wellcare eob explanation codes wellcare eob explanation codes

Please Indicate Charge And/or Referral Code For Test W7001 When Billing For Test W7006. Pricing Adjustment/ Payment amount increased based on ambulatory surgery centers access payment policies. Excessive height and/or weight reported on claim. trevor lawrence 225 bench press; new internal . Back-up dialysis sessions are limited to three per lifetime. 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. Default Prescribing Physician Number XX5555555 Was Indicated. Documentation Does Not Justify Medically Needy Override. The Clinical Profile/Diagnosis Makes This Member Ineligible For AODA Services. Please Re-submit This Claim With The Insurance EOB Showing A Denial OrPartial Payment. Requests For Training Reimbursement Denied Due To Late Billing. Duplicate ingredient billed on same compound claim. Consultation or surgical procedures are not reimbursable in conjuctions with Emergency Room services. To allow for Medicare Pricing correct detail denials and resubmit. These services are not allowed for members enrolled in Tuberculosis-Related Services Only Benefit Plan. Claims may deny for a CT head or brain, CTA head, MRA head, MRI brain or CT follow-up when the only diagnosis on the claim is a migraine. The amount in the Other Insurance field is invalid. Unable To Process Your Adjustment Request due to Original Claim ICN Not Found. The Treatment Request Is Not Consistent With The Members Diagnosis. Header and/or Detail Dates of Service are missing, incorrect or contain futuredates. Avoiding denial reason code CO 22 FAQ Q: We received a denial with claim adjustment reason code (CARC) CO 22. Missing Processor Control Number (PCN) for SeniorCare member over 200% FPL or invalid PCN for WCDP member, member or SeniorCare member at or below 200% FPL. Service Allowed Once Per Lifetime, Per Tooth. Indicator for Present on Admission (POA) is not a valid value. Claim Denied. Explanation of Benefit Codes (EOBs) Mar 14, 2022 4. Please submit claim to HIRSP or BadgerRX Gold. Principal Diagnosis 8 Not Applicable To Members Sex. Claim Denied. The disposable medical supply Procedure Code has a quantity limit as indicated in the DMS Index. No Matching, Complete Reporting Form Is On File For This Client. Prescription limit of five Opioid analgesics per month. Medicare Coinsurance Amount Was Not Provided On Crossover Claim. A new set of Generic Reason codes and statements for Part A, Part B and DME have been added and approved for use across all Prior Authorization (PA), Claim reviews . Pricing Adjustment/ Repackaging dispensing fee applied. Day Treatment exceeding 120 hours per month is not payable regardless of PriorAuthorzation. Member eligibility file indicates that BadgerCare Plus Benchmark, CorePlan or Basic Plan member. Incorrect Liability Start/end DatesOr Dollar Amounts Must Be Corrected Through County Social Services Agency. The Procedure(s) Requested Are Not Medical In Nature. Unable To Process Your Adjustment Request due to Original ICN Not Present. Timeframe Between The CNAs Training Date And Test Date Exceeds 365 Days. This procedure is age restricted. Once 50 Initial Visits/year Has Been Reached Within Any One Discipline All Home Health Services Require Pa. Claims With Dollar Amounts Greater Than 9 Digits. Pricing Adjustment. The Members Clinical Profile/diagnosis Is Not Within Diagnostic Limitations for Psychotherapy Services. Unable To Process Your Adjustment Request due to Member Not Found. Prescription limit of five Opioid analgesics per month. NFs Eligibility For Reimbursement Has Expired. Denied. Denied/Cutback. The Service Requested Was Performed Less Than 3 Years Ago. Member is enrolled in Medicare Part D for the Dispense Date Of Service(DOS). Voided Claim Has Been Credited To Your 1099 Liability. Claim Paid Under DRG Reimbursement, Except For Transplants Billed Using Suffixes 05 Through 09. Medically Unbelievable Error. The Screen Date Is Either Missing Or Invalid. The Requested Transplant Is Not Covered By . Service Denied. Second Other Surgical Code Date is invalid. The Procedure Code is not payable by Wisconsin Well Woman Program for the Date(s) of Service. Pricing Adjustment/ Pharmacy dispensing fee applied. NDC- National Drug Code billed is not appropriate for members gender. 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). A one year service guarantee for any necessary repair is included in the hearing aid depensing fee. Please Resubmit Your Non-healthcheck Services Using The Appropriate Claim SortIndicator Or Electronic Format. The Billing Providers taxonomy code is invalid. CO/204/N182 . Please Select A Procedure Code In The 58980-58988 Range That Best Describes The Procedure Being Performed. Please Submit With Completed timely Filing Form In The All Provider Handbook And Supporting Documentation. NDC was reimbursed at AWP (Average Wholesale Price) (Average Wholesale Price) rate. 690 Canon Eb R-FRAME-EB Header From Date Of Service(DOS) is after the header To Date Of Service(DOS). wellcare eob explanation codes. Denied. Principle Surgical Procedure Code Date is missing. A Trading Partner Agreement/profile Form(s) Authorizing Electronic Claims Submission Is Required. Intensive Multiple Modality Treatment Is Not Consistent With The Information Provided. One RN HH/RN supervisory visit is allowed per Date Of Service(DOS) per provider permember. Additional services mustbe billed as treatment services and count towards the Mental Health and/or substance abuse treatment policy for prior authorization. The Type Of Psychotherapy Service Requested For This Member Is Considered To be Professionally Unacceptable, Unproven And/or Experimental. Third Other Surgical Code Date is invalid. Denied. Number On Claim Does Not Match Number On Prior Authorization Request. Procedure Not Payable As Submitted. Member Is Eligible For Champus. Not A WCDP Benefit. Refer to the Onine Handbook. (National Drug Code). Member Name Missing. Outside Lab,element 20 On CMS 1500 Claim Form Must Be Checked Yes When Handling Charges Are Billed. WCDP member enrolled in Medicare Part D. Claim is excluded from Drug Rebate Invoicing. Compound Drug Service Denied. Billing Provider Received Payment From Both Medicare And For Clai m. An Adjustment/reconsideration Request Has Been Made To The Billing Providers Account. A Primary Occurrence Code Date is required. Adjustment/reconsideration Request Denied Due To Incorrect/insufficient Information. A WCDP drug rebate agreement for this drug is not on file for the Date Of Service(DOS). Provider Must Have A CLIA Number To Bill Laboratory Procedures. Number Is Missing Or Incorrect. Payment Subject To Pharmacy Consultant Review. This Mutually Exclusive Procedure Code Remains Denied. . Pricing Adjustment/ Anesthesia pricing applied. 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. Denied. These are EOB codes, revised for NewMMIS, that may appear on your PDF remittance advice. Your Adjustment/reconsideration Request For Additional Payment Has Been Denied, Request Was Received Beyond The 90 Day Requirement For Payment Reconsideration. The Second Occurrence Code Date is invalid. Six hour limitation on evaluation/assessment services in a 2 year period has been exceeded. The Rendering Providers taxonomy code in the detail is not valid. Medical Necessity For Food Supplements Has Not Been Documented. Claim Detail Denied. Services on this claim were previously partially paid or paid in full. Pharmaceutical care indicates the prescription was not filled. Emergency Services Indicator must be "Y" or Pregnancy Indicator must be "Y" for this aid code. The Procedure Requested Is Not Appropriate To The Members Sex. Occupational therapy limited to 35 treatment days per lifetime without prior authorization. Please familiarize yourself with these new explanation codes and update your accounts receivable as indicated. Submit Claim To Insurance Carrier. Provider Not Eligible For Outlier Payment. Please Correct And Submit. Additional information is needed for unclassified drug HCPCS procedure codes. Computed tomography (CT) of the head or brain (CPT 70450, 70460, 70470), Computed tomographic angiography (CTA) of the head (CPT 70496), Magnetic resonance angiography (MRA) of the head (CPT 70544, 70545, 70546), Magnetic resonance imaging (MRI) of the brain (CPT 70551, 70552, 70553), Duplex scan of extracranial arteries (CPT 93880,93882), Computed tomographic angiography (CTA) of the neck(CPT 70498), Magnetic resonance angiography (MRA) of the neck(CPT 70547, 70548, 70549), ICD-10 Diagnosis codes G43.009, G43.109, G43.709, G43.809, G43.829, G43.909. Denied. Revenue Code 0001 Can Only Be Indicated Once. Fourth Diagnosis Code (dx) is not on file. Claim Detail from Date Of Service(DOS) And to Date Of Service(DOS) Are Required And Must Be Within The Same Calendar Month. Your 1099 Liability Has Been Credited. If not, the procedure code is not reimbursable. Prior Authorization Is Required For Payment Of Hospital Exceptional Claims. This claim is a duplicate of a claim currently in process. Procedure not allowed for the CLIA Certification Type. Medicare Part A Services Must Be Resubmitted. Condition codes 71, 72, 73, 74, 75, and 76 cannot be present on the same ESRD claim at the same time. The Surgical Procedure Code is not payable for the Date Of Service(DOS). that provide either supplemental explanation for a monetary adjustment or policy information are required in the remittance advice transaction. Professional Components Are Not Payable On A Ub-92 Claim Form. The Procedure Requested Is Not Allowable For The Process Type Indicated On TheRequest. The Fifth Diagnosis Code (dx) is invalid. $150.00 Reimbursement Limit Has Been Reached For Individual And Group Pncc Health Education/nutritional Counseling. Missing Or Invalid Level Of Effort And/or Reason For Service Code, Professional Service Code, Result Of Service Code Billed In Error. Reimbursement Rate Applied To Allowed Amount. A number is required in the Covered Days field. One BMI Incentive payment is allowed per member, per renderingprovider, per calendar year. Fourth Other Surgical Code Date is required. Procedure Not Payable for the Wisconsin Well Woman Program. This Adjustment Was Initiated By . Denied due to The Members Last Name Is Missing. This Claim Is Being Returned. Denied due to Procedure Billed Not A Covered Service For Dates Indicated. Only Healthcheck Modifiers Can Be Billed With Healthcheck Services. Claim Is Pended For 60 Days. Description. Other Therapies Currently Provide Sufficient Services To Meet The Members Needs. Billing Provider indicated is not certified as a billing provider. The From Date Of Service(DOS) and To Date Of Service(DOS) must be in the same calendar month and year. Maximum Reimbursement Amount Has Been Determined By Professional Consultant. Panel And Individual Test Not Payable For Same Member/Provider/ Date Of Service(DOS). Please Correct And Resubmit. Department of Health Services (DHS) Authorized Payment Is Being Withheld Due toa Final Rate Settlement. When a provider submits an E&M level of service that exceeds the maximum level of E&M service level based on the diagnosis submitted, the E&M code is recoded (and allowed to pay) to match the maximum level of E&M service allowed based on the severity of the medical diagnosis submitted. The Maximum Allowable Was Previously Approved/authorized. CPT Code 88305 (Level IV Surgical pathology, gross and microscopic examination) includes different types of biopsies. Assessment Is Not A Covered Service Unless All Four Components Of Skilled Nursing Are Present: Assessment, Planning, Intervention And Evaluation. WellCare Known Issues List EOP Denial Code or Rejection Reason Code Issue Description Impacted Provider Specialty . Good Faith Claim Correctly Denied. 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. Diagnosis Treatment Indicator is invalid. Admission Date does not match the Header From Date Of Service(DOS). Denied. EOB EOB DESCRIPTION. An NCCI-associated modifier was appended to one or both procedure codes. Wellcare uses cookies. Supplement Payment Authorized By Department of Health Services (DHS) Due to a Final Rate Settlement. Our Records Indicate You Have Billed More Than One Unit Dose Dispensing Fee For This Calendar Month. Health (3 days ago) Webwellcare explanation of payment codes and comments. Reimbursement Is Limited To The Average Monthly Nursing Home Cost And Services Above That Amount Are Considered Non-covered Services. Only two dispensing fees per month, per member are allowed. Additional Encounter Service(s) Denied. Surgical Procedure Code is not related to Principal Diagnosis Code. Please Review The Covered Services Appendices Of The Dental Handbook. CO - Contractual Obligations: This group code is used when a contractual agreement between the payer and payee, or a regulatory requirement, resulted in an adjustment.These adjustments are considered a write off for the provider and are not billed to . Documentation Does Not Justify Fee For ServiceProcessing . This National Drug Code (NDC) has diagnosis restrictions. Outside Lab Indicator Must Be Y For The Procedure Code Billed. Previously Paid Individual Test May Be Adjusted Under a Panel Code. 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). Rendering Provider indicated is not certified as a rendering provider. CPT/HCPCS codes are not reimbursable on this type of bill. Member has commercial dental insurance for the Date(s) of Service. Payment Recouped. The second occurrence span from Date Of Service(DOS) is after to to Date Of Service(DOS). Please Ask Prescriber To Update DEA Number On TheProvider File. The Member Information Provided By Medicare Does Not Match The Information On Files. The Documentation Submitted Does Not Substantiate Additional Care. Claim Is Being Special Handled, No Action On Your Part Required. Please submit claim to BadgerRX Gold. Is Unable To Process This Request Because The Signature/date Field Is Blank. Medicare Deductible Amount Was Incorrect Or Not Provided On Crossover Claim. Part A Reason Codes are maintained by the Part A processing system. and other medical information at your current address. Services Must Be Submitted On Proper Claim/adjustment/reconsiderationRequest Form. Payment may be reduced due to submitted Present on Admission (POA) indicator. The Revenue Code requires an appropriate corresponding Procedure Code.