The Related Surgical Procedure is not a covered service under Wisconsin Medicaid or BadgerCare Plus. The respiratory care services billed on this claim exceed the limit. Member Is Enrolled In A Family Care CMO. The information on the claim isinvalid or not specific enough to assign a DRG. Condition code 20, 21 or 32 is required when billing non-covered services. Documentation Does Not Justify Fee For ServiceProcessing . Date Of Service/procedure/charges On Medicare EOMB Do Not Match The Original Claim. Complete Refusal Detail Is Not Payable Without Referral/treatment Details. The To Date Of Service(DOS) for the Second Occurrence Span Code is required. Critical care in non-air ambulance is not covered. Discharge Diagnosis 4 Is Not Applicable To Members Sex. Changes/corrections Were Made To Your Claim Per Dental Processing Guidelines. Result of Service submitted indicates the prescription was filled witha different quantity. Referral Codes Must Be Indicated For W7001, W7002, W7003, W7006, W7008 And W7013. The Member Is Involved In group Physical Therapy Treatment. All services should be coordinated with the primary provider. The following table outlines the new coding guidelines. This Procedure Code Is Denied As Incidental/Integral To Another Procedure CodeBilled On This Claim. The procedure code has Family Planning restrictions. A Version Of Software (PES) Was In Error. Diagnosis V25.2 May Only Be Used When Billing For Sterilization Procedures. Duplicate Item Of A Claim Being Processed. HIPAA EOB codes are returned on the 835 Remittance Advice file and are maintained by the Washington Publishing Company. Continue ToUse Appropriate Codes On Billing Claim(s). The Rendering Providers taxonomy code in the header is not valid. NDC- National Drug Code is invalid for the Dispense Date Of Service(DOS). Please Reference Payment Report Mailed Separately. 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 . Members Are Limited To 45 Dates Of Service Per Therapy/spell Of Illness without Prior Authorization. Prior authorization requests for this drug are not accepted. ACTION TYPE LEGEND: The American College of Emergency Physicians (ACEP) also indicates that it is not appropriate to perform screening with advanced imaging for syncope patients, however be guided by the patients history and physical exam findings. We update the Code List to conform to the most recent publications of CPT and HCPCS . Denied/Cuback. We Are Recouping The Payment. This Is Not A Reimbursable Level I Screen. Reimbursement For This Detail Does Not Include Unit DoseDispensing Fee. Charges Paid At Reduced Rate Based Upon Your Usual And Customary Pricing Profile. Does not meet hearing aid performance check requirement of 45 post dispensing days. The Header and Detail Date(s) of Service conflict. This obstetrical service was previously paid for this Date Of Service(DOS) for thismember. One or more Occurrence Code Date(s) is invalid in positions nine through 24. The Treatment Request Is Not Consistent With The Members Diagnosis. Value Code 48 And 49 Must Have A Zero In The Far Right Position. Code. Refer To Dental HandbookOn Billing Emergency Procedures. 1 PC Dispensing Fee Allowed Per Date Of Service(DOS). Reimb Is Limited to the Average Monthly NH Cost and Services Above that Amount Are Considered non-Covered Services. The Medical Need For This Service Is Not Supported By The Submitted Documentation. Claim or adjustment/reconsideration request must have both a Revenue Code and either a HCPCS Code or CPT Code. The diagnosis code on the claim requires Condition code A6 be present on the Type of Bill. Reason Code Remark Code(s) Denial Denial Description; 16: M51 | N56: Service Denied. Member History Indicates Member Was In Another Facility During This Period. Date Of Service/procedure/charges Billed On The Adjustment/reconsideration Request Do Not Match The Original Claim. Denied due to Some Charges Billed Are Non-covered. Please note that the submission of medical records is not a guarantee of payment. The Billing Providers taxonomy code is missing. Other Insurance Disclaimer Code Invalid. The Total Billed Amount is missing or incorrect. Submitted referring provider NPI in the detail is invalid. The detail From Date Of Service(DOS) is required. Acknowledgement Of Receipt Of Hysterectomy Info Form Is Missing, Incomplete, Or Contains Invalid Information. Medicare Coinsurance Amount Was Not Provided On Crossover Claim. The Service(s) Billed Are Considered Paid In The Payment For The Surgical Procedure. Bilateral Procedures Must Be Billed On One Detail With Modifier 50, Quantity Of 1.detail With Modifier 50 May Be Adjusted If Necessary. Please Resubmit. No Functional Regression Has Occurred To Warrant A Spell Of Illness; Submit AsA Prior Authorization Request. Here are just a few of them: EOB CODE. The Dispense As Written (Daw) Indicator Is Not Allowed For The National Drug Code. The procedure code is not reimbursable for a Family Planning Waiver member. 2. Denied due to Provider Signature Date Is Missing Or Invalid. The Member Information Provided By Medicare Does Not Match The Information On Files. Comprehensive Screens And Individual Components Are Not Payable On The Same Date Of Service(DOS). Pricing Adjustment/ Prescription reduction applied. The Number In The National Provider Identifier (NPI) Section On This Request IsNot A Number Assigned To A Certified Nursing Facility For This Date Of Service(DOS). CO/96/N216. Quantity Would Always Be 00010 If Number Of Pounds Not Indicated. Pricing Adjustment/ Ambulatory Payment Classification (APC) pricing applied. Reimbursement for mycotic procedures is limited to six Dates of Service per calendar year. Adequate Justification For Starting Member In AODA Day Treatment Prior To Authorization being Obtained Has Not Been Provided. EOB Code: EOB Description: 0000: This claim/service is pending for program review. OA 10 The diagnosis is inconsistent with the patient's gender. Child Care Coordination services are reimbursable only if both the member and provider are located in Milwaukee County. Please Furnish An ICD-9 Surgical Code And Corresponding Description. The sum of the Accommodation Days is not equal to the sum of Covered plus Non-Covered Days. Acute Care General And Specialty Hospitals Are Subject To Pre-admission Requirements Or The Pre-admission Review Number Indicated Is Invalid. From Date Of Service(DOS) is before Admission Date. No policy override available for BadgerCare Plus Benchmark Plan, Core Plan or Basic Plan. Discharge Diagnosis 3 Is Not Applicable To Members Sex. Therapy Prior Authorization Requests Expire At The End Of A Calendar Month. Healthcheck screenings or outreach is limited to six per year for members up to one year of age. The Tooth Is Not Essential To Maintain An Adequate Occlusion. 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. This Report Was Mailed To You Separately. The Service Requested Is Not Medically Necessary. The Maximum limitation for dosages of EPO is 500,000 UIs (value code 68) per month and the maximum limitation for dosages of ARANESP is 1500 MCG (1 unit=1 MCG) per month. Denied. Ulcerations Of The Skin Do Not Warrant A New Spell Of Illness. Non-preferred Drug Is Being Dispensed. Healthcheck screenings or outreach limited to two per year for members betweenthe ages of two and three years. Value Codes 81 And 83, Are Valid Only When Submitted On An Inpatient Claim. This Is A Manual Decrease To Your Accounts Receivable Balance. Panel And Individual Test Not Payable For Same Member/Provider/ Date Of Service(DOS). CPT/HCPCS codes are not reimbursable on this type of bill. Personal care subsequent and/or follow up visits limited to seven per Date Of Service(DOS) per member. Revenue Codes 0110 (N6) And 0946 (N7) Are Not Payable When Billed On The Same Dateof Service As Bedhold Days. Transplants and transplant-related services are not covered under the Basic Plan. Benefit Payment Determined By DHS Medical Consultant Review. Payment Subject To Pharmacy Consultant Review. Training Reimbursement DeniedDue To late Billing. Claim Denied. Service not allowed, benefits exhausted occurrence code billed. Denied. Denied due to Discharge Diagnosis 1 Missing Or Invalid, Denied due to Diagnosis Pointer To Diagnosis Code 1 Invalid, Denied due to Diagnosis Pointer To Diagnosis Code 2 Invalid, Denied due to Diagnosis Pointer To Diagnosis Code 3 Invalid, Denied due to Diagnosis Pointer To Diagnosis Code 4 Invalid, Denied due to Diagnosis Pointer To Diagnosis Code 5 Invalid, Denied due to Diagnosis Pointer(s) Are Invalid. You Must Either Be The Designated Provider Or Have A Referral. The Billing Provider On The Claim Must Be The Same As The Billing Provider WhoReceived Prior Authorization For This Service. Denied. Wk. A Procedure Code without a modifier billed on the same day as a Procedure Codewith modifier 11 are viewed as the same trip. 100 Days Supply Opportunity. Referring Physician With Credential Other Than Md Is Not Applicable To Type Of Service Provided. One or more To Date(s) of Service is invalid for Occurrence Span Codes in positions three through 24. The diagnosis code is not reimbursable for the claim type submitted. Denied due to Member Is Eligible For Medicare. The diagnosis codes must be coded to the highest level of specificity. Incorrect or invalid NDC/Procedure Code/Revenue Code billed. Claim Is Being Reprocessed Through The System. Basic knowledge of CPT and ICD-codes. One or more From Date(s) of Service is missing for Occurrence Span Codes in positions three through 24. Claims With Dollar Amounts Greater Than 9 Digits. Hospital discharge must be within 30 days of from Date Of Service(DOS). Valid NCPDP Other Payer Reject Code(s) required. A code with no Trip Modifier billed on same day as a code with Modifier U1 are considered the same trip. Find top links about Wellcare Cvs Caremark Login along with social links, FAQs, and more. Please Indicate Computation For Unloaded Mileage. Claim Detail Denied. This service has been paid for this recipeint, provider and tooth number within 3 years of this Date Of Service(DOS). The Total Number Of Sessions Requested Exceeds Quarterly Guidelines. For FQHCs, place of service is 50. 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. Tooth number or letter is not valid with the procedure code for the Date Of Service(DOS). Refer To The Wisconsin Website @ dhs.state.wi.us. this Procedure Code Is Denied As Mutually Exclusive To Another Code Billed On This Claim. Valid Numbers Are Important For DUR Purposes. Claim Detail Denied For Invalid CPT, Invalid CPT/modifier Combination, Or Invalid Type Of Quantity Billed. Please Clarify. Denied/recouped. The Quantity Allowed Was Reduced To A Multiple Of The Products Package Size. Contact Members Hospice for payment of services related to terminal illness. All Home Health Services Exceeding 8 Hours Per Day Or 40 Or More Hours Per Week Require Prior Authorization. Pharmaceutical care code must be billed with a valid Level of Effort. Admission Date is on or after date of receipt of claim. Medically Needy Claim Denied. Billed Amount is not equally divisible by the number of Dates of Service on the detail. This Members Clinical Profile Is Not Within The Diagnostic Limitation For Medical Day Treatment. Please Disregard Additional Informational Messages For This Claim. The Duration Of Treatment Sessions Exceed Current Guidelines. Request Denied Because The Screen Date Is After The Admission Date. Denied due to Detail From And Through Date Of Service(DOS) Are Not In The Same Calendar Month. Service(s) exceeds four hour per day prolonged/critical care policy. The Medicare Claims Processing Manual and the UB-04 Data Specifications Manual outlines requirements for billing outpatient claims including that (HCPCS) codes are required on outpatient claims (UB-04) with related revenue codes. Effective 1/1: Electronic Prescribing of Controlled Substances Required. Documentation You Have Submitted Does Not Meet The Requirements Of HSS 107.09(4)(k). This drug is not covered for Core Plan members. Denied. Procedure Not Payable As Submitted. Providers should submit adequate medical record documentation that supports the claim (services) billed. Claim Denied. Two different providers cannot be reimbursed for the same procedure for the same member on the same Date Of Service(DOS). To access the training video's in the portal, please register for an account and request access to your contract or medical group. A Fourth Occurrence Code Date is required. Denied. The Medical Necessity For The Hours Requested Is Not Supported By The Information Submitted In The Personal Care Assessment Tool. Denied. Initial Visit/Exam limited to once per lifetime per provider. subsequent hospital care (CPT 99231-99233) or inpatient consultations (CPT 99251-99255) in the previous week. If laboratory costs exceed reimbursement, submit a claim adjustment request with lab bills for reconsideration. The topic of Requirements for Compression Garments can be found in the Claims Section, Submission Chapter. SMV Or Prescribing Provider Description Code(s) Missing OrInvalid. Compound Drug Service Denied. Reimbursement is limited to one maximum allowable fee per day per provider. Resubmit Claim With Corrected Tooth Number/letter Or With X-ray Documenting Tooth Placement. No Action On Your Part Required. Provider Must Have A CLIA Number To Bill Laboratory Procedures. Seventh Diagnosis Code (dx) is not on file. Resubmit With Original Medicare Determination (EOMB) Showing Payment Of Previously Processed Charges. 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. Denied due to Provider Signature Is Missing. It has now been removed from the provider manuals . Modifiers submitted are invalid for the Date Of Service(DOS) or are missing.. An ICD-9-CM Diagnosis Code of greater specificity must be used for the Sixth Diagnosis Code. Adjustment Denied For Insufficient Information. OA 13 The date of death precedes the date of service. Please Review Remittance And Status Report. EPSDT/healthcheck Indicator Submitted Is Incorrect. Was Unable To Process This Request. This Claim HasBeen Manually Priced Using The Medicare Coinsurance, Deductible, And Psyche RedUction Amounts As Basis For Reimbursement. Principal Diagnosis 9 Not Applicable To Members Sex. The Fifth Diagnosis Code (dx) is invalid. Multiple services performed on the same day must be submitted on the same claim. By continuing to use our site, you agree to our Privacy Policy and Terms of Use. Member is assigned to a Hospice provider. Therefore, physician provider claim would deny. All Outpatient Services/or Accommodations And Ancillaries Are Denied, Therefore The Total Charge Is Denied. Risk Assessment/Care Plan is limited to one per member per pregnancy. Reimbursement also may be subject to the application of Denied due to Procedure/Revenue Code Is Not Allowable. Claim Is Pended For 60 Days. Denied. Denied. Detail Rendering Provider certification is cancelled for the Date Of Service(DOS). Only preferred drugs are covered for the member?s program, Only generic drugs are covered for the member?s program. Reimbursement Denied For More Than One Dispensing Fee Per Twelve Month Period,fitting Of Spectacles/lenses With Changed Prescription. Pricing Adjustment/ Long Term Care pricing applied. Other Therapies Currently Provide Sufficient Services To Meet The Members Needs. The code next to this was 264, which was described on the back of Frank's EOB as "Over What Medicare Allows" Total Patient Cost: $15.00 - Frank's office visit copayment; Amount Paid to the Provider: $50.00 - the amount of money that Frank's Medicare Advantage Plan sent to Dr. David T. Prior Authorization Is Required For Payment Of Hospital Exceptional Claims. Reimbursement For HCPCS Procedure Code 58300 Includes IUD Cost. Medicare Paid The Total Allowable For The Service. Third Other Surgical Code Date is invalid. Claim Previously/partially Paid. Lenses Only Are Approved; Please Dispense A Contracted Frame. Unable To Process Your Adjustment Request due to Financial Payer Not Indicated. Reimbursement For Training Is One Time Only. This Is A Manual Increase To Your Accounts Receivable Balance. Member must receive this service from the state contractor if this is for incontinence or urological supplies. Contingency Plan for CORE and HIRSP Kids Suspend all non-pharmacy claims. Claim date(s) of service modified to adhere to Policy. Use The ICN which Is In An Allowed Or Paid Status When Filing An Adjustment/ReconsiderationRequest. The Member Is School-age And Services Must Be Provided In The Public Schools. Pricing Adjustment/ Revenue code flat rate pricing applied. Second Other Surgical Code Date is invalid. Individual Audiology Procedures Included In Basic Comprehensive Audiometry. Please Correct And Resubmit. The Insurance EOB Does Not Correspond To The Dates Of Service/servicesBeing Billed. Prescription Date is after Dispense Date Of Service(DOS). Policy override must be granted by the Drug Authorizationand Policy Override Center to dispense early. According To Our Records, The Hospital Has Not Received Prior Authorization For This Surgery. The Skills Of A Therapist Are Not Required To Maintain The Member. A Payment Has Already Been Issued To A Different Nf. Pricing Adjustment/ SeniorCare claim cutback because of Patient Liability and/or other insurace paid amounts. Good Faith Claim Denied. 1. The Services Requested Are Not Reasonable Or Appropriate For The AODA-affectedmember. The initial rental of a negative pressure wound therapy pump is limited to 90 days; member lifetime. Timely Filing Request Denied. Payment Is Limited To One Unit Dose Service Per Calendar Month, Per Legend Drug, Per Member. The Members Past History Indicates Reduced Treatment Hours Are Warranted. Reimbursement limits for Community Care Services for the calendar year are close to being exceeded. This level not only validates the code sets , but also ensures the usage is appropriate for any MLN Matters Number: MM6229 Related . Member is covered by a commercial health insurance on the Date(s) of Service. The Service Requested Was Performed Less Than 5 Years Ago. The Date Of The Screening Request Or The Date Of Screening Is Invalid Or Missing. Claim Denied. Please Do Not Resubmit Your Claim, And Disregard Additional Informational Messages for this claim. Claim Denied. Urinalysis And X-rays Are Reimbursed Only When Performed In Conjunction With An Initial Office Visit On Same Date Of Service(DOS). Denied. Fourth Other Surgical Code Date is required. (part JHandbook). Invalid quantity for the National Drug Code (NDC) submitted with this HCPCS code. Pap Smears, Hematocrit, Urinalysis Are Not Reimbursable Separately In Conjunction With Family Planning Medical Visits. Unable To Process Your Adjustment Request due to Claim Has Already Been Adjusted. The Billing Providers taxonomy code in the header is invalid. Physical Therapy Limited To 35 Treatment Days Per Spell Of Illness W/o Prior Authorization. The Member Was Not Eligible For On The Date Received the Request. The Procedure Requested Is Not On s Files. The Seventh Diagnosis Code (dx) is invalid. A Previously Submitted Adjustment Request Is Currently In Process. Etiology Diagnosis Code(s) (E-Codes) are invalid as the Admitting/Principal Diagnosis 1. Assistant Surgery Must Be Billed Separately By The Assistant Surgeon With Modifier 80. Approved. Denied due to Service Is Not Covered For The Diagnosis Indicated. Reimbursement For This Service Has Been Approved. 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. Medical explanation of benefits. Home Health visits (Nursing and therapy) in excess of 30 visits per calendar year per member require Prior Authorization. Units Billed Are Inconsistent With The Billed Amount. Adjustment To Crossover Paid Prior To Aim Implementation Date. Billing Provider is not certified for the Dispense Date. Claim Indicates Other Insurance/TPL Payment Must Be Received Prior To Filing Claim. Admit Date and From Date Of Service(DOS) must match. Claims Cannot Exceed 28 Details. Use Of Therapy Equipment Alone Is Not Sufficient To Justify Maintenance Therapy. The Clinical Status Of The Member Does Not Meet Standards Accepted By The Department Of Health And Family Services For Transplant. The service is not reimbursable for the members benefit plan. Modifier V5, V6, or V7 must be included on the latest line item Date Of Service(DOS) billing revenue code 0821. You Must Adjust The Nursing Home Coinsurance Claim. Documentation Does Not Justify Reconsideration For Payment. One or more Diagnosis Code(s) is not payable by Wisconsin Chronic Disease Program for the Date Of Service(DOS). Policy override must be granted by the Drug Authorization and Policy Override Center to dispense less than a 100 day supply. Please Use This Claim Number For Further Transactions. The Request Has Been Back datedto Date of Receipt. Pricing Adjustment/ Provider Level of Care (LOC) pricing applied. Do Not Indicate NS On The Claim When The NDC Billed Is For A Generic Drug. There is no action required. Payment Recovered For Claim Previously Processed Under Wrong Member ID Number. Incidental modifier is required for secondary Procedure Code. An approved PA was not found matching the provider, member, and service information on the claim.