wellcare eob explanation codes wellcare eob explanation codes

Pediatric Community Care is limited to 12 hours per DOS. X-rays and some lab tests are not billable on a 72X claim. One or more Diagnosis Code(s) is not payable by Wisconsin Well Woman Program for the Date(s) of Service. Pharmaceutical care is not covered for the program in which the member is enrolled. Total billed amount is less than the sum of the detail billed amounts. ESRD claims are not allowed when submitted with value code of A8 (weight) and a weight of more than 500 kilograms and/or the value code of A9 (height) and the height of more than 900 centimeters. According to the American Society of Anesthesiologists and the International Spine Intervention Society, minor pain procedures such as epidural steroid injections, epidural blood patch, trigger point injections, sacroiliac joint injection, bursal injections, occipital nerve block and facet injections under most routine circumstances, require only local anesthesia. WellCare Known Issues List Please be advised: Claims that have either rejected or denied . Pricing Adjustment/ Maximum allowable fee pricing applied. Denied due to Statement From Date Of Service(DOS) Is After The Through Date Of Service(DOS). Claim Is Being Special Handled, No Action On Your Part Required. Earn Money by doing small online tasks and surveys, What is Denials Management in Medical Billing? Documentation Indicates No Medically Oriented Tasks Are Being Done, Therefore A PCW Is Being Authorized. Paid In Accordance With Dental Policy Guide Determined By DHS. The Provider Type/specialty Is Not Recognized For These Date(s) Of Service. Denied due to Procedure Is Not Allowable For Diagnosis Indicated. A Primary Occurrence Code Date is required. Principal Diagnosis 9 Not Applicable To Members Sex. Reimbursement for this procedure and a related procedure is limited to once per Date Of Service(DOS). Medicaid Denial Codes vs Medicaid Explanation Codes - BridgestoneHRS Complex Care Services Are Limited To One Per Date Of Service(DOS) Per Member. Reimbursement rate is not on file for members level of care. Other Insurance Disclaimer Code Used Is Inappropriate For This Members Insurance Coverage. Other payer patient responsibility grouping submitted incorrectly. Formal Speech Therapy Is Not Needed. Denied. Denied due to Medicare Allowed Amount Is Greater Than Total Billed Amount. Claim Detail from Date Of Service(DOS) And to Date Of Service(DOS) Are Required And Must Be Within The Same Calendar Month. POS codes are required under the provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Pricing Adjustment/ Inpatient Per-Diem pricing. wellcare eob explanation codes - cirujanoplasticoleon.com You Must Either Be The Designated Provider Or Have A Referral. Indicated Diagnosis Is Not Applicable To Members Sex. Acute Care General And Specialty Hospitals Are Subject To Pre-admission Requirements Or The Pre-admission Review Number Indicated Is Invalid. Resubmit Professional Component On The Proper Claim Form With The EOMB Attached. Other Medicare Managed Care Response not received within 120 days for providerbased bill. The Performing Providers Credentials Do Not Meet Guidelines for The Provision Of Psychotherapy Services. and other medical information at your current address. WellCare Known Issues List This Program Does Not Appear To Meet The Minimum Requirement For AODA Day Treatment Programming (10hrs) And Does Not Qualify For Aoda Day Treatment. All services should be coordinated with the Hospice provider. No Interim Billing Allowed On Or After 01-01-86. 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. We update the Code List to conform to the most recent publications of CPT and HCPCS . Please Clarify. Prescription Drug Plan (PDP) payment/denial information required on the claim to WCDP. Rn Visit Every Other Week Is Sufficient For Med Set-up. Type of Bill indicates services not reimbursable or frequency indicated is notvalid for the claim type. Service(s) paid in accordance with program policy limitation. Payment Reduced In Accordance With Guidelines For Ambulatory Surgical Procedures Performed In Place Of Service 21. Pricing Adjustment/ Prior Authorization pricing applied. Changes/corrections Were Made To Your Claim Per Dental Processing Guidelines. A Third Occurrence Code Date is required. In addition, when distinct service modifier 59 or modifier XE is not appended to auditory screening services and tympanometry/impedance testing, these services may be denied. Reimbursement Is At The Unilateral Rate. First Other Surgical Code Date is required. Did You check More Than One Box?If So, Correct And Resubmit. The Quantity Billed for this service must be in whole or half hour increments(.5) Increments. Header From Date Of Service(DOS) is required. Claim Previously/partially Paid. Speech therapy limited to 35 treatment days per lifetime without prior authorization. Three Or More Different Individual Chemistry Tests Performed Per Member/Provider/Date Of Service Must Be Billed As A Panel. Wellcare Explanation Of Payment Codes USA Health Prescription limit of five Opioid analgesics per month. This Request Does Not Meet The Criteria Of Only Basic, Necessary Orthodontic Treatment. If You Have Already Obtained SSOP, Please Disregard This Message. A Payment For The CNAs Competency Test Has Already Been Issued. 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. Denied/Cutback. Adjustment To Eyeglasses Not Payable As A Repair Service. A valid Prior Authorization is required for non-preferred drugs. Department of Health Services (DHS) Authorized Payment Is Being Withheld Due toa Department Of Justice Settlement. Split Decision Was Rendered On Expansion Of Units. Benefit Payment Determined By DHS Medical Consultant Review. More than 6 hours of evaluation/assessment in a 2 year period must be billed astreatment services and count toward the MH/SA policy limits for prior authorization. The Skills Of A Therapist Are Not Required To Maintain The Member. Rendering Provider is not a certified provider for Wisconsin Well Woman Program. Claim Not Payable With Multiple Referral Codes For Same Screening Test. Billed Amount On Detail Paid By WWWP. Printable . ACode With No Modifier Billed On The Same Day As A Code With Modifier 11 Are Viewed as the same trip. 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. Valid Numbers Are Important For DUR Purposes. This Modifier has been discontinued by CMS or AMA for the Date Of Service(DOS)(s). This Member Has Prior Authorization For Therapy Services. The following table outlines the new coding guidelines. All three DUR fields must indicate a valid value for prospective DUR. Thank You For Your Assessment Interest Payment. Once medical records are received, medical review professionals will review the documentation to determine whether the claim is supported as submitted and pay or deny accordingly. Emergency Services Indicator must be "Y" or Pregnancy Indicator must be "Y" for this aid code. Home Health services for CORE plan members are covered only following an inpatient hospital stay. Quantity submitted matches original claim. Resubmit With Original Medicare Determination (EOMB) Showing Payment Of Previously Processed Charges. Adjustment Denied For Insufficient Information. Vision Diagnostic Services Limited To 1 Of These: Vision Exam, Diagnostic Review, Supplemental Test Or Contact Lens Therapy. Treatment With More Than One Drug Per Class Of Ulcer Treatment Drug At The Same Time Is Not Allowed Through Stat PA. Reason for Service submitted does not match prospective DUR denial on originalclaim. Claim Denied In Order To Reprocess WithNew ID. Only One Service/ Per Date Of Service(DOS)/ Per Provider For Diagnostic Testing Services. Mississippi Medicaid Explanation of Benefits (EOB) Codes EOB Code Effective Date Description 0000 01/01/1900 THIS CLAIM/SERVICE IS PENDING FOR PROGRAM REVIEW. Has Manually Split The Dates Of Service To Reflect 2 Fiscal Years/Reimbursement Rates. You Must Adjust The Nursing Home Coinsurance Claim. Reimbursement also may be subject to the application of The Evaluation Was Received By Fiscal Agent More Than Two Weeks After The Evaluation Date. Amount Recouped For Duplicate Payment on a Previous Claim. The first position of the attending UPIN must be alphabetic. Rqst For An Acute Episode Is Denied. Denied. 0300-0319 (Laboratory/Pathology). There is no action required. PDF How to read EOB codes - Washington Refer To Notice From DHS. ambulatory surgical center, outpatient hospital) exists for the same member, same date of service and the same procedure or service. Billed Procedure Not Covered By WWWP. Procedure Code and modifiers billed must match approved PA. Diagnosis 635-635.92 May Only Be Used When Billing For Abortion Procedures. Assessment limit per calendar year has been exceeded. Please Contact Your District Nurse To Have This Corrected. Multiple Tooth Extract On Same Date Of Service(DOS) Must Be Billed As Single And Additional Tooth Extract In Same Quadrant. Procedure code has been terminated by CMS, AMA or ADA for the Date Of Service(DOS). The amount in the Other Insurance field is invalid. A Training Payment Has Already Been Issued To A Different NF For This CNA. The Information Provided Indicates This Member Is Not Willing Or Able To Participate Inaftercare/continuing Care Services And Is Therefore Not Eligible For AODA Day Treatment. Member Has Already Been Granted Actute Episode for 3 Months In This Cal Yr. Reimb Is Limited To Average Monthy NH Cost And Services Above That Are Consider Non-covered Services. Pricing Adjustment/ Medicare pricing cutbacks applied. The Screen Date Is Either Missing Or Invalid. This Is Not A Good Faith Claim. The value code 48 (Hemoglobin reading) or 49 (Hematocrit) is required for the revenue code/HCPCS code combination. Denied. Training CompletionDate Exceeds The Current Eligibility Timeline. Here are just a few of them: EOB CODE. MedicalBillingRCM.com is a participant in the Amazon Services LLC Associates Program, an affiliate advertising program designed to provide a means for sites to earn advertising fees by advertising and linking to Amazon.com. Unable To Process This Request Due To Either Missing, Invalid OrMismatched National Provider Identifier # (NPI)/Provider Name/POP ID. The Surgical Procedure Code is restricted. NDC- National Drug Code is invalid for the Dispense Date Of Service(DOS). Outpatient Services To Be Billed As Inpatient Ancillaries When Same Day Stay Occurs Please File An Adjustment/reconsideration Request To Correct Inpatiet Billing. Activities To Promote Diversion Or General Motivation Are Non-covered Services. Procedure Code billed is not appropriate for members gender. Result of Service code is invalid. Denied/Cutback. ACCOM REV CODE QTY BILLED NOT EQUAL TO DTL DOS. The Member Has Shown No Significant Functional Progress Toward Meeting Or Maintaining Established & Measurable Treatment Goals Over A 6 Month Period. Established in 1975 and incorporated in 1987, WPC is widely recognized as a leading expert in supporting the development, publishing, and licensing of complex . Denied/Cutback. No Matching, Complete Reporting Form Is On File For This Client. Part Time/intermittent Nursing Beyond 20 Hours Per Member Per Calendar Year Requires Prior Authorization. The Materials/services Requested Are Principally Cosmetic In Nature. Detail To Date Of Service(DOS) is invalid. 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. Bilateral Procedures Must Be Billed On One Detail With Modifier 50, Quantity Of 1.detail With Modifier 50 May Be Adjusted If Necessary. Medicare Part A Or B Charges Are Missing Or Incorrect. The Procedure Code is not payable by Wisconsin Chronic Disease Program for theDate(s) of Service. Denied due to Member Not Eligibile For All/partial Dates. An amount in the Gross Amount Due field and/or Usual and Customary Charge field is required. Denied due to Medicare Allowed Amount Required. Denied. Claims For Sterilization Procedures Must Reflect ICD-9 Diagnosis Code V25.2. This claim has been adjusted due to Medicare Part D coverage. General Assistance Payments Should Not Be Indicated On Claims. Unable To Process Your Adjustment Request due to Provider ID Not Present. A discrepancy exists between the Other Coverage Indicator and the Other Paid Amount. HMO Extraordinary Claim Denied. This Adjustment Was Initiated By . Denied due to Claim Contains Future Dates Of Service. Denied. Medicare Part A Services Must Be Resubmitted. Denied. Referring Provider ID is not required for this service. This Dental Service Limited To Once A Year. PDF WellCare Procedure Codes - HealthHelp Service(s) paid at the maximum daily amount per provider per member. Please Bill Your Medicare Intermediary Prior To Submitting To . MLN Matters Number: MM6229 Related . A Separate Notification Letter Is Being Sent. Good Faith Claim Denied For Timely Filing. Revenue codes 082X, 083X, 084X, 085X, 0800 or 0881 (X frequency not equal to 5) exist on an ESRD claim for a member who has selected method 1 or no method and the claim does not contain condition codes 71, 72, 73 ,74, 75, or 76. This National Drug Code (NDC) has Encounter Indicator restrictions. Bilateral Surgeries Reimbursed At 150% Of The Unilateral Rate. Remittance Advice Remark Codes (RARCs) are used to provide additional explanation for an adjustment already described by a Claim Adjustment Reason Code (CARC) or to convey information about remittance processing. Other Payer Coverage Type is missing or invalid. Understanding Your Explanation of Benefits (EOB) - Verywell Health This Payment Is To Satisfy Amount Owed For A Drug Rebate Prior Quarter Correction. Denied. Billed amount exceeds prior authorized amount. The submitted claim contains value code 68 and 48 or 49 but does not contain revenue code 0634 or 0635 and HCPCS Q4055. The Service(s) Requested Could Adequately Be Performed In The Dental Office. The Revenue Code is not reimbursable for the Date Of Service(DOS). The Members Demonstrated Response To Current Therapy Does Not Warrant The Intense Freqency Requested. FFS CLAIM PROFESSIONAL ASC X12N VERSION . Please Submit With Completed timely Filing Form In The All Provider Handbook And Supporting Documentation. An ICD-9-CM Diagnosis Code of greater specificity must be used for the Third Diagnosis Code. Denied. Principal Diagnosis 7 Not Applicable To Members Sex. A group code is a code identifying the general category of payment adjustment. Home Health Services In Excess Of 60 Visits Per Calendar Month Per Member Required Prior Authorization. Pricing Adjustment/ Claim has pricing cutback amount applied. Procedure Code and modifiers billed must match approved PA. Provider Must Have A CLIA Number To Bill Laboratory Procedures. This service was previously paid under an equivalent Procedure Code. Nine Digit DEA Number Is Missing Or Incorrect. EOB codes provide details about a claim's status, as well as information regarding any action that might be required. Intermittent Peritoneal Dialysis hours must be entered for this revenue code. Denied. Research Has Determined That The Member Does Not Qualify For Retroactive Eligibility According To Hfs 106.03(3)(b) Of The Wisconsin Administrative Code. Only Medicare crossover claims are reimbursable. Pricing Adjustment/ Pharmaceutical Care dispensing fee applied. 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). Service Denied. Prior Authorization (PA) is required for payment of this service. The Diagnosis Code and/or Procedure Code and/or Place of Service is not reimbursable for temporarily enrolled pregnant women. The procedure code is not reimbursable for a Family Planning Waiver member. Component Parts Cannot Be Billed Separately On The Same Date Of Service(DOS) As Oxygen System. Resubmit Private Duty Nursing Services For Complex Children With Documentation Supporting The Level Of Care. Claim Denied. This diabetic supply has been paid under an equivalent code on this Date Of Service(DOS). Once you register and have access to the provider portal, you will find a variety of video training available in the Resources section of the portal. 2. The Header and Detail Date(s) of Service conflict. 0001 01/01/1900 NOT USED - MEMBER'S DMAP I.D. Please submit future claims with the appropriate NPI, taxonomy and/or Zip +4 Code. Please adjust quantities on the previously submitted and paid claim. Pharmacuetical care limitation exceeded. Denied/cutback. Due To Miscellaneous Or Unspecified Reason, Adjustment/Resubmission was initiated by Provider, Adjustment/Resubmission was initiated by DHS, Adjustment/Resubmission was initiated by EDS, Adjustment Generated Due To Change In Patient Liability, Payout Processed Due To Disproportionate Share. Independent Laboratory Provider Number Required. The Request Has Been Approved To The Maximum Allowable Level. A Qualified Provider Application Is Being Mailed To You. Diagnosis V25.2 May Only Be Used When Billing For Sterilization Procedures. Wellcare uses cookies. Unable To Process Your Adjustment Request due to Member ID Number On The Claim And On The Adjustment Request Do Not Match.