wellcare eob explanation codes

Services Cutback/denied, Charges Greater Than Patient Liability, Not Responsible For Noncovered Services In Excess Of Patient Liability. Claim Previously/partially Paid. Services Submitted On Improper Claim Form. This Procedure Is Denied Per Medical Consultant Review. The Dispense As Written (DAW) indicator is not allowed for the National Drug Code. Denied due to Prescription Number Is Missing Or Invalid. The Documentation Submitted Does Not Indicate Medically Oriented Tasks Are Medically Necessary, Therefore Personal Care Services Have Been Approved. Payment Reduced Due To Patient Liability. We Have Determined There Were (are) Several Home Health Agencies Willing To Provide Medically Necessary Skilled Nursing Services To This Member. . This service is not payable with another service on the same Date Of Service(DOS) due to National Correct Coding Initiative. This drug is limited to a quantity for 34 days or less. Value code 48 exceeds 13.0 or value code 49 exceeds 39.0 and HCPCS codes Q4081or J0882 are present but either modifer ED or EE are not present. CO/204/N182 . Denied due to Statement Covered Period Is Missing Or Invalid. Header To Date Of Service(DOS) is invalid. If you are still unable to resolve the login problem, read the troubleshooting steps or report your issue. Cutback/denied. Procedure Added Due To Alt Code Replacement (age), Procedure Added Due To Alt Code Replacement (sex), Denied Duplicate- Includes Unilateral Or Bilat, Denied Duplicate/ Only Done XX Times In Lifetime, Denied Duplicate/ Only Done XX Times In A Day, Procedure Added Due To Duplicate Rebundling. The Rendering Providers taxonomy code is missing in the header. Claims may deny for audiology screening (CPT 92551, 92560, V5008) may be denied when a provider bills for auditory screening services at the same time as a preventive medicine visit (CPT 99381-99397) or wellness visit (CPT G0438-G0439), without appropriate modifier appended to the E&M service to identify a separately identifiable procedure. 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. Denied due to Member Not Eligibile For All/partial Dates. Member is enrolled in Medicare Part B on the Date(s) of Service. Pricing Adjustment/ Repackaging dispensing fee applied. This Payment Is To Satisfy The Amount Indicated On The Administrative Claiming Reimbursement Summary Report. Second Surgical Opinion Guidelines Not Met. Please Indicate Separately On Each Detail. This Adjustment/reconsideration Request Was Initiated By . Serviced Denied. Please verify the accuracy of the procedure code and the presence of the appropriate procedure code modifier before cont acting ACS for assistance. X . NFs Eligibility For Reimbursement Has Expired. The following table outlines the new coding guidelines. Denied. This National Drug Code is not covered under the Core Plan or Basic Plan for the diagnosis submitted. The Diagnosis Is Not Covered By WWWP. Dental X-rays Indicate A Dental Cleaning, Followed By Good Dental Care At Home, Would Be Sufficient To Maintain Healthy Gums. Member Expired Prior To Date Of Service(DOS) On Claim. Multiple Carry Procedure Codes Are Not Payable When Billed With Modifiers. Denied. Review Of Adjustment/reconsideration Request Shows Original Claim Payment Was Max Allowed For Medical Service/Item/NDC. Second Rental Of Dme Requires Prior Authorization For Payment. 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. Alternatively, the provider has billed a prior inpatient E&M visit, without an inpatient discharge service (CPT 99238-99239) in the interim. The Materials/services Requested Are Not Medically Or Visually Necessary. The Procedure Code has Encounter Indicator restrictions. Drug Dispensed Under Another Prescription Number. This drug/service is included in the Nursing Facility daily rate. The Documentation Submitted Indicates The Tasks Specified Can Be Completed During The Visits Approved. Discharge Diagnosis 2 Is Not Applicable To Members Sex. Rendering Provider is not certified for the Date(s) of Service. No Action On Your Part Required. By continuing to use our site, you agree to our Privacy Policy and Terms of Use. A Third Occurrence Code Date is required. This Claim Cannot Be Processed. Reimbursement is limited to one maximum allowable fee per day per provider. Resubmit Your Services Using The Appropriate Modifier After YouReceive A Update Providing Additional Billing Information. This limitation may only exceeded for x-rays when an emergency is indicated. Activities To Promote Diversion Or General Motivation Are Non-covered Services. Refer To Provider Handbook. Denied due to The Members Last Name Is Missing. Denied. ACTION TYPE LEGEND: A HCPCS code is required when condition code A6 is included on the claim. Denied due to Diagnosis Code Is Not Allowable. The content shared in this website is for education and training purpose only. Other Therapies Currently Provide Sufficient Services To Meet The Members Needs. Information Required For Claim Processing Is Missing. The Second Occurrence Code Date is invalid. Complex care of 17-plus hours and complex care of less than 17 hours are not allowed on the same Date Of Service(DOS). Denied. Adjustment/reconsideration Denied, Provider Signature/date Was Not Provided OnThe Adjustment/reconsideration Request. Supplemental Payment Authorized By Department of Health Services (DHS) Due to a Department Of Justice Settlement. 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. Detail Quantity Billed must be greater than zero. Original Payment/denial Processed Correctly. Therapy visits in excess of one per day per discipline per member are not reimbursable. Resubmit Using Valid Rn/lpn Procedure Codes And A Valid PA Number. If some of the services were previously paid, submit an adjustment/reconsideration request for the paid claim. Please Select A Procedure Code In The 58980-58988 Range That Best Describes The Procedure Being Performed. Denied. Please Resubmit A New Adjustment/reconsideration Request Form And Indicate TheMost Recent Cclaim Number Where Payment Was Made Or Allowed. Reimbursement Is Limited To The Average Monthly Nursing Home Cost And Services Above That Amount Are Considered Non-covered Services. 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. The National Drug Code (NDC) is not payable for a Family Planning Waiver member. Timely Filing Request Denied. 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. No Private HMO Or HMP On File. Allowance For Coinsurance Is Limited To Allowable Amount Less Medicares Payment. Additional services mustbe billed as treatment services and count towards the Mental Health and/or substance abuse treatment policy for prior authorization. The first occurrence span from Date Of Service(DOS) is after the to Date Of Service(DOS). A Training Payment Has Already Been Issued For This Cna. The Rendering Providers taxonomy code in the header is invalid. HIPAA EOB codes are returned on the 835 Remittance Advice file and are maintained by the Washington Publishing Company. Money Will Be Recouped From Your Account. One or more Diagnosis Code(s) in positions 10 through 25 is not on file. Thank You For The Payment On Your Account. Medicaid Remittance Advice Remark Code:M86 MMIS EOB Code:100. The sum of all Value Code amounts must be numeric and less than or equal to 999.999.999. Drugs Prescribed and Filled on the Same Day, Cannot have a Refill Greater thanZero. Master Level Providers Must Bill Under A Mental Health Clinic Number; Not Under a Private Practice Or Supervisor Number. Procedure Code is not covered for members with a Nursing Home Authorization onthe Date(s) of Service. Service Denied. You should receive it within 30 to 60 days of services provided, but it's not an official bill. Denied. Dollar Amount Of Claim Was Adjusted To Correct Mathematical Error. Provider Is Responsible For Averaging Costs During Cal Year Not To Exceed YrlyTotal (12 x $2325.00). These case coordination services exceed the limit. Prior Authorization (PA) is required for payment of this service. Claim Is Pended For 60 Days. Claims may deny when reported with incompatible ICD-10-CM Laterality policy for Diagnosis-to-Modifier comparison. Denied. 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 Medicare Part A Response not received within 120 days for provider basedbill. Effective July 15, 2021 through December 31, 2021: Temporary Relaxation of Prior Authorization . Pricing Adjustment/ Spenddown deductible applied. Procedure not allowed for the CLIA Certification Type. In addition, duplex scan of extracranial arteries, computed tomographic angiography (CTA) of the neck and magnetic resonance angiography (MRA) of the neck are not medically necessary for evaluation of syncope in patients with no suggestion of seizure and no report of other neurologic symptoms or signs. Extended Care Is Limited To 20 Hrs Per Day. Lab Procedures Billed In Conjunction With Family Planning Pharmacy Visit Denied as not a Benefit. Prior Authorization (PA) required for payment of this service. The Members Profile Indicates This Member Is Possibly Alcoholic And/or Chemically Dependent, And Intensive Aoda Treatment Appears Warranted. Billing Provider indicated is not certified as a billing provider. Service is reimbursable only once per calendar month. Default Prescribing Physician Number XX5555555 Was Indicated. 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. Services not allowed for your Provider Type or for your Provider Type without a TB diagnosis. Please Request A Corrected EOMB Through The Medicare Carrier And Adjust With The Corrected EOMB. Escalations. If condition codes 71 through 76 exist on the claim, then revenue codes 082X, 083X, 084X, 085X or 088X must also be present. Subsequently hospital care services (CPT 99221-99223 or 99231-99233) will be denied when billed for the same date of service as observation services (CPT G0378, 99218-99220 or 99224-99226) for Bill Type 0130-013Z (hospital outpatient). Dates of Service reflected by the Quantity Billed for dialysis exceeds the Statement Covers Period. The Timeframe Between Certification, Test, Date And Hire Date Exceeds A Year. Claim Detail Pended As Suspect Duplicate. Printable . 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. You Must Either Be The Designated Provider Or Have A Refer. This Revenue Code has Encounter Indicator restrictions. Member enrolled in Tuberculosis-Related Services Only Benefit Plan. Pricing Adjustment/ The submitted charge exceeds the allowed charge. Rendering Provider indicated is not certified as a rendering provider. The Header and Detail Date(s) of Service conflict. This Procedure Code Is Denied As Incidental/Integral To Another Procedure CodeBilled On This Claim. Per Information From Insurer, Claims(s) Was (were) Paid. 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. Inpatient Respite Care Is Not Covered For Hospice Members Residing In Nursing Homes. Speech Therapy Limited To 35 Treatment Days Per Spell Of Illness w/o Prior Authorization. Supplemental Payment Authorized By Department of Health Services (DHS) Due to an Interim Rate Settlement. A Payment Has Already Been Issued For This SSN. Service Denied. All Outpatient Services/or Accommodations And Ancillaries Are Denied, Therefore The Total Charge Is Denied. This Service Is Included In The Hospital Ancillary Reimbursement. The Functional Assessment Indicates This Member Has Less Than A 50% Likelihoodof Benefit, Therefore Day Treatment Is Not Appropriate. A federal drug rebate agreement for this drug is not on file for the Date Of Service(DOS)(DOS). The Request Has Been Back datedto Date of Receipt. Billing Provider Name Does Not Match The Billing Provider Number. Contact Provider Services For Further Information. An ICD-9-CM Diagnosis Code of greater specificity must be used for the Second Diagnosis Code. Services Denied. 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. Result of Service code is invalid. A Procedure Code without a modifier billed on the same day as a Procedure Codewith modifier 11 are viewed as the same trip. Service Denied. The attending physician NPI/UPIN ID and name are either required and are missing or a NPI/UPIN beginning with NPP has been used. Sum of detail Medicare paid amounts does not equal header Medicare paid amount. The Services Requested Are Not Reasonable Or Appropriate For The AODA-affectedmember. Provider Is Not A Qualified Provider For presumptively Eligible Recipients. Diagnosis of malignancies and inflammatory conditions frequently requires numerous biopsies of a particular organ or suspicious site. FFS CLAIM PROFESSIONAL ASC X12N VERSION . A dispense as written indicator is not allowed for this generic drug. Assessment Is Not A Covered Service Unless All Four Components Of Skilled Nursing Are Present: Assessment, Planning, Intervention And Evaluation. Description. The To Date Of Service(DOS) for the Second Occurrence Span Code is invalid. HCPCS Procedure Code is required if Condition Code A6 is present. Supplement Payment Authorized By Department of Health Services (DHS) Due to a Final Rate Settlement. PNCC Risk Assessment Not Payable Without Assessment Score. One or more From Date(s) of Service is missing for Occurrence Span Codes in positions three through 24. 0001: Member's . Documentation Does Not Justify Medically Needy Override. Prescription limit of five Opioid analgesics per month. The diagnosis code on the claim requires Condition code A6 be present on the Type of Bill. Member is enrolled in Medicare Part D for the Dispense Date Of Service(DOS). Nursing Home Visits Limited To One Per Calendar Month Per Provider. If A Reporting Form Is Not Submitted Within 60 Days, The claim detail will be denied. Dispense Date Of Service(DOS) is required. Please Contact Your District Nurse To Have This Corrected. Claim Denied. Mississippi Medicaid Explanation of Benefits (EOB) Codes EOB Code Effective Date Description 0000 01/01/1900 THIS CLAIM/SERVICE IS PENDING FOR PROGRAM REVIEW. Goals Are Not Realistic To The Members Way Of Life Or Home Situation, And Serve No Functional Or Maintenance Service. Basic knowledge of CPT and ICD-codes. Billed Amount Is Greater Than Reimbursement Rate. Wellcare uses cookies. Member is enrolled in a commercial health insurance on the Dispense Date Of Service(DOS). Denied due to Medicare Allowed Amount Is Greater Than Total Billed Amount. Other Insurance Disclaimer Code Invalid. Recip Does Not Meet The Reqs For An Exempt. (8 days ago) WebMassHealth List of EOB Codes Appearing on the Remittance Advice. Medicare Part A Services Must Be Resubmitted. This change to be effective 4/1/2008: Submission/billing error(s). 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. Member is in a divestment penalty period. Third Other Surgical Code Date is invalid. Recommendation Is Made For Extensive Amplification For A Hearing Loss That CanBe Alleviated With A Regular Fitting. Pediatric Community Care is limited to 12 hours per DOS. If Required Information Is Not Received Within 60 Days,the claim will be denied. WWWP Does Not Process Interim Bills. You Must Either Be The Designated Provider Or Have A Referral. An ICD-9-CM Diagnosis Code of greater specificity must be used for the First Diagnosis Code. According to the American College of Radiology and the International Society for Clinical Densitometry, dual-energy X-ray absorptiometry (DXA) bone density screening (77080 or 77081) is not indicated for women under age 65 or men under age 70 without risk factors for osteoporosis. Personal Care In Excess Of 250 Hrs Per Calendar Year Requires Prior Authorization. A Version Of Software (PES) Was In Error. At Least One Of The Compounded Drugs Must Be A Covered Drug. 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. According to CMS Medicare Claims Processing Manual, Place of Service codes (POS) are used to identify where, i.e., physician office, inpatient hospital, a procedure or service is furnished to a patient. NDC was reimbursed at AWP (Average Wholesale Price) (Average Wholesale Price) rate. 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. As A Reminder, This Procedure Requires SSOP. Resubmit Claim With Corrected Tooth Number/letter Or With X-ray Documenting Tooth Placement. WellCare 2022 schedule; NOFEE: Code is not a covered service on your fee schedule modifiers, Part 2 for CR, GT and blank modifiers IH033: Exceeds clinical guidelines; IH038: Please Correct And Resubmit. Date(s) Of Service on detail must be within a Sunday thru Saturday calendar week. A valid Prior Authorization is required for non-preferred drugs. An ICD-9-CM Diagnosis Code of greater specificity must be used for the SeventhDiagnosis Code. 1. Claim Denied For Invalid Billing Type Frequency Code, Claim Type, Or SubmittedAdjustment Provider Number Does Not Match Original Claims Provider Number. Principal Diagnosis 6 Not Applicable To Members Sex. One or more Surgical Code(s) is invalid in positions six through 23. Discharge Diagnosis 4 Is Not Applicable To Members Sex. Next step verify the application to see any authorization number available or not for the services rendered. Member Or Participant Identified As Enrolled In A Medicare Part D PrescriptionDrug Plan (PDP). Pregnancy Indicator must be "Y" for this aid code. Unable To Process This Request Because The Competency Test Date And TrainingCompletion Date Fields Are Blank. Unable To Process Your Adjustment Request due to The Claim Type Of The Adjustment Does Not Match The Claim Type Of The Original Claim. Members age does not fall within the approved age range. This National Drug Code (NDC) requires a whole number for the Quantity Billed. Claim Denied Due To Invalid Occurrence Code(s). A Training Payment Has Already Been Issued To Your NF For This CNA. Pricing Adjustment/ Prescription reduction applied. This Unbundled Procedure Code Remains Denied. 191. Member is enrolled in Medicare Part A on the Date(s) of Service. One or more Diagnosis Code(s) is not payable by Wisconsin Chronic Disease Program for the Date Of Service(DOS). Dispensing replacement parts and complete appliance on same Date Of Service(DOS) not Allowed. Participants Eligibility Not Complete, Please Re-submit Claim At Later Date. Description.

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