Denied due to The Member WCDP Id Number Is Incorrect Or Not On Our Current Eligibility File. Hearing aid repairs are limited to once per six months, per provider, per hearing aid. Claim Detail Is Pended For 60 Days. Pricing Adjustment/ Medicare pricing cutbacks applied. Revenue Code 082X is present on an ESRD claim which also contains revenue codes 083X, 084X, or 085X. WWWP Does Not Process Interim Bills. Services Can Only Be Authorized Through One Year From The Prescription Date. Detail From Date Of Service(DOS) is after the ICN Date. Recasing Or Replacement Of Hearing Aid Case Is Limited To Once Per 2 Year Period Per Member Per Provider. Name And Complete Address Of Destination. Bilateral Surgeries Reimbursed At 150% Of The Unilateral Rate. The revenue accomodation billing code on the claim does not match the revenue accomodation billing code on the member file or does not match for these dates of service. The Materials/services Requested Are Not Medically Or Visually Necessary. If correct, special billing instructions apply. If not, the procedure code is not reimbursable. Endurance Activities Do Not Require The Skills Of A Therapist. Do not insert a period in the ICD-9-CM or ICD-10-CM codes. Other Medicare Part A Response not received within 120 days for provider basedbill. The total billed amount is missing or is less than the sum of the detail billed amounts. Claim Explanation Codes View Fee Schedules Electronic Payments and Remittances Submit Behavioral Health Claim Durable Medical Equipment - Rental/Purchase Grid Claims Submission Process Procedure Code Modifiers Submitting Medical Records Submitting Medicare Part D Claims . The Surgical Procedure Code is not payable for /BadgerCare Plus for the Date Of Service(DOS). Valid group codes for use on Medicare remittance advice are:. Service is reimbursable only once per calendar month. Header From Date Of Service(DOS) is after the header To Date Of Service(DOS). Hospice Member Services Related To The Terminal Illness Must Be Billed By Hospice Or Attending Physician. Billing Provider Received Payment From Both Medicare And For Clai m. An Adjustment/reconsideration Request Has Been Made To The Billing Providers Account. Claim Reduced Due To Member Income Available Toward Cost Of Care (Nursing Home Liability). Providers should submit adequate medical record documentation that supports the claim (services) billed. Amount Paid On Detail By WWWP Is Less Than Billed Or Reimbursement Rate Due ToPrior Payment By Other Insurance. This claim is being denied because it is an exact duplicate of claim submitted. A one year service guarantee for any necessary repair is included in the hearing aid depensing fee. Please Resubmit. Review Has Determined No Adjustment Payment Allowed. DME rental beyond the initial 30 day period is not payable without prior authorization. Admit Date and From Date Of Service(DOS) must match. Prescriber must contact the Drug Authorization and Policy Override Center for policy override. The Seventh Diagnosis Code (dx) is invalid. The Service Requested Is Included In The Nursing Home Rate Structure. Denied due to Detail Dates Are Not Within Statement Covered Period. The second occurrence span from Date Of Service(DOS) is after to to Date Of Service(DOS). Occurance code or occurance date is invalid. Payment Subject To Pharmacy Consultant Review. Amount Indicated In Current Processed Line On R&S Report Is The Manual Check You Recently Received. For additional information on HIPAA EOB codes, visit the Code List section of the WPC website at www.wpc-edi.com. Please Correct And Resubmit. Because a claim can have edits and audits at both the header and detail levels, EOB codes are listed . A Total Charge Was Added To Your Claim. Service Denied. One or more Condition Code(s) is invalid in positions eight through 24. Prescription limit of five Opioid analgesics per month. Pricing Adjustment/ Pharmaceutical Care dispensing fee applied. Normal delivery payment includes the induction of labor. This Is A Manual Increase To Your Accounts Receivable Balance. 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 . . Number Is Missing Or Incorrect. RN Home Health visits and Supervisory visits are not reimbursable on the same Date Of Service(DOS) for same provider. Reimbursement rate is not on file for members level of care. Phone: 800-723-4337. Unable To Process Your Adjustment Request due to Original Claim ICN Not Found. Pricing Adjustment/ Payment amount increased based on hospital access paymentpolicies. Occupational Therapy Limited To 45 Treatment Days Per Spell Of Illness w/o Prior Authorization. Pap Smears, Hematocrit, Urinalysis Are Not Reimbursable Separately In Conjunction With Family Planning Medical Visits. Information Required For Claim Processing Is Missing. This claim/service is pending for program review. Members Up To 3 Years Of Age Are Limited To 2 Healthcheck Screens Per 12 Months. Details Include Revenue/surgical/HCPCS/CPT Codes. This diabetic supply has been paid under an equivalent code on this Date Of Service(DOS). Do Not Indicate NS On The Claim When The NDC Billed Is For A Generic Drug. Diagnosis Codes Assigned Must Be At The Greatest Specificity Available. A Training Payment Has Already Been Issued For This Cna. Review Of Adjustment/reconsideration Request Shows Original Claim Payment Was Max Allowed For Medical Service/Item/NDC. Denied. Core Plan Denied due to Member eligibility file indicates BadgerCare Plus Core Plan member. Claim Denied. Provider Must Have A CLIA Number To Bill Laboratory Procedures. Pricing AdjustmentUB92 Hospice LTC Pricing. Denied. Documentation Indicates That Client Is Able To Direct Cares And Can Safely Direct A PCW. These Services Paid In Same Group on a Previous Claim. Other Insurance Disclaimer Code Used Is Inappropriate For This Members Insurance Coverage. The Narrative History Does Not Indicate the Members Functioning is Impaired due To AODA Usage. Resubmit Using Valid Rn/lpn Procedure Codes And A Valid PA Number. Please Disregard Additional Information Messages For This Claim. The Member Appears To Be At A Maximum Level For Age, Diagnosis, And Living Arrangement. Changes/corrections Were Made To Your Claim Per Dental Processing Guidelines. Dollar Amount Of Claim Was Adjusted To Correct Mathematical Error. Services Included In The Inpatient Hospital Rate Are Not Separately Reimbursable. Only preferred drugs are covered for the member?s program, Only generic drugs are covered for the member?s program. Acknowledgement Of Receipt Of Hysterectomy Info Form Is Missing, Incomplete, Or Contains Invalid Information. Also, to ensure claims process and pay accurately, Staywell may deny a claim and ask for pertinent medical documentation from the provider or supplier who submitted the claim. Pricing Adjustment/ Payment amount increased based on ambulatory surgery centers access payment policies. These Urinalysis Procedures Reimbursed Collectively At The Maximum For Routine Urinalysis With Microscopy. These are EOB codes, revised for NewMMIS, that may appear on your PDF remittance advice. Please Resubmit Using Newborns Name And Number. PNCC Risk Assessment Not Payable Without Assessment Score. Please Clarify. Explanation of Benefit Codes (EOBs) Mar 14, 2022 4. Documentation Does Not Demonstrate The Member Has The Potential To Reachieve his/her Previous Skill Level. Prior Authorization is required for manipulations/adjustments exceeding 20 perspell of illness. Reconsideration With Documentation Warranting More X-rays. Do not leave blank fields between the multiple occurance codes. Private Duty Nursing Beyond 30 Hrs /Member Calendar Year Requires Prior Authorization. Professional Service code is invalid. You should receive it within 30 to 60 days of services provided, but it's not an official bill. Members Age 3 And Older Must Have An Oral Assessment And Blood Pressure Check.With Appropriate Referral Codes, For Payment Of A Screening. Non-scheduled drugs are limited to the original dispensing plus 11 refills or 12 months. Fifth Other Surgical Code Date is invalid. Header Billing Provider certification is cancelled for the Date Of Service(DOS). Service Denied. 2. Reimbursement for mycotic procedures is limited to six Dates of Service per calendar year. Was Unable To Process This Request. A Procedure Code without a modifier billed on the same day as a Procedure Codewith modifier 11 are viewed as the same trip. Claims may deny when reported with incompatible ICD-10-CM Laterality policy for Diagnosis-to-Modifier comparison. Services billed are included in the nursing home rate structure. Explanation of Benefit codes (EOBs) Explanation of Benefit (EOB) codes are reported on your remittance statement. Recd Beyond 90 Days Special Filing Deadline FOr System Generated Adjmts/Medicare X-overs/Other Insurance Reconsideration/Cou rt Order/Fair Hearing. The From Date Of Service(DOS) for the Second Occurrence Span Code is required. The Procedure Code/Modifier combination is not payable for the Date Of Service(DOS). Denied/Cutback. General Assistance Payments Should Not Be Indicated On Claims. Independent RHCs Must Bill Codes W6251, W6252, W6253, W6254 Or W6255. All services should be coordinated with the primary provider. Valid Numbers AreImportant For DUR Purposes. The Procedure Code Indicated Is For Informational Purposes Only. Please Correct And Resubmit. 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 . Medicare Part A Or B Charges Are Missing Or Incorrect. Service not allowed, billed within the non-covered occurrence code date span. Please Supply NDC Code, Name, Strength & Metric Quantity. Per Information From Insurer, Claim(s) Was (were) Not Submitted. Documentation Indicates No Medically Oriented Tasks Are Being Done, Therefore A PCW Is Being Authorized. This Service Is Included In The Hospital Ancillary Reimbursement. Service Fails To Meet Program Requirements. Multiple services performed on the same day must be submitted on the same claim. ACTION TYPE LEGEND: Rqst For An Acute Episode Is Denied. Multiple Service Location Found For the Billing Provider NPI. Per Information From Insurer, Prior Authorization Was Not Requested/approved Prior To Providing Services. Dental X-rays Indicate A Dental Cleaning, Followed By Good Dental Care At Home, Would Be Sufficient To Maintain Healthy Gums. Only Medicare crossover claims are reimbursable. The Member Is Also Involved In A Structured Living And/or Working Arrangement.A Reduction In Day Treatment Hours Is Indicated. Service(s) Must Be Submitted On Paper Claim Form Along With Preoperative History And Physical Report And Operation Report. Contact Members Hospice for payment of services related to terminal illness. FFS CLAIM PROFESSIONAL ASC X12N VERSION . Please Bill Your Medicare Intermediary Prior To Submitting To . The content shared in this website is for education and training purpose only. Header Bill Date is before the Header From Date Of Service(DOS). Medical Need For Equipment/supply Requested Is Not Supported By Documentation Submitted. Allowed Amount On Detail Paid By WWWP. Training Request Denied Because Either The Training Date On The Request Is After The CNAs Certification Test Date Or Its Not Within A Year Of That Date. Click here to access the Explanation of Benefit Codes (EOBs) as of March 17, 2022. Billing Provider Type and Specialty is not allowable for the Place of Service. Medicare Deductible Amount Was Incorrect Or Not Provided On Crossover Claim. Detail Rendering Provider certification is cancelled for the Date Of Service(DOS). Refer To Your Pharmacy Handbook For Policy Limitations. Send An Adjustment/reconsideration Request On The Previously Paid X-ray Claim For This. Denied. 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. A Third Occurrence Code Date is required. Denied due to NDC Is Not Allowable Or NDC Is Not On File. The Service Requested Is Not A Covered Benefit Of The Program. Pricing Adjustment/ Ambulatory Payment Classification (APC) pricing applied. The Rendering Providers taxonomy code is missing in the header. Combine Like Details And Resubmit. Please familiarize yourself with these new explanation codes and update your accounts receivable as indicated. Diagnosis Code indicated is not valid as a primary diagnosis. wellcare eob explanation codes. The Reimbursement Code Assigned To This CNA Does Not Authorize A NAT Payment. Claim Reduced Due To Member/participant Spenddown. The Information Provided Indicates Regression Of The Member. In 2015 CMS began to standardize the reason codes and statements for certain services. Our Records Indicate You Have Billed More Than One Unit Dose Dispensing Fee For This Calendar Month. Claim Denied Due To Incorrect Billed Amount. Denied. Start: 01/01/2000 | Last Modified: 03/06/2012 Notes: (Modified 2/28/03, 3/6/2012) N5: The From Date Of Service(DOS) and To Date Of Service(DOS) must be in the same calendar month and year. The Date Of The Screening Request Or The Date Of Screening Is Invalid Or Missing. Please Attach Copy Of Medicare Remittance. NDC was reimbursed at AWP (Average Wholesale Price) (Average Wholesale Price) rate. Treatment With More Than One Drug Per Class Of Ulcer Treatment Drug At The Same Time Is Not Allowed Through Stat PA. Claim Currently Being Processed. Denied. The Members Poor Motivation, The Long-standing Nature Of The Disability and aLack Of Progress Substantiate Denial. A discrepancy exists between the Other Coverage Indicator and the Other Paid Amount. Additional servcies may be billed with H0046 and will count toward mental health and/or substance abuse treatment policy limits for prior authorization. You Must Either Be The Designated Provider Or Have A Refer. Language Comprehension And Language Production Are Equivalent To Cognition, Thus Formal Speech Therapy Is Not Needed. All rental payments have been deducted from the purchase costsince the DME item was rented and subsequently purchased for the member. . Cannot Be Reprocessed Unless There Is Change In Eligibility Status. Denied. Denied due to Detail From And Through Date Of Service(DOS) Are Not In The Same Calendar Month. Reimbursement Is At The Unilateral Rate. Member is not enrolled in the program submitted in the Plan ID field for the Dispense Date Of Service(DOS) or an invalid Plan ID was submitted. Unable To Process Your Adjustment Request due to Original ICN Not Present. This Adjustment/reconsideration Request Was Initiated By . Certifying Agency Did Not Verify Member Eligibility within 70 Day Period. subsequent hospital care (CPT 99231-99233) or inpatient consultations (CPT 99251-99255) in the previous week. Denied/recouped. Reimbursement limits for Community Care Services for the calendar year are close to being exceeded. Has Recouped Payment For Service(s) Per Providers Request. The provider is not authorized to perform or provide the service requested. Activities To Promote Diversion Or General Motivation Are Non-covered Services. 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. HMO Extraordinary Claim Denied. Medicare Coinsurance Amount Was Not Provided On Crossover Claim. Physical Therapy Treatment Limited To One Modality, One Procedure, One Evaluation Or One Combination Per Day. Denied/Cutback. Denied. Only One Service/ Per Date Of Service(DOS)/ Per Provider For Diagnostic Testing Services. Service Denied. wellcare eob explanation codes. Prior Authorization Required For Day Treatment Services If Members FunctionalAssessment Negative. Payment For Immunotherapy Service Included In Reimbursement For Allergy Extract Injection. Claims may deny when a nerve conduction study is billed without a needle EMG, or a needle EMG is billed without a Nerve conduction study, and the only diagnosis is radiculopathy (ICD-10 codes M50.1-M50.23, M51.1-M51.27, M51.9, M53.80, M54.10-M54.18, M54.30-M54.42, and M79.2). Earn Money by doing small online tasks and surveys, What is Denials Management in Medical Billing? BY . ACCOM REV CODE QTY BILLED NOT EQUAL TO DTL DOS. Ancillary Codes Dates Of Service And/or Quantity Billed Do Not Match Level Of Care authorized Dates. Denied. Unable To Process Your Adjustment Request due to The Claim Type Of The Adjustment Does Not Match The Claim Type Of The Original Claim. Based on these reimbursement guidelines, claims may deny when the following revenue codes are billed without the appropriate HCPCS code: The Hearing Aid Recommended Is Not Necessary; The Member Could Be Adequately Fitted With A Conventional Aid. Inpatient Respite Care Is Not Covered For Hospice Members Residing In Nursing Homes. Reason Code Remark Code(s) Denial Denial Description; 16: M51 | N56: Condition code must be blank or alpha numeric A0-Z9. Please watch future remittance advice. Pricing Adjustment/ Payment reduced due to the inpatient or outpatient deductible. The Members Clinical Profile/diagnosis Is Not Within Diagnostic Limitations for Psychotherapy Services. 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. Area of the Oral Cavity is required for Procedure Code. and other medical information at your current address. NDC was reimbursed at Employer Medical Assistance Contribution (EMAC) rate. Services restricted to EPSDT clients valid only with a Full Scope, EPSDT-eligible Aid Code. Fourth Diagnosis Code (dx) is not on file. The Fourth Occurrence Code Date is invalid. flora funeral home rocky mount va. Jun 5th, 2022 . The Primary Occurrence Code Date is invalid. Services Billed Denied As Being Covered In The Payment For Day Rx Per Medical Day Treatment Guidelines. Pricing Adjustment/ Traditional dispensing fee applied. All services should be coordinated with the Hospice provider. Payment may be reduced due to submitted Present on Admission (POA) indicator. Claim Is Being Special Handled, No Action On Your Part Required. Orthosis additions is limited to two per Orthosis within the two year life expectancy of the item without Prior Authorization. This service was previously paid under an equivalent Procedure Code. Continuous home care and routine home care may not be billed for the same member on the same Date Of Service(DOS). Auditory Screening with Preventive Medicine Visits. Claim Submitted To Good Faith Without Proper Documentation. The Eighth Diagnosis Code (dx) is invalid. Reimbursement Rate Applied To Allowed Amount. Effective 1/1: Electronic Prescribing of Controlled Substances Required. The Member Has Shown No Significant Functional Progress Toward Meeting Or Maintaining Established & Measurable Treatment Goals Over A 6 Month Period. To Date Of Service(DOS) Precedes From Date Of Service(DOS). This CNAs Social Security Number, SSN, Is Not On The EDS Nurse Aide Registry File. Referral/treatment Procedures Are Not Payable When Billed With A Complete Refusal Detail. A Hospital Stay Has Been Paid For DOS Indicated. Panel And Individual Test Not Payable For Same Member/Provider/ Date Of Service(DOS). Denied. Service (Procedure Code/Modifier Combination) is not reimbursable for Date Of Service(DOS). (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). Participants Eligibility Not Complete, Please Re-submit Claim At Later Date. 51.42 Board Stamp Required On All Outpatient Specialty Hospital Claims For Dates Of Service On Or After January 1, 1986. This Claim Cannot Be Processed. With Payspan's eEOB member-friendly functionality, members can log into the payer's secure portal and . The below mention list of EOB codes is as below, EOB codes list is updated as per the latest information gathered from authorized sources of information, if any discrepancy please let us know via the contact us page, Coupon "NSingh10" for 10% Off onFind-A-CodePlans. 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. Timely Filing Deadline Exceeded. Request was not submitted Within A Year Of The CNAs Hire Date. 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. Service Provided Before Prior Authorization Was Obtained Is Not Allowable. A covered DRG cannot be assigned to the claim. Members Aged 3 Through 21 Years Old Are Limited To One Healthcheck Screening per 12 months. Pharmaceutical Care Codes Are Billable On Non-compound Drug Claims Only. This service or a related service performed on this date has already been billed by another provider and paid. The Screen Date Must Be In MM/DD/CCYY Format. Acute Care General And Specialty Hospitals Are Subject To Pre-admission Requirements Or The Pre-admission Review Number Indicated Is Invalid. Questionable Long-term Prognosis Due To Decay History. Watch FutureRemittance And Status Reports For Its Finalization Before Resubmitting. Explanation of Benefit Codes (EOBs) Mar 14, 2022 1 EOB EOB DESCRIPTION. Department of Health Services (DHS) Authorized Payment Is Being Withheld Due toa Department Of Justice Settlement. Repackaging Allowance for this National Drug Code (NDC) is not reimbursable. Member eligibility file indicates that BadgerCare Plus Benchmark, CorePlan or Basic Plan member. Members I.d. The Tooth Is Not Essential For Support Of A Partial Denture. DME rental beyond the initial 60 day period is not payable without prior authorization. HIPAA EOB codes are returned on the 835 Remittance Advice file and are maintained by the Washington Publishing Company. Member is enrolled in Medicare Part D for the Dispense Date Of Service(DOS). Services Beyond The Six Week Postpartum Period Are Not Covered, Per DHS. August 14, 2013, 9:23 am . The Request Does Not Meet Generally Accepted Conditions Requiring Fluoride Treatments. Billing Provider does not have required Certification Addendum on file. Healthcheck screenings or outreach is limited to six per year for members up to one year of age. DX Of Aphakia Is Required For Payment Of This Service. The Requested Procedure Is Cosmetic In Nature, Therefore Not Covered By . There is no action required. Please Verify The Units And Dollars Billed. Payment Recouped. Claim Denied. This Adjustment Was Initiated By . This Unbundled Procedure Code Remains Denied. Secondary Diagnosis Code(s) in positions 2-9 cannot duplicate the Primary Discharge Diagnosis. This Payment Is To Satisfy Amount Owed For A Drug Rebate Prior Quarter Correction. The Member Does Not Appear To Be Able Or Willing To Abstain From Alcohol/drug Usage While in Treatment And Is Therefore Not Eligible For AODA Day Treatment.