Only One Panel Code Within Same Category (CBC Or Chemistry) Maybe Performed Per Member/Provider/Date Of Service. -OR- The claim contains value code 49but does not contain revenue code 0636 and HCPCS Q4054. Reimbursement For This Certification, Test, Segment Has Already Been Issued ToYour NF. Do not insert a period in the ICD-9-CM or ICD-10-CM codes. Revenue codes 0822, 0823, 0825, 0832, 0833, 0835, 0842, 0843, 0845, 0852, 0853, or 0855 exist on the ESRD claim that does not contain condition code 74. Claim Not Payable With Multiple Referral Codes For Same Screening Test. For Review, Forward Additional Information With R&S To WCDP. Prior Authorization is needed for additional services. Only Healthcheck Modifiers Can Be Billed With Healthcheck Services. Adjustment Requested Member ID Change. Documentation Does Not Justify Fee For ServiceProcessing . 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). Please correct and resubmit. Room And Board Is Only Reimbursable If Member Has A BQC Nursing Home Authorization. FL 44 HCPCS/Rates/HIPPS Rate Codes Required. A valid Prior Authorization is required. The service requested is not allowable for the Diagnosis indicated. With Payspan's eEOB member-friendly functionality, members can log into the payer's secure portal and . Please show the appropriate multichanel HCPCS code rather than the individual HCPCS code. Less Expensive Alternative Services Are Available For This Member. PleaseReference Payment Report Mailed Separately. Schedule 3, 4 or 5 drugs are limited to the original dispensing plus 5 refillsor 6 months. Good Faith Claim Denied. Training Completion Date Is Not A Valid Date. Use This Claim Number If You Resubmit. Cannot bill for both Assay of Lab and other handling/conveyance of specimen. Unable To Process Your Adjustment Request due to The Claim Type Of The Adjustment Does Not Match The Claim Type Of The Original Claim. Denied due to The Members Last Name Is Incorrect. Medicare Id Number Missing Or Incorrect. The Service Requested Is Covered By The HMO. Service (Procedure Code/Modifier Combination) is not reimbursable for Date Of Service(DOS). the patient (or parent or guardian) at the address noted on the claim, be sure your doctor has updated your records with your current address. Denied. Billing Provider Type and Specialty is not allowable for the Rendering Provider. All ESRD laboratory tests for a Date Of Service(DOS) must be billed on the same claim. The taxonomy code for the attending provider is missing or invalid. Member Is Enrolled In A Family Care CMO. The Surgical Procedure Code is not payable for the Date Of Service(DOS). Second Rental Of Dme Requires Prior Authorization For Payment. No Complete WWWP Participation Agreement Is On File For This Provider. codes are provided per day by the same individual physician or other health care professional. Program guidelines or coverage were exceeded. Denied due to Diagnosis Code Is Not Allowable. The Header and Detail Date(s) of Service conflict. Case Planning And/or On-going Monitoring For Both Targeted Case Managementand Child Care Coordination Are Not Allowed In The Same Month. Reimbursement Is At The Unilateral Rate. Tooth surface is invalid or not indicated. Correction Made Per Medical Consultant Review. Traditional dispensing fee may be allowed. Superior HealthPlan News. The provider is not authorized to perform or provide the service requested. Medicare Paid The Total Allowable For The Service. If it is medical necessary for more than 13 or 14 services per calendar month, submit an adjustment request with supporting documentation. Please Furnish Length Of Time For Services Rendered. Services For Members With Medical Status Code TR, SH, SJ, TS Or ST NotAllowed For Your Provider Type, Or For Your Provider Type without a TB Diagnosis. The drug code has Family Planning restrictions. 12/06/2022 . Pricing Adjustment/ Maximum Allowable Fee pricing used. Adjustment/reconsideration Request Denied Due To Incorrect/insufficient Information. The Rendering Providers taxonomy code in the detail is not valid. Member is not Medicare enrolled and/or provider is not Medicare certified. Please Supply Modifier Code(s) Corresponding To The Procedure Code Description. Resubmit the Claim with the Appropriate Modifier for Provider Type andSpecialty. Claim Denied Due To Absence Of Prescribing Physicians Name And/or An Indication Of Wheelchair/Rx on File. Other payer patient responsibility grouping submitted incorrectly. Pricing Adjustment/ Ambulatory Payment Classification (APC) pricing applied. This Dental Service Limited To Once Every Six Months, Unless Prior Authorized. Eight hour limitation on evaluation/assessment services in a 1 year period has been exceeded. Use The ICN which Is In An Allowed Or Paid Status When Filing An Adjustment/ReconsiderationRequest. Denied. WellCare Known Issues List Please be advised: Claims that have either rejected or denied . Please Correct And Resubmit. Third Other Surgical Code Date is invalid. Only One Ventilator Allowed As Per Stated Condition Of The Member. Accident Related Service(s) Are Not Covered By WCDP. A WCDP drug rebate agreement for this drug is not on file for the Date Of Service(DOS). Complex care of 17-plus hours and complex care of less than 17 hours are not allowed on the same Date Of Service(DOS). WellCare_Consult_ManagedProcedureCodeList_2023_20221222 Page 2 of 7 Remote afterloading high dose rate radionuclide interstitial or intracavitary brachytherapy, includes NFs Eligibility For Reimbursement Has Expired. Denied. Please Furnish A UB92 Revenue Code And Corresponding Description. Claim Has Been Adjusted Due To Previous Overpayment. Please Indicate One Prior Authorization Number Per Claim. Service Denied. First Other Surgical Code Date is invalid. Revenue code requires submission of associated HCPCS code. Claim Denied. Other Coverage Code is missing or invalid. NCPDP Format Error Found On Medicare Drug Claim. This limitation may only exceeded for x-rays when an emergency is indicated. If Required Information Is Not Received Within 60 Days,the claim will be denied. Dates Of Service For Purchased Items Cannot Be Ranged. Please Provide The Type Of Drug Or Method Used To Stop Labor. No payment allowed for Incidental Surgical Procedure(s). Condition code 70-76 is required on an ESRD claim when Influenza/PPV/HEP B HCPCS codes are the only codes being billed with condition code A6. Unable To Process Your Adjustment Request due to Financial Payer Not Indicated. Denied due to Medicare Allowed, Deductible, Coinsurance And Paid Amounts Do Not Balance. Pregnancy Indicator must be "Y" for this aid code. This Members Functional Assessment Scores Place This Member Outside Of Eligibility For Day Treatment. Incidental modifier is required for secondary Procedure Code. The information on the claim isinvalid or not specific enough to assign a DRG. Header Bill Date is before the Header From Date Of Service(DOS). Whenever claim denied with CO 197 denial code, we need to follow the steps to resolve and reimburse the claim from insurance company: First step is to verify the denial reason and get the denial date. Pricing Adjustment/ Payment amount increased based on hospital access paymentpolicies. Denied. Discharge Date is before the Admission Date. Please Correct And Resubmit. This Procedure Is Limited To Once Per Day. This Service Is A Resubmission Of A Service Previously Denied For Prior Authorization. This Member Has Received Primary AODA Treatment In The Last Year And Is Therefore Not Eligible For Primary Intensive AODA Treatment At This Time. Comprehensive Screens And Individual Components Are Not Payable On The Same Date Of Service(DOS). Please Reference Payment Report Mailed Separately. . Other Medicare Part B Response not received within 120 days for provider basedbill. Dental service limited to twice in a six month period. Drugs Prescribed and Filled on the Same Day, Cannot have a Refill Greater thanZero. Revenue code is not valid for the type of bill submitted. 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. A Payment Has Already Been Issued To A Different Nf. Rendering Provider may not submit claims for reimbursement as both the Surgeonand Assistant Surgeon For The Same Member On The Same DOS. Number Is Missing Or Incorrect. Dental service is limited to once every six months. Date Of Service/procedure/charges On Medicare EOMB Do Not Match The Original Claim. According To Our Records, The Surgeon For This Sterilization Procedure Has NotSubmitted The Members Consent Form. Handwritten Changes/corrections On The Medicare EOMB Are Not Acceptable. RN Home Health visits and Supervisory visits are not reimbursable on the same Date Of Service(DOS) for same provider. . ACCOM REV CODE QTY BILLED NOT EQUAL TO DTL DOS. There Is Evidence That The Member Is Not Detoxified From Alcohol And/or Other Drugs and is Therefore Not Currently Eligible For AODA Day Treatment. Previously Paid Individual Test May Be Adjusted Under a Panel Code. Please verify the accuracy of the procedure code and the presence of the appropriate procedure code modifier before cont acting ACS for assistance. Urinalysis And X-rays Are Reimbursed Only When Performed In Conjunction With An Initial Office Visit On Same Date Of Service(DOS). The member is locked-in to a pharmacy provider or enrolled in hospice. Admit Diagnosis Code is invalid for the Date(s) of Service. The Member Is Enrolled In An HMO. Missing or invalid level of effort submitted and/or reason for service, professional service, or result of service code billed in error. Denied due to Add Dates Not In Ascending Order Or DD/DD/DD Format. These coding rules are published within the Medicare Claims Processing Manual, Current Procedural Terminology (CPT) by the American Medical Association (AMA) and ICD-10-CM guidelines governed by Medicare and Medicaid Services (CMS) and the National Center for Health Statistics (NCHS). The sum of the Medicare paid, deductible(s), coinsurance, copayment and psychiatric reduction amounts does not equal the Medicare allowed amount. Alternatively, the provider has billed a prior inpatient E&M visit, without an inpatient discharge service (CPT 99238-99239) in the interim. The number of treatments/days reflected by the units entered with revenue code0821, 0831, 0841, 0851, 0880, 0881 exceeds the number of days included in the FROM and TO dates entered on this claim. Provider Is Not A Qualified Provider For presumptively Eligible Recipients. Service(s) Approved By DHS Transportation Consultant. Adjustment To Crossover Paid Prior To Aim Implementation Date. Prior Authorization Is Required For Payment Of This Service With This Modifier. Multiple Unloaded Trips For Same Day/same Recip. As a result, providers experience more continuity and claim denials are easier to understand. The Rendering Providers taxonomy code is missing in the detail. Capitation Payment Recouped Due To Member Disenrollment. NFs Eligibility For Reimbursement Has Expired. Prescriber must contact the Drug Authorization and Policy Override Center for policy override. Authorization For Surgery Requiring Second Opinion Valid For 6Months After Date Approved. What steps can we take to avoid this denial? The Surgical Procedure Code is not payable for /BadgerCare Plus for the Date Of Service(DOS). wellcare explanation of payment codes and comments. Referring Provider ID is invalid. Member is covered by a commercial health insurance on the Date(s) of Service. Emergency Services Indicator must be "Y" or Pregnancy Indicator must be "Y" for this aid code. wellcare eob explanation codes. When the nerve conduction study or the needle EMG is performed on its own, the results can be misleading and important diagnoses may be missed. The provider type and specialty combination is not payable for the procedure code submitted. Services restricted to EPSDT clients valid only with a Full Scope, EPSDT-eligible Aid Code. An Approved AODA Day Treatment Program Cannot Exceed A 6 Week Period. Ninth Diagnosis Code (dx) is not on file. Do Not Submit Claims With Zero Or Negative Net Billed. Please Submit Charges Minus Credit/discount. 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. Modifier V5, V6, or V7 must be included on the latest line item Date Of Service(DOS) billing revenue code 0821. Please Correct And Resubmit. Personal care subsequent and/or follow up visits limited to seven per Date Of Service(DOS) per member. Dispensing replacement parts and complete appliance on same Date Of Service(DOS) not Allowed. An explanation of benefits is a document from your insurance company outlining the services you received and how much they cost. We Have Determined There Were (are) Several Home Health Agencies Willing To Provide Medically Necessary Skilled Nursing Services To This Member. Modifiers are required for reimbursement of these services. This Program Does Not Appear To Meet The Minimum Requirement For AODA Day Treatment Programming (10hrs) And Does Not Qualify For Aoda Day Treatment. Additional rental of a negative pressure wound therapy pump is limited to 90 days in a 12 month period. A valid procedure code is required on WWWP institutional claims. An exception will apply for anesthesia services billed with modifiers indicating severe systemic disease (Physical status modifiers P3, P4 or monitored anesthesia care modifier G9). The revenue code and HCPCS code are incorrect for the type of bill. Default Prescribing Physician Number XX5555555 Was Indicated. This list was formerly published as Part 6 of the administrative and billing instructions in Subchapter 5 of your MassHealth provider manual. Hospice Member Services Related To The Terminal Illness Must Be Billed By Hospice Or Attending Physician. 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. OA 11 The diagnosis is inconsistent with the procedure. This drug is not covered for Core Plan members. The Diagnosis Code is not payable for the member. Denied. The Member Has Shown No Ability Within 6 Months To Carry Over Abilities GainedFrom Treatment In A Facility To The Members Place Of Residence. Denied. The Performing Provider Id, Member Id, And Date Of Service(DOS) Must Match The Completion Certificate Received From Ddes. This Member Appears To Continue To Abuse Alcohol And/or Other Drugs And Is Therefore Not Eligible For Day Treatment.