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. The Members Gait Is Not Functional And Cannot Be Carried Over To Nursing. In general, the more complex the visit, the higher the E&M level of code you may bill within the appropriate category. Please Furnish An ICD-9 Surgical Code And Corresponding Description. This Incidental/integral Procedure Code Remains Denied. OA 11 The diagnosis is inconsistent with the procedure. Services are not payable. Service Denied. Please Do Not File A Duplicate Claim. Channel: Medicare covered Codes Explanation Viewing all 30 articles Browse latest View live Explanation of Benefit. Services Requested Do Not Meet The Criteria for an Acute Episode. HTTP Status Code Connect Time (ms) Result; 2023-03-01 04:10:52: 200: 255: Page Active: Nine Digit DEA Number Is Missing Or Incorrect. Prescription Drug Plan (PDP) payment/denial information required on the claim to WCDP. Member is enrolled in Medicare Part D for the Dispense Date Of Service(DOS). Comprehension And Language Production Are Age-appropriate. FACIAL. One or more Diagnosis Code(s) is not payable by Wisconsin Chronic Disease Program for the Date Of Service(DOS). An ICD-9-CM Diagnosis Code of greater specificity must be used for the Eighth Diagnosis Code. Rimless Mountings Are Not Allowable Through . Claim Currently Being Processed. Auditory Screening with Preventive Medicine Visits. 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. Explanation of Benefit Codes (EOBs) Mar 14, 2022 1 EOB EOB DESCRIPTION. 51.42 Board Stamp Required On All Outpatient Specialty Hospital Claims For Dates Of Service On Or After January 1, 1986. Please watch for periodic updates. For more information on which codes are considered "Mutually Exclusive", see the "ICD-10 2019 The Complete Official Codebook. If The Proc Code Does Not Require A Modifier, Please Remove The Modifier. Details Include Revenue/surgical/HCPCS/CPT Codes. The Procedure Requested Is Not Appropriate To The Members Sex. Denied. Reimbursement rate is not on file for members level of care. Service Denied A Physician Statement (including Physical Condition/diagnosis) Must Be Affixed To Claims For Abortion Services Refer To Physician Handbook. Compound Drug Service Denied. Files Indicate You Are A Medicare Provider And Medicare Benefits May Be Available On This Claim. Members Age 3 And Older Must Have An Oral Assessment And Blood Pressure Check.With Appropriate Referral Codes, For Payment Of A Screening. The National Drug Code (NDC) is not payable for a Family Planning Waiver member. The Reimbursement Code Assigned To This Certification Segment Does Not Authorize a Training Payment. Procedure Code and modifiers billed must match approved PA. The Billing Providers taxonomy code in the header is invalid. Unable To Reach Provider To Correct Claim. Wis Adm Code 106.04(3)(b) Requires Providers To Reimburse The Person/party (eg, County) That Previously. This Payment Is To Satisfy The Amount Owed For OBRA Level 1. Pricing Adjustment/ Medicare crossover claim cutback applied. Urinalysis And X-rays Are Reimbursed Only When Performed In Conjunction With An Initial Office Visit On Same Date Of Service(DOS). The Travel component for this service must be billed on the same claim as the associated service. The Surgical Procedure Code has Diagnosis restrictions. Do Not Submit Claims With Zero Or Negative Net Billed. Description. Procedure Code 59420 Must Be Used For 5 Or More Prenatal Visits With One Charge. Please Request Prior Authorization For Additional Days. Rendering Provider Type and/or Specialty is not allowable for the service billed. Provider Reminders: Claims Definitions. Quantity Billed is not equally divisible by the number of Dates of Service on the detail. If laboratory costs exceed reimbursement, submit a claim adjustment request with lab bills for reconsideration. CO/204/N182 . The Sixth Diagnosis Code (dx) is invalid. Prior Authorization is required for service(s) exceeding mental health and/or substance abuse benefit guidelines. Six hour limitation on evaluation/assessment services in a 2 year period has been exceeded. Has Processed This Claim With A Medicare Part D Attestation Form. Critical care in non-air ambulance is not covered. Reduction To Maintenance Hours. This Member, As Indicated By Narrative History, Does Not Agree To Abstinence from Alcohol Or Other Drugs And Is Ineligible For AODA Treatment. All Requests Must Have A 9 Digit Social Security Number. Prior Authorization (PA) is required for payment of this service. Please Bill Appropriate PDP. An Individual CBC Or Chemistry Test With A CBC Or Chemistry Panel, Performed Per Member/Provider/Date Of Service Must Be Billed w/ Appropriate Panel Code. A Fourth Occurrence Code Date is required. Claim Detail Denied As Duplicate. Ninth Diagnosis Code (dx) is not on file. This Adjustment Was Initiated By . 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). A Version Of Software (PES) Was In Error. 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. Claim Or Adjustment/reconsideration Request Should Include An Operative Or Pathology Report For This Procedure. Training Completion Date Must Be Within A Year Of The CNAs Certification, Test, Date. 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. Service is covered only during the first month of enrollment in the Home and Community Based Waiver. Remark Codes: N20. Provider Is Not A Qualified Provider For presumptively Eligible Recipients. One or more To Date(s) of Service is invalid for Occurrence Span Codes in positions three through 24. Next step verify the application to see any authorization number available or not for the services rendered. . Second modifier code is invalid for Date Of Service(DOS) (DOS). Referral Codes Must Be Indicated For W7001, W7002, W7003, W7006, W7008 And W7013. Units Billed Are Inconsistent With The Billed Amount. Intensive Multiple Modality Treatment Is Not Consistent With The Information Provided. An ICD-9-CM Diagnosis Code of greater specificity must be used for the Ninth Diagnosis Code. Revenue code submitted is no longer valid. A Second Occurrence Code Date is required. This member is eligible for Medication Therapy Management services. Eighth Diagnosis Code (dx) is not on file. Superior HealthPlan News. Denied. Subsequent Aide Visits Limited To 7 Hrs Per Day/per Member/per Provider. Resubmit Using Valid Rn/lpn Procedure Codes And A Valid PA Number. WI Can Not Issue A NAT Payment Without A Valid Hire Date. Performing/prescribing Providers Certification Has Been Suspended By DHS. Claim Detail Denied. Service Denied. Unable To Process Your Adjustment Request due to Provider Not Found. Timely Filing Deadline Exceeded. Timely Filing Deadline Exceeded. The first occurrence span from Date Of Service(DOS) is after the to Date Of Service(DOS). Services Billed Denied As Being Covered In The Payment For Day Rx Per Medical Day Treatment Guidelines. Claim Detail Is Pended For 60 Days. The Tooth Is Not Essential For Support Of A Partial Denture. Member enrolled in Medicare Part D for the Dispense Date Of Service(DOS). Invalid Procedure Code For Dx Indicated. 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. External Cause Diagnosis May Not Be The Single Or Primary Diagnosis. The Surgical Procedure Code is not payable for /BadgerCare Plus for the Date Of Service(DOS). 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. For RHCs, place of service is 72, however, you can bill lab services with a place of service 11. Prospective DUR denial on original claim can not be overridden. Competency Test Date Is Not A Valid Date. Fourth Diagnosis Code (dx) is not on file. Surgical Procedure Code billed is not appropriate for members gender. Claim Paid Under DRG Reimbursement, Except For Transplants Billed Using Suffixes 05 Through 09. This Claim Cannot Be Processed. Department of Health Services (DHS) Authorized Payment Is Being Withheld Due toan Interim Rate Settlement. This Adjustment/reconsideration Request Was Initiated By . Pharmacuetical care limitation exceeded. 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. Please verify billing. Valid group codes for use on Medicare remittance advice are:. Pricing Adjustment/ Payment reduced due to the inpatient or outpatient deductible. No Extractions Performed. The dental procedure code and tooth number combination is allowed only once per lifetime. Seventh Occurrence Code Date is required. Gastrointestinal Surgery For The Purpose Of Weight Control Is Covered Only As An Emergency Procedure. Please show the appropriate multichanel HCPCS code rather than the individual HCPCS code. This Member Is Involved In Intensive Day Treatment, Which Is To Include Psychotherapy Services. The Services Requested Are Not Reasonable Or Appropriate For The AODA-affectedmember. This Individual Is Either Not On The Registry Or The SSN On The Request D oesnt Match The SSN Thats Been Inputted On The Registry. 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. Please Review Remittance AndStatus Reports For More Recent Adjustment Claim Number, Correct And Resubmit. Additional Encounter Service(s) Denied. Multiple Tooth Extract On Same Date Of Service(DOS) Must Be Billed As Single And Additional Tooth Extract In Same Quadrant. If Required Information Is Not Received Within 60 Days,the claim will be denied. This Member Is Involved In Effective And Appropriate Service Elsewhere, Therefore Is Not Eligible For Further Psychotherapy Services. Service Denied. 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. Type of Bill is invalid for the claim type. Please Correct And Submit. Denied/Cutback. Drug(s) Billed Are Not Refillable. Requested Documentation Has Not Been Submitted. Condition Code is missing/invalid or incorrect for the Revenue Code submitted. Pricing Adjustment/ The submitted charge exceeds the allowed charge. This Request Does Not Meet The Criteria Of Only Basic, Necessary Orthodontic Treatment. Denied/Cutback. Rendering Provider is not a certified provider for Wisconsin Chronic Disease Program. This Claim Is Being Returned. Pricing Adjustment. Also, to ensure claims process and pay accurately, Staywell may deny a claim and ask for pertinent medical documentation from the provider or supplier who submitted the claim. The Materials/services Requested Are Principally Cosmetic In Nature. Note: This PA Request Has Been Backdated A Maximum Of 3 Weeks Prior To Its First Receipt By EDS, Based Upon Difficulty In Obtaining The Physicians Written Prescription. The From Date Of Service(DOS) for the First Occurrence Span Code is invalid. We Are Recouping The Payment. Providers must ensure that the E&M CPT codes selected reflect the services furnished. The Rendering Providers taxonomy code in the detail is not valid. Up to a $1.10 reduction has been applied to this claim payment. Take care to review your EOB to ensure you understand recent charges and they all are accurate. Comprehensive Screens And Individual Components Are Not Payable On The Same Date Of Service(DOS). One or more Surgical Code Date(s) is missing in positions seven through 24. Please Correct And Resubmit. Claim Denied. The Surgical Procedure Code of greatest specificity must be used. As a result, providers experience more continuity and claim denials are easier to understand. This limitation may only exceeded for x-rays when an emergency is indicated. Correct And Resubmit. Total Rental Payments For This Item Have Exceeded The Maximum Allowable Forthe Purchase Of This Item. 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. One or more From Date Of Service(DOS) (DOS) is invalid for Occurrence Span Codes in positions three through 24. Quantity indicated for this service exceeds the maximum quantity limit established by the National Correct Coding Initiative. Assessment limit per calendar year has been exceeded. Other Insurance Or Medicare Response Not Received Within 120 Days For ProviderBased Bill. Original Payment/denial Processed Correctly. Duplicate ingredient billed on same compound claim. Rendering Provider is not certified for the From Date Of Service(DOS). Do Not Bill Intraoral Complete Series Components Separately. Denied. This Member Is Receiving Concurrent AODA/Psychotherapy Services And Is Therefore Only Eligible For Maintenance Hours. The National Drug Code (NDC) submitted with this HCPCS code is CMS terminated or not covered by the program. 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. Provider Must Have A CLIA Number To Bill Laboratory Procedures. Reimbursement also may be subject to the application of The Revenue Code is not reimbursable for the Date Of Service(DOS). Services Included In The Inpatient Hospital Rate Are Not Separately Reimbursable. Effective 1/1: Electronic Prescribing of Controlled Substances Required. Resubmit Claim With Copyof A Temporary ID Card, EVS Printed Response Or Indicate The AVR Transaction Log Number. Denied due to Diagnosis Code Is Not Allowable. Please Resubmit A New Adjustment/reconsideration Request Form And Indicate TheMost Recent Cclaim Number Where Payment Was Made Or Allowed. This Service Is Not Payable Without A Modifier/referral Code. Procedure Code billed is not appropriate for members gender. CORE Plan Members are limited to 25 non-emergency outpatient hospital visits per enrollment year. Dates Of Service Must Be Itemized. A National Provider Identifier (NPI) is required for the Performing Provider listed in the header. 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. You can choose to receive only your EOBs online, eliminating the paper . Services Cutback/denied, Charges Greater Than Patient Liability, Not Responsible For Noncovered Services In Excess Of Patient Liability. Medicaid id number does not match patient name. Denied. Multiple Referral Charges To Same Provider Not Payble. Multiple Screens Performed Within A Fifteen Day Time Frame For This SSN. Prescriber ID is invalid.e. Please Reference Payment Report Mailed Separately. Procedure Denied Per DHS Medical Consultant Review. Adjustment To Crossover Paid Prior To Aim Implementation Date. Pricing Adjustment/ Anesthesia pricing applied. 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. A Google Certified Publishing Partner. Please Indicate Computation For Unloaded Mileage. This service is not payable for the same Date Of Service(DOS) as another service included on this claim. Denied. Correction Made Per Medical Consultant Review. Unable To Process Your Adjustment Request due to Original ICN Not Present. Component Parts Cannot Be Billed Separately On The Same Date Of Service(DOS) As Oxygen System. The Primary Diagnosis Code is inappropriate for the Procedure Code. The Member Appears To Be At A Maximum Level For Age, Diagnosis, And Living Arrangement. Your Adjustment/reconsideration Request For Additional Payment Has Been Denied, Request Was Received Beyond The 90 Day Requirement For Payment Reconsideration. Provider signature and/or date is required. Claim Denied For Invalid Diagnosis Code Or Diagnosis Code/CPT Combination. Claim Is Being Reprocessed Through The System. Emergency Services Indicator must be "Y" or Pregnancy Indicator must be "Y" for this aid code. Please Indicate The Dollar Amount Requested For The Service(s) Requested. This service is not payable with another service on the same Date Of Service(DOS) due to National Correct Coding Initiative.