Please Correct And Resubmit. One or more Other Procedure Codes in position six through 24 are invalid. Pricing AdjustmentUB92 Hospice LTC Pricing. MassHealth List of EOB Codes Appearing on the Remittance Advice. The procedure code has Family Planning restrictions. This service is not covered under the ESRD benefit. Occurrence Code is required when an Occurrence Date is present. This Procedure Is Limited To Once Per Day. The Tooth Is Not Essential For Support Of A Partial Denture. Member is enrolled in a commercial health insurance on the Dispense Date Of Service(DOS). 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. Separate reimbursement for drugs included in the composite rate is not allowed. Amount Paid By Other Insurance Exceeds Amount Allowed By . FFS CLAIM PROFESSIONAL ASC X12N VERSION . Please note that the submission of medical records is not a guarantee of payment. This Diagnosis Code Has Encounter Indicator restrictions. An ICD-9-CM Diagnosis Code of greater specificity must be used for the First Diagnosis Code. Submit copy of the dated and signed evaluation and indicate if this is an initial Evaluation. These are EOB codes, revised for NewMMIS, that may appear on your PDF remittance advice. NDC- National Drug Code billed is not appropriate for members gender. This Adjustment Was Initiated By . Services not allowed for your Provider Type or for your Provider Type without a TB diagnosis. Occupational therapy limited to 35 treatment days per lifetime without prior authorization. Service Allowed Once Per Lifetime, Per Tooth. Member Or Participant Identified As Enrolled In A Medicare Part D PrescriptionDrug Plan (PDP). Claims may deny for the initial inpatient admission E&M if a provider from the same provider group and same specialty bills any other inpatient E&M visit, i.e. This Member Has Already Received Intensive Day Treatment In The Past Year and is Only Eligible For Reduced Hours At This Time. First Other Surgical Code Date is required. Non-preferred Drug Is Being Dispensed. The Tooth Is Not Essential To Maintain An Adequate Occlusion. Revenue code submitted is no longer valid. Part C Explanation of Benefits (EOB) Materials. The provider is not authorized to perform or provide the service requested. Continue ToUse Appropriate Codes On Billing Claim(s). These same rules are used by most healthcare claims payers and enforced by the Centers for Medicare and Medicaid Services. Medicaid Remittance Advice Remark Code:M86 MMIS EOB Code:100. 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. The header total billed amount is invalid. Header Bill Date is before the Header From Date Of Service(DOS). Speech Therapy Is Not Warranted. RN And LPN Subsequent Care Visits Limited To 6 Hrs Per Day/per Member/per Provider. A valid procedure code is required on WWWP institutional claims. is unable to is process this claim at this time. Copyright 2023 Wellcare Health Plans, Inc. New Coding Integrity Reimbursement Guidelines. These case coordination services exceed the limit. Maximum Number Of Outreach Refusals Has Been Reached For This Period. Please Furnish An ICD-9 Surgical Code And Corresponding Description. A HCPCS code is required when condition code A6 is included on the claim. Service billed is bundled with another service and cannot be reimbursed separately. Initial Visit/Exam limited to once per lifetime per provider. The provider enters the appropriate revenue codes to identify specific accommodation and/or ancillary charges. Questionable Long-term Prognosis Due To Decay History. The Maximum Allowable Was Previously Approved/authorized. Other Therapies Currently Provide Sufficient Services To Meet The Members Needs. Principal Diagnosis 6 Not Applicable To Members Sex. Non-scheduled drugs are limited to the original dispensing plus 11 refills or 12 months. Please verify billing. Total billed amount is less than the sum of the detail billed amounts. The Maximum limitation for dosages of EPO is 500,000 UIs (value code 68) per month and the maximum limitation for dosages of ARANESP is 1500 MCG (1 unit=1 MCG) per month. Prescribing Provider UPIN Or Provider Number Missing From Claim And Attachment. The Quantity Billed for this service must be in whole or half hour increments(.5) Increments. Denied due to Member Is Eligible For Medicare. Reimbursement Is Limited To The Average Monthly Nursing Home Cost And Services Above That Amount Are Considered Non-covered Services. Denied. Reference: Transmittal 477, change request 3720 issued February 18, 2005. Members Age 3 And Older Must Have An Oral Assessment And Blood Pressure Check.With Appropriate Referral Codes, For Payment Of A Screening. The Pharmaceutical Care Code (PCC) does not have a rate on file for the Date Of Service(DOS). The Documentation Submitted Does Not Substantiate Additional Care. This National Drug Code (NDC) requires a whole number for the Quantity Billed. Duplicate Item Of A Claim Being Processed. When coding HCPCS for outpatient services, the provider enters the HCPCS code describing the procedure. This Member Is Receiving Concurrent AODA/Psychotherapy Services And Is Therefore Only Eligible For Maintenance Hours. The Medical Necessity For Psychotherapy Services Has Not Been Documented, ThusMaking This Member Ineligible For The Requested Service. Service(s) paid at the maximum daily amount per provider per member. Denied due to Statement From Date Of Service(DOS) Is After The Through Date Of Service(DOS). Service Denied. The Member Has At Least 4 Posterior Teeth, Including Bicuspids On Each Side, which Can Be Used For Chewing. Members do not have to wait for the post office to deliver their EOB in a paper format. The Member Has Shown No Ability Within 6 Months To Carry Over Abilities GainedFrom Treatment In A Facility To The Members Place Of Residence. Prior Authorization is needed for additional services. This diabetic supply has been paid under an equivalent code on this Date Of Service(DOS). Denied. Pricing Adjustment/ Inpatient Per-Diem pricing. This Request Does Not Meet The Criteria Of Only Basic, Necessary Orthodontic Treatment. Physical Therapy Treatment Limited To One Modality, One Procedure, One Evaluation Or One Combination Per Day. Denied. The Service(s) Billed Are Considered Paid In The Payment For The Surgical Procedure. EOB Codes List|Explanation of Benefit Reason Codes (2023) February 7, 2022 by medicalbillingrcm. Only One Panoramic Film Or Intraoral Radiograph Series, By The Same Provider, Per Year Allowed. Purchase Only Allowed; Medical Need For Rental Has Not Been Documented. Ancillary Billing Not Authorized By State. Denied. Rebill Using Correct Claim Form As Instructed In Your Handbook. Diagnosis Treatment Indicator is invalid. Please Contact The Surgeon Prior To Resubmitting this Claim. Transplant services not payable without a transplant aquisition revenue code. This Revenue Code has Encounter Indicator restrictions. Default Prescribing Physician Number XX5555555 Was Indicated. Refer To Notice From DHS. This claim is eligible for electronic submission. Inicio Quines somos? Denied. 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. Do not leave blank fields between the multiple occurance codes. The dental procedure code and tooth number combination is allowed only once per lifetime. Pharmaceutical care code must be billed with a valid Level of Effort. 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. The Billing Providers taxonomy code is missing. An ICD-9-CM Diagnosis Code of greater specificity must be used for the SeventhDiagnosis Code. Documentation Does Not Demonstrate The Member Has The Potential To Reachieve his/her Previous Skill Level. Pricing Adjustment/ Payment reduced due to the inpatient or outpatient deductible. OA 14 The date of birth follows the date of service. CORE Plan Members are limited to 25 non-emergency outpatient hospital visits per enrollment year. Claims may be denied if an advanced imaging procedure is billed with a diagnosis of syncope and there is no history of a 12-lead EKG being performed/billed the same date or in the previous 90 days. Indicated Diagnosis Is Not Applicable To Members Sex. A split claim is required when the service dates on your claim overlaps your Federal fiscal year end (FYE) date. Multiple Unloaded Trips For Same Day/same Recip. Submitted rendering provider NPI in the header is invalid. Denied due to Claim Contains Future Dates Of Service. . Pricing Adjustment/ Level of effort dispensing fee applied. One or more Occurrence Code(s) is invalid in positions nine through 24. Pharmaceutical Care Code must be billed with a payable drug detail or if a prescription was not filled, the quantity dispensed must be zero. 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. Therefore itIs Not Necessary To Wait The Full 6 Weeks After Extractions Before Taking Denture Impressions. Valid group codes for use on Medicare remittance advice are:. Received Beyond Special Filing Deadline For ThisType Of Claim Or Adjustment/reconsideration. Unable To Process Your Adjustment Request due to The Claim Type Of The Adjustment Does Not Match The Claim Type Of The Original Claim. Detail To Date Of Service(DOS) is required. 2. Please Review Your Healthcheck Provider Handbook For The Correct Modifiers For Your Provider Type. A Pharmaceutical Care Code (PCC) must include a valid diagnosis code. First modifier code is invalid for Date Of Service(DOS). Header To Date Of Service(DOS) is required. Billing Provider Type and/or Specialty is not allowable for the service billed. "Laterality" (side of the body affected) is a coding convention added to relevant ICD-10 codes to increase specificity. Member Name Missing. CNAs Eligibility For Training Reimbursement Has Expired. This Procedure Code Is Not Valid In The Pharmacy Pos System. The Revenue Code is not payable by Wisconsin Well Woman Program 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). An ICD-9-CM Diagnosis Code of greater specificity must be used for the Eighth Diagnosis Code. Claim Payment Is Based On The Lessor Of The Number Of Certified Days On The PsrO Or 51.42 Board Stamp Or Admitting Calendar Month Days In Specialty Hospital. Pricing Adjustment/ Pharmacy dispensing fee applied. A New Prior Authorization Number Has Been Assigned To This Request In Order ToProcess. Please Verify The Units And Dollars Billed. Proposed Orthodontic Service Denied; Examination/study Models Are Approved. Service(s) exceeds four hour per day prolonged/critical care policy. Restorative Nursing Involvement Should Be Increased. Request For Training Reimbursement Denied. Payment Subject To Pharmacy Consultant Review. Services Can Only Be Authorized Through One Year From The Prescription Date. Hearing Aid Batteries Are Limited To 12 Monaural/24 Binaural Batteries Per 30-day Period, Per Provider, Per Hearing Aid. Service not allowed, benefits exhausted occurrence code billed. Other payer patient responsibility grouping submitted incorrectly. The Rendering Providers taxonomy code is missing in the header. Pricing Adjustment/ Medicare pricing cutbacks applied. The Member Is Also Involved In A Structured Living And/or Working Arrangement.A Reduction In Day Treatment Hours Is Indicated. Missing Or Invalid Level Of Effort And/or Reason For Service Code, Professional Service Code, Result Of Service Code Billed In Error. Claim reimbursement has been cutback to reimbursement limits for denture repairs performed within 6 months. Multiple Prescriptions For Same Drug/ Same Fill Date, Not Allowed. You can choose to receive only your EOBs online, eliminating the paper . Panel And Individual Test Not Payable For Same Member/Provider/ Date Of Service(DOS). Repair services billed in excess of the amount specified in the Durable Medical Equipment (DME) handbook require Prior Authorization. Service paid in accordance with program requirements. No Substitution Indicator Invalid For Non-innovator Drugs Not On The Current Wisconsin MAC List. This Procedure, When Billed With Modifier HK, Is Payable Only If The Member Is Under The Age Of 19. Please Disregard Additional Messages For This Claim. Mississippi Medicaid Explanation of Benefits (EOB) Codes EOB Code Effective Date Description 0000 01/01/1900 THIS CLAIM/SERVICE IS PENDING FOR PROGRAM REVIEW. Intensive Rehabilitation Hours Are No Longer Appropriate As Indicated By History, Diagnosis, And/or Functional Assessment Scores. Claim Reduced Due To Member/participant Spenddown. Payment Recovered For Claim Previously Processed Under Wrong Member ID Number. Header From Date Of Service(DOS) is after the date of receipt of the claim. Questionable Long-term Prognosis Due To Apparent Root Infection. Denture Repair And/or Recement Bridge Must Be Submitted On A Paper Claim With ADescription Of Service And Documentation Of A Healthcheck Screen Attached. DN017 Medicare EOB Denials BH N/A 10/15/2017 9/26/2017 6815, 321095 CE034 99213 99214 in Place of Service 52 Permanent Tooth Restoration/sealant, Limited To Once Every 3 Years Unless Narrative Documents Medical Necessity. Resubmit charges for covered service(s) denied by Medicare on a claim. Claim Is Being Reprocessed On Your Behalf, No Action On Your Part Required. This notice gives you a summary of your prescription drug claims and costs. Denial Codes. The From Date Of Service(DOS) for the First Occurrence Span Code is required. The member is locked-in to a pharmacy provider or enrolled in hospice. They are used to provide information about the current status of . 1. Rendering Provider Type and/or Specialty is not allowable for the service billed. Time Spent In AODA Day Treatment By Affected Family Members Is Not Covered. 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. Please Indicate The Dollar Amount Requested For The Service(s) Requested. Denied. A National Provider Identifier (NPI) is required for the Performing Provider listed in the header. TPA Certification Required For Reimbursement For This Procedure. Charges Paid At Reduced Rate Based Upon Your Usual And Customary Pricing Profile. Strong knowledge of adjustment and denial reason codes from Electronic Remittance Advices (ERA/835 files) and from paper Explanation of benefits (EOB's) / Explanation of payments (EOP's), CPT . Claim or Adjustment received beyond 365-day filing deadline. The service is not reimbursable for the members benefit plan. Designated codes for conditions such as fractures, burns, ulcers and certain neoplasms require documentation of the side/region of the body where the condition occurs. Service(s) Billed Are Included In The Total Obstetrical Care Fee. Additional Reimbursement Is Denied. Claim Denied Due To Incorrect Accommodation. Diagnosis Code is restricted by member age. Claim Is Being Reprocessed Through The System. This HMO Capitation Payment Is Being Recouped It Was Inappropriately Paid During The Inital February HMO Capitation Cycle. Diag Restriction On ICD9 Coverage Rule edit. The Screen Date Is Either Missing Or Invalid. Authorizations. This revenue code requires value code 68 to be present on the claim. The National Drug Code (NDC) was reimbursed at a generic rate. The Ninth Diagnosis Code (dx) is invalid. Please submit claim to HIRSP or BadgerRX Gold. Denied due to Provider Signature Is Missing. Denied. Backdating Allowed Only In Cases Of Retroactive Member/provider Eligibility. Rendering Provider is not a certified provider for . Service is covered only during the first month of enrollment in the Home and Community Based Waiver. Was Unable To Process This Request. If you are having difficulties registering please . Rqst For An Acute Episode Is Denied. Denied due to Some Charges Billed Are Non-covered. Prescriber must contact the Drug Authorization and Policy Override Center for policy override. Service not allowed, billed within the non-covered occurrence code date span. Procedure Code or Drug Code not a benefit on Date Of Service(DOS). Denied/Cutback. 0300-0319 (Laboratory/Pathology). Claim Paid In Accordance With Family Planning Contraceptive Services Guidelines. One or more Diagnosis Codes has a gender restriction. Reimbursement Rate Applied To Allowed Amount. Pricing Adjustment/ Prescription reduction applied. Basic Knowledge of Explanation of Benefits (EOB) interpretation. and other medical information at your current address. Pricing Adjustment/ Medicare crossover claim cutback applied. The Comprehensive Community Support Program reimbursement limitations have been exceeded. . Normal delivery reimbursement includes anesthesia services. We have redesigned our website to help you find the information you need more easily. The Surgical Procedure Code is restricted. Home care ongoing assessments are allowed once every sixty days per member.nt, But Arepayable Every Fifty-fourth Day For Flexibility In Scheduling. All services should be coordinated with the primary provider.