wellcare eob explanation codes

Refer To Your Pharmacy Handbook For Policy Limitations. Denied. Reason Code 234 | Remark Codes N20 - JD DME - Noridian DME rental beyond the initial 60 day period is not payable without prior authorization. Please Indicate Mileage Traveled. Only two dispensing fees per month, per member are allowed. Dialysis/EPO treatment is limited to 13 or 14 services per calendar month. Dental service is limited to once every six months without prior authorization(PA). Initial Visit/Exam limited to once per lifetime per provider. Dispense Date Of Service(DOS) is required. From Date Of Service(DOS) is before Admission Date. Claim reduced to fifteen Hospital Bedhold Days for stays exceeding fifteen days. The Revenue Code is not payable by Wisconsin Chronic Disease Program for the Date(s) of Service. Reimbursement For HCPCS Procedure Code 58300 Includes IUD Cost. . . Four X-rays are allowed per spell of illness per provider. The National Drug Code (NDC) submitted with this HCPCS code is CMS terminated or not covered by the program. CNAs Eligibility For Nat Reimbursement Has Expired. This National Drug Code Has Diagnosis Restrictions. Research Has Determined That The Member Does Not Qualify For Retroactive Eligibility According To Hfs 106.03(3)(b) Of The Wisconsin Administrative Code. One or more Diagnosis Codes are not applicable to the members gender. The Documentation Submitted Indicates The Tasks Specified Can Be Completed During The Visits Approved. A Google Certified Publishing Partner. Outside Lab Indicator Must Be Y For The Procedure Code Billed. An xray or diagnostic urinalysis is reimbursable only when performed on the same Date Of Service(DOS) and billed on the same claim as the initial office visit. This Service Is Included In The Hospital Ancillary Reimbursement. This Adjustment Was Initiated By . Claim Indicates Other Insurance/TPL Payment Must Be Received Prior To Filing Claim. The Fifth Diagnosis Code (dx) is invalid. Errors in one of the following data elements exceed their field size: Statement covered FROM Date, Admission date, Date Of Service(DOS), Revenue code. Each month you fill a prescription, your Medicare Prescription Drug Plan mails you an "Explanation of Benefits" (EOB). NDC was reimbursed at AWP (Average Wholesale Price) (Average Wholesale Price) rate. No payment allowed for Incidental Surgical Procedure(s). A valid Prior Authorization is required for non-preferred drugs. Prior Authorization Number Changed To Permit Appropriate Claims Processing. Modifier Submitted Is Invalid For The Member Age. 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. Services Not Allowed For Your Provider T. The Procedure Code has Place of Service restrictions. Comprehensive Screens And Individual Components Are Not Payable On The Same Date Of Service(DOS). Claim Is For A Member With Retro Ma Eligibility. 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. Copyright 2023 Wellcare Health Plans, Inc. New Coding Integrity Reimbursement Guidelines. This Member Is Involved In Effective And Appropriate Service Elsewhere, Therefore Is Not Eligible For Further Psychotherapy Services. A Second Occurrence Code Date is required. Other Insurance Disclaimer Code Invalid. Valid NCPDP Other Payer Reject Code(s) required. Medicaid Claim Adjustment Reason Code:B13 - thePracticeBridge Rinoplastia; Blefaroplastia 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. Name And Complete Address Of Destination. Only One Panoramic Film Or Intraoral Radiograph Series, By The Same Provider, Per Year Allowed. Please Request Prior Authorization For Additional Days. Denied/Cutback. Resubmit Claim Through Regular Claims Processing. Concurrent Services Are Not Appropriate. Homecare Services W/o PA Are Not Payable When Prior Authorized HomecAre Services Have Been Provided To The Same Member. Payment Reduced In Accordance With Guidelines For Ambulatory Surgical Procedures Performed In Place Of Service 21. This Report Was Mailed To You Separately. Billed Amount Is Greater Than Reimbursement Rate. This Member, As Indicated By Narrative History, Does Not Agree To Abstinence from Alcohol Or Other Drugs And Is Ineligible For AODA Treatment. 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. Pricing Adjustment/ Traditional dispensing fee applied. WCDP member enrolled in Medicare Part D. Claim is excluded from Drug Rebate Invoicing. Denied due to Detail Add Dates Not In MM/DD Format. Services Billed Denied As Being Covered In The Payment For Day Rx Per Medical Day Treatment Guidelines. Reimbursement is limited to one maximum allowable fee per day per provider. This detail is denied. Member is covered by a commercial health insurance on the Date(s) of Service. Payment Recovered For Claim Previously Processed Under Wrong Member ID Number. All services should be coordinated with the Hospice provider. Recoding/adjusting claim may result in a different DRG code assignmentand reimbursement. Please Ask Prescriber To Update DEA Number On TheProvider File. Denied. Service Must Be Billed On Drug Claim Form Utilizing NDC Codes. Unable To Process Your Adjustment Request due to The Claim Type Of The Adjustment Does Not Match The Claim Type Of The Original Claim. Records Indicate This Tooth Has Previously Been Extracted. Claims may deny the chest X-ray billed when the only diagnoses is one of the following routine screening diagnoses: General medical exam (ICD-10 codes Z00.0-Z00.01, Z00.5, Z00.6, Z00.8), Pre-admission/administrative exam (ICD-10 codes Z02.0-Z02.6, Z02.8-Z02.89, Z04.6), Pre-operative exam (ICD-10 codes Z01.810-Z01.811, Z01.818), FL 42 Revenue Code Required. Denied. Header From Date Of Service(DOS) is required. Pricing Adjustment/ Payment reduced due to benefit plan limitations. Has Recouped Payment For Service(s) Per Providers Request. The Revenue Code is not payable for the Date(s) of Service. The Other Payer ID qualifier is invalid for . 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). The Diagnosis Code is not payable for the member. Multiple Unloaded Trips For Same Day/same Recip. Medical explanation of benefits. 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). Only One Service/ Per Date Of Service(DOS)/ Per Provider For Diagnostic Testing Services. No Complete WWWP Participation Agreement Is On File For This Provider. This claim has been adjusted because a service on this claim is not payable inconjunction with a separate paid service on the same Date Of Service(DOS) due to National Correct Coding Initiative. Occupational Therapy Limited To 45 Treatment Days Per Spell Of Illness w/o Prior Authorization. Restorative Nursing Can Provide Follow-through, Based On Diagnosis Of Long-standing Nature, And The Amount Of Therapy. Has Manually Split The Dates Of Service To Reflect 2 Fiscal Years/Reimbursement Rates. 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: Claim Denied Due To Invalid Pre-admission Review Number. An ICD-9-CM Diagnosis Code of greater specificity must be used for the Fifth Diagnosis Code. Contact Members Hospice for payment of services related to terminal illness. Claim Reduced Due To Member/participant Spenddown. Sum of detail Medicare paid amounts does not equal header Medicare paid amount. Continue ToUse Appropriate Codes On Billing Claim(s). Pricing Adjustment/ Ambulatory Payment Classification (APC) pricing applied. Please Clarify Services Rendered/provide A Complete Description Of Service. Denied due to Detail Dates Are Not Within Statement Covered Period. Rendering Provider Type and/or Specialty is not allowable for the service billed. Was Unable To Process This Request. This Procedure Code Is Denied As Incidental/Integral To Another Procedure CodeBilled On This Claim. Procedure Denied Per DHS Medical Consultant Review. PDF Remittance and Status (R&S) Reports - Tmhp 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. Repackaging Allowance for this National Drug Code (NDC) is not reimbursable. 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 . Auditory Screening with Preventive Medicine Visits. If authorization number available . Effective 5/31/2019, we will introduce new Coding Integrity Reimbursement Guidelines. CO/204/N30. Please Contact The Surgeon Prior To Resubmitting this Claim. Payment(s) For Capital Or Medical Education Are Generated By EDS And May Not Be Billed By The Provider. Department of Health Services (DHS) Authorized Payment Is Being Withheld Due toa Final Rate Settlement. Reimbursement for this procedure and a related procedure is limited to once per Date Of Service(DOS). Claim Denied. Do Not Submit Claims With Zero Or Negative Net Billed. Result of Service code is invalid. . It Must Be In MM/DD/YY Format AndCan Not Be A Future Date. Claim/adjustment Received Beyond The 455 Day Resubmission Deadline. Prospective DUR denial on original claim can not be overridden. Certifying Agency Did Not Verify Member Eligibility within 70 Day Period. A quantity dispensed is required. Day Treatment Exceeding 5 Hours/day Not Payable Regardless Of Prior Authorization. Remittance Advice Remark Codes | X12 (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). Claims With Dollar Amounts Greater Than 9 Digits. The Service(s) Requested Could Be Adequately Performed With Local Anesthesia In The Dental Office. A valid Level of Effort is also required for pharmacuetical care reimbursement. Claim Detail Denied. This Member Has Received Primary AODA Treatment In The Last Year And Is Therefore Not Eligible For Primary Intensive AODA Treatment At This Time. No Functional Regression Has Occurred To Warrant A Spell Of Illness; Submit AsA Prior Authorization Request. Different Drug Benefit Programs. Member has Medicare Managed Care for the Date(s) of Service. Services billed are included in the nursing home rate structure. Pricing Adjustment/ The submitted charge exceeds the allowed charge. Request Denied Due To Late Billing. Service Billed Limited To Three Per Pregnancy Per Guidelines. Use the most current year's ICD-9-CM or ICD-10-CM codes, depending on the date(s) of service.

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