted Exceeds The Number Of Clms Allowed Per Cal. All services should be coordinated with the Hospice provider. General Exercise To Promote Overall Fitness And Flexibility Are Non-covered Services. The Medicare copayment amount is invalid. 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. 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. Other Payer Date can not be after claim receipt date. The Medical Necessity For Psychotherapy Services Has Not Been Documented, ThusMaking This Member Ineligible For The Requested Service. Total Rental Payments For This Item Have Exceeded The Maximum Allowable Forthe Purchase Of This Item. Intensive Multiple Modality Treatment Is Not Consistent With The Information Provided. Single Bitewing X-rays Limited To Once Per Day And No More Than Two InA Six Month Period. The Members Demonstrated Response To Current Therapy Does Not Warrant The Intense Freqency Requested. Reimb Is Limited to the Average Monthly NH Cost and Services Above that Amount Are Considered non-Covered Services. The maximum number of details is exceeded. CPT Code 88305 (Level IV - Surgical pathology, gross and microscopic examination) includes different types of biopsies. Recd Beyond 90 Days Special Filing Deadline FOr System Generated Adjmts/Medicare X-overs/Other Insurance Reconsideration/Cou rt Order/Fair Hearing. If you haven't created an account yet, register now. A National Provider Identifier (NPI) is required for the Rendering Provider listed in the header. All rental payments have been deducted from the purchase costsince the DME item was rented and subsequently purchased for the member. Please Refer To The PDL For Preferred Drugs In This Therapeutic Class. Ancillary Billing Not Authorized By State. Claims With Dollar Amounts Greater Than 9 Digits. The Insurance EOB Does Not Correspond To The Dates Of Service/servicesBeing Billed. Default Prescribing Physician Number XX5555555 Was Indicated. Discharge Diagnosis 2 Is Not Applicable To Members Sex. Denied due to Diagnosis Not Allowable For Claim Type. Claim Denied Due To Incorrect Accommodation. Pricing Adjustment/ Revenue code flat rate pricing applied. The Documentation Submitted Indicates The Tasks Specified Can Be Completed During The Visits Approved. Denied. Training Completion Date Must Be Prior To And Within A Year Of The CNAs Certification Date. Prior authorization is required for Maxalt when Maxalt or sumatriptan productshave not been reimbursed within 365 days. 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. Prescription Drug Plan (PDP) payment/denial information required on the claim to WCDP. Certifying Agency Verified Member Was Not Eligible for Dates Of Services. Denied/cutback. Your 1099 Liability Has Been Credited. We thank you for your continued partnership in servicing the Wellcare By Fidelis Care membership. Denied. Please Correct And Resubmit. Dispense Date Of Service(DOS) is required. Rebill Using Correct Claim Form As Instructed In Your Handbook. It Must Be In MM/DD/YY Format AndCan Not Be A Future Date. All services should be coordinated with the Inpatient Hospital provider. Goals Are Not Realistic To The Members Way Of Life Or Home Situation, And Serve No Functional Or Maintenance Service. Six hour limitation on evaluation/assessment services in a 2 year period has been exceeded. Either The Date Was Not In MM/DD/CCYY Format Or Its AFuture Date. No Action On Your Part Required. Psych Evaluation And/or Functional Assessment Ser. Procedure not payable for Place of Service. Compound drugs not covered under this program. HMO Extraordinary Claim Denied. A quantity dispensed is required. Find top links about Wellcare Cvs Caremark Login along with social links, FAQs, and more. 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. Inicio Quines somos? Please Correct And Resubmit. The National Drug Code (NDC) is not a benefit for the Date Of Service(DOS). If correct, special billing instructions apply. Procedure Code and modifiers billed must match approved PA. All three DUR fields must indicate a valid value for prospective DUR. Routine foot care is limited to no more than once every 61days per member. Please Provide The Type Of Drug Or Method Used To Stop Labor. Missing or invalid level of effort submitted and/or reason for service, professional service, or result of service code billed in error. Excessive height and/or weight reported on claim. Denied due to Some Charges Billed Are Non-covered. Claims Cannot Exceed 28 Details. Diagnosis of malignancies and inflammatory conditions frequently requires numerous biopsies of a particular organ or suspicious site. Please familiarize yourself with these new explanation codes and update your accounts receivable as indicated. Assistant Surgery Must Be Billed Separately By The Assistant Surgeon With Modifier 80. Child Care Coordination services are reimbursable only if both the member and provider are located in Milwaukee County. Early Refill Alert. Another PNCC Has Billed For This Member In The Last Six Months. We have redesigned our website to help you find the information you need more easily. For Review, Forward Additional Information With R&S To WCDP. Service Billed Exceeds Restoration Policy Limitation. Claim Detail from Date Of Service(DOS) And to Date Of Service(DOS) Are Required And Must Be Within The Same Calendar Month. Denied. Prior Authorization Is Required For Payment Of This Service With This Modifier. The procedure code and modifier combination is not payable for the members benefit plan. Refer To Your Pharmacy Handbook For Policy Limitations. Valid Numbers Are Important For DUR Purposes. 0001: Member's . Header From Date Of Service(DOS) is invalid. The Duration Of Treatment Sessions Exceed Current Guidelines. This Dental Service Limited To Once A Year. Does not reimburse both the global service and the individual component parts of the service for the same Date Of Service(DOS). Do Not Indicate A Hcpcs Or Cpt Procedure Code On An Inpatient Claim. Preventive Medicine Code Billed Is Allowed For Health Check Agencies Only With The Appropriate Healthcheck Modifier. Follow specific Core Plan policy for PA submission. Referral/treatment Procedures Are Not Payable When Billed With A Complete Refusal Detail. The Second Other Provider ID is missing or invalid. Multiple Service Location Found For the Billing Provider NPI. Unable To Process Your Adjustment Request due to Member ID Not Present. Two different providers cannot be reimbursed for the same procedure for the same member on the same Date Of Service(DOS). Claim Denied For No Client Enrollment Form On File. Reimbursement determination has been made under DRG 981, 982, or 983. Sixth Diagnosis Code (dx) is not on file. Personal care subsequent and/or follow up visits limited to seven per Date Of Service(DOS) per member. CNAs Eligibility For Training Reimbursement Has Expired. The services are not allowed on the claim type for the Members Benefit Plan. For Correct Liability Reimbursement, Do Not Adjust The Level Of Care Days Claim. Resubmit Claim With Copyof A Temporary ID Card, EVS Printed Response Or Indicate The AVR Transaction Log Number. Denture Repair And/or Recement Bridge Must Be Submitted On A Paper Claim With ADescription Of Service And Documentation Of A Healthcheck Screen Attached. A number is required in the Covered Days field. For Revenue Code 0820, 0821, 0825 or 0829, HCPCS Code 90999 or Modifier G1-G6 must be present. This obstetrical service was previously paid for this Date Of Service(DOS) for thismember. Diagnosis V25.2 May Only Be Used When Billing For Sterilization Procedures. A National Drug Code (NDC) is required for this HCPCS code. The value code 48 (Hemoglobin reading) or 49 (Hematocrit) is required for the revenue code/HCPCS code combination. Out of State Billing Provider not certified on the Dispense Date. Service is not reimbursable for Date(s) of Service. wellcare eob explanation codes. Because a claim can have edits and audits at both the header and detail levels, EOB codes are listed . CO/96/N216. EOB EOB DESCRIPTION. Principal Diagnosis 9 Not Applicable To Members Sex. Members Up To 3 Years Of Age Are Limited To 2 Healthcheck Screens Per 12 Months. The relationship between the Billed and Allowed Amounts exceeds a variance threshold. Records Indicate This Tooth Has Previously Been Extracted. Hearing Aid Batteries Are Limited To 12 Monaural/24 Binaural Batteries Per 30-day Period, Per Provider, Per Hearing Aid. The topic of Requirements for Compression Garments can be found in the Claims Section, Submission Chapter. The Comprehensive Community Support Program reimbursement limitations have been exceeded. Please Resubmit. To access the training video's in the portal, please register for an account and request access to your contract or medical group. Claim Denied. Assessment Is Not A Covered Service Unless All Four Components Of Skilled Nursing Are Present: Assessment, Planning, Intervention And Evaluation. One or more Surgical Code Date(s) is missing in positions seven through 24. Procedure Code is allowed once per member per lifetime. 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. 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. Please Verify That Physician Has No DEA Number. Reimbursement For This Service Has Been Approved. Referring Provider is not currently certified. This Member Has Completed Intensive AODA Treatment Within The Past 12 Months and Documentation Provided Is Not Adequate To Justify Intensive Treatment at this time. The National Drug Code (NDC) was reimbursed at a generic rate. 51.42 Board Directors Or Designees Statement & Signature Required OnThe Claim Form For Payment Of Functional Assessment. 3101. Member Expired Prior To Date Of Service(DOS) On Claim. Risk Assessment/Care Plan is limited to one per member per pregnancy. Day Treatment Exceeding 5 Hours/day Not Payable Regardless Of Prior Authorization. View the Part C EOB materials in the Downloads section below. Received Beyond Special Filing Deadline For ThisType Of Claim Or Adjustment/reconsideration. 2D3D CODES: Radiation treatment delivery, superficial and/or ortho voltage, per day 77401 Radiation treatment delivery, >1 MeV; simple 77402 . This Is A Manual Decrease To Your Accounts Receivable Balance. Rinoplastia; Blefaroplastia Valid NCPDP Other Payer Reject Code(s) required. This Dms Item Is Limited To 12 Per 30 Days, Per Provider, Without Prior Authorization. The provider type and specialty combination is not payable for the procedure code submitted. Member is not Medicare enrolled and/or provider is not Medicare certified. Birth to 3 enhancement is not reimbursable for place of service billed. Denied due to The Members Last Name Is Incorrect. An amount in the Gross Amount Due field and/or Usual and Customary Charge field is required. Unable To Process Your Adjustment Request due to Provider Not Found. Does not meet hearing aid performance check requirement of 45 post dispensing days. Out-of-State non-emergency services require Prior Authorization. August 14, 2013, 9:23 am . Please submit claim to HIRSP or BadgerRX Gold. Please Resubmit. Eighth Diagnosis Code (dx) is not on file. Example: Diagnosis code 285.21 is entered as 28521, without a period or space. Claim Denied. Number Is Missing Or Incorrect. Claim Detail Is Pended For 60 Days. 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. Denied/recouped. Occupational therapy limited to 35 treatment days per lifetime without prior authorization. Home Health Services In Excess Of 60 Visits Per Calendar Month Per Member Required Prior Authorization. Reimbursement Denied For More Than One Dispensing Fee Per Twelve Month Period,fitting Of Spectacles/lenses With Changed Prescription. Denied. Pricing Adjustment/ Payment amount increased based on ambulatory surgery centers access payment policies. Timely Filing Request Denied. 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. The total billed amount is missing or is less than the sum of the detail billed amounts. 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. If Required Information Is Not Received Within 60 Days,the claim will be denied. Unable To Process Your Adjustment Request due to This Claim Is In Post Pay Billing For Third Party Liability Payment. Ulcerations Of The Skin Do Not Warrant A New Spell Of Illness. Claim Denied. Member Name Missing. Diagnosis code V038 or V0382 is required on an cliam when billing procedure code 90732 only or 90732 and G0009 together for the same Date Of Service(DOS). NDC- National Drug Code is restricted by member age. Service Denied. Denied. Member Is Enrolled In A Family Care CMO. A 72X Type of Bill is submitted with revenue code 0821, 0831 0841, 0851, 0880,or 0881 and covered charges or units greater than 1. No Substitution Indicator Invalid For Non-innovator Drugs Not On The Current Wisconsin MAC List. Please Do Not Resubmit Your Claim, And Disregard Additional Informational Messages for this claim. Capitation Payment Recouped Due To Member Disenrollment. This Is Not A Good Faith Claim. Drug Dispensed Under Another Prescription Number. Revenue Code 082X is present on an ESRD claim which also contains revenue codes 083X, 084X, or 085X. Claim Denied for implementation of new Wisconsin Medicaid Interchange System.Resubmission of the claim is required due to new claim submission guidelines. Member is not enrolled for the detail Date(s) of Service. WWWP Does Not Process Interim Bills. Denied due to Diagnosis Code Is Not Allowable. Copyright 2023 Wellcare Health Plans, Inc. New Coding Integrity Reimbursement Guidelines. Billed Amount On Detail Paid By WWWP. The three key components when selecting the appropriate level of E&M services provided are history, examination, and medical decision-making. Prior Authorization Is Required For Payment Of Hospital Exceptional Claims. Please Rebill Inpatient Dialysis Only. Request Denied. Prior Authorization is needed for additional services. Claimchecks Editing And Your Supporting Documentation Was Reviewed By The DHS Medical Consultant. Other Therapies Currently Provide Sufficient Services To Meet The Members Needs. Pricing Adjustment/ Paid according to program policy. Rebill Using Correct Procedure Code. Inpatient Respite Care Is Not Covered For Hospice Members Residing In Nursing Homes. No payment allowed for Incidental Surgical Procedure(s). The sum of the Accommodation Days is not equal to the sum of Covered plus Non-Covered Days. Dispense Date Of Service(DOS) is after Date of Receipt of claim. We maintain and annually update a List of Current Procedural Terminology (CPT)/Healthcare Common Procedure Coding System (HCPCS) Codes (the Code List), which identifies all the items and services included within certain designated health services (DHS) categories or that may qualify for certain exceptions. Pricing Adjustment/ Medicare crossover claim cutback applied. Claim/adjustment Received Beyond The 455 Day Resubmission Deadline. Contact. The CNA Is Only Eligible For Testing Reimbursement. Was Unable To Process This Request. Time Spent In AODA Day Treatment By Affected Family Members Is Not Covered. Use The New Prior Authorization Number When Submitting Billing Claim. This service is not covered under the ESRD benefit. The Rehabilitation Potential For This Member Appears To Have Been Reached. The Automated Voice Response System is encouraged to obtain claims status using a touch-tone phone. Effective With Claims Received On And After 10/01/03 , Occurrence Codes 50 And 51 Are Invalid. This Adjustment Was Initiated By . HMO Payment Equals Or Exceeds Hospital Rate Per Discharge. Denied. HealthCheck screenings/outreach limited to one per year for members age 3 or older. Day Treatment Services For Members With Inpatient Status Limited To 20 Hours. Members File Shows Other Insurance. Verify billed amount and quantity billed. Detail To Date Of Service(DOS) is invalid. Denied due to Provider Signature Date Is Missing Or Invalid. Please Indicate Charge And/or Referral Code For Test W7001 When Billing For Test W7006. Psychotherapy Provided In The Members Home Is Not A Covered Benefit Of . Resubmit Using Valid Rn/lpn Procedure Codes And A Valid PA Number. The Processor Control Number (PCN) for SeniorCare member over 200% FPL is missing, or the PCN is invalid for a WCDP member, member or SeniorCare member at or below 200% FPL. The Revenue Code is not payable by Wisconsin Chronic Disease Program for the Date Of Service(DOS). Limited to once per quadrant per day. Medicaid Remittance Advice Remark Code:M86 MMIS EOB Code:100. ACTION DESCRIPTION. Please Complete Information. The Total Number Of Hours Per Day Requested For AODA Day Treatment Exceeds Guidelines And The Request Has Been Adjusted Accordingly. A Rendering Provider is not required but was submitted on the claim. Member first name does not match Member ID. Total billed amount is less than the sum of the detail billed amounts. LO DENIED - RCVD MORE THAN 60 DAYS AFTER DATE ON EOB FROM OTHER MA67 2D ADJUSTMENT - DENIAL UPHELD-TIMELINESS NOT JUSTIFIED: 31 N30 34: DENIED - NOT A PLAN MEMBER,PROVIDER MUST BILL E.D.S. Contact Provider Services For Further Information. Denied. Supervising Nurse Name Or License Number Required. Denied. Prior Authorization is required for service(s) exceeding mental health and/or substance abuse benefit guidelines. Invalid Provider Type To Claim Type/Electronic Transaction. Claim Generated An Informational ProDUR Alert, Drug-Drug Interaction prospective DUR alert, Drug-Disease (reported) prospective DUR alert, Drug-Disease (inferred) prospective DUR alert, Therapeutic Duplication prospective DUR alert, Suboptimal Regiment prospective DUR alert, Insufficient Quantity prospective DUR alert. Claims may deny when a procedure defined as requiring an anatomical modifier is billed without an associated anatomical modifier. Denied. (8 days ago) WebMassHealth List of EOB Codes Appearing on the Remittance Advice. Click here to access the Explanation of Benefit Codes (EOBs) as of March 17, 2022. Continuous home care must be billed in an hourly quantity equal to or greater than eight hours, up to and including 24 hours. Dental X-rays Indicate A Dental Cleaning, Followed By Good Dental Care At Home, Would Be Sufficient To Maintain Healthy Gums. Denied due to Member Not Eligibile For All/partial Dates. Service not covered as determined by a medical consultant. The disposable medical supply Procedure Code has a quantity limit as indicated in the DMS Index. Denied due to Procedure Billed Not A Covered Service For Dates Indicated. Provider Not Eligible For Outlier Payment. 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. Tooth number or letter is not valid with the procedure code for the Date Of Service(DOS). If A Reporting Form Is Not Submitted Within 60 Days, The claim detail will be denied. Referring Physician With Credential Other Than Md Is Not Applicable To Type Of Service Provided. The Member Has Shown No Ability Within 6 Months To Carry Over Abilities GainedFrom Treatment In A Facility To The Members Place Of Residence. Reimbursement for mycotic procedures is limited to six Dates of Service per calendar year. Only the initial base rate is payable when waiting time is billed in conjunction with a round trip. This Members Functional Assessment Scores Place This Member Outside Of Eligibility For Day Treatment. FFS CLAIM PROFESSIONAL ASC X12N VERSION . Room And Board Is Only Reimbursable If Member Has A BQC Nursing Home Authorization. A Payment Has Already Been Issued To A Different Nf. -OR- The claim contains value code 48, 49, or 68 but does not contain revenue codes 0634 or 0635. Effective 04/01/09, the BadgerCare Plus Core Plan will limit coverage for Hypoglycemics-Insulin to Humalog and Lantus. Claim Denied. Laboratory Is Not Certified To Perform The Procedure Billed. TPA Certification Required For Reimbursement For This Procedure. EPSDT/healthcheck Indicator Submitted Is Incorrect. The Member Was Not Eligible For On The Date Received the Request. HIPAA EOB codes are returned on the 835 Remittance Advice file and are maintained by the Washington Publishing Company. Professional Service code is invalid. CPT is registered trademark of American Medical Association. By continuing to use our site, you agree to our Privacy Policy and Terms of Use. Competency Test Date Is Not A Valid Date. Amount Recouped For Duplicate Payment on a Previous Claim. Please Correct Claim And Resubmit. Explanation of Benefit Codes (EOBs) Mar 14, 2022 4. Start: 01/01/2000 | Last Modified: 03/06/2012 Notes: (Modified 2/28/03, 3/6/2012) N5: Wis Adm Code 106.04(3)(b) Requires Providers To Reimburse The Person/party (eg, County) That Previously. Discharge Diagnosis 3 Is Not Applicable To Members Sex. Please verify the accuracy of the procedure code and the presence of the appropriate procedure code modifier before cont acting ACS for assistance. Please Disregard Additional Informational Messages For This Claim. Please note that the submission of medical records is not a guarantee of payment. If A CNA Obtains his/her Certification After Theyve Been Hired By A NF, A NF Has A Year From Their Certification, Test, Date To Submit A Reimbursement Request To . Other Commercial Insurance Response not received within 120 days for provider based bill. 0300-0319 (Laboratory/Pathology). Claims may deny when reported and not meeting the ICD-10-CM Laterality policy for Diagnosis-to-Diagnosis comparison. Denied. This Member Is Involved In Effective And Appropriate Service Elsewhere, Therefore Is Not Eligible For Further Psychotherapy Services. Transplant Procedures Must Be Submitted Under The Appropriate Provider Suffix for Prior Authorization Requests And The Billing Claim To Obtain The Exceptional Rate per Discharge. Denied. Once 50 Initial Visits/year Has Been Reached Within Any One Discipline All Home Health Services Require Pa. Pricing Adjustment/ Prior Authorization pricing applied. Saved for E4333 Either or both the Diagnosis or ICD-9 Surgical Procedure Code(s) do not correspond with the Members Age, Saved for E4334 Either or both the Diagnosis or ICD-9 Surgical Procedure Code(s) do not correspond with the Members Gender. Non-Reimbursable Service. Discrepancy Between The Other Insurance Indicator And OI Paid Amount. Claim Currently Being Processed. Prior Authorization is required for manipulations/adjustments exceeding 20 perspell of illness. Staywell is committed to continually improving its claims review and payment processes. This Mutually Exclusive Procedure Code Remains Denied. For FQHCs, place of service is 50. Unable To Process Your Adjustment Request due to A Different Adjustment Is Pending For This Claim.