Diagnosis Code indicated is not valid as a primary diagnosis. Hospice Member Services Related To The Terminal Illness Must Be Billed By Hospice Or Attending Physician. The changes in the brain that happen during a migraine cannot be seen by the imaging studies since a migraine is caused by a complicated interaction between the brain and the blood vessels in the face and head. Independent Nurses, Please Note Payable Services May Not Exceed 12 Hours/dayOr 60 Hours/week. A quantity dispensed is required. WellCare has established maximum frequency per day (MFD) values, which are the highest number of units eligible for reimbursement of services on a single date of service. The Medical Records Submitted With The Current Request Conflict Or Disagree With Our Medical Records On This Member. This Dental Service Limited To Once A Year. NCPDP Format Error Found On Medicare Drug Claim. Dental X-rays Indicate A Dental Cleaning, Followed By Good Dental Care At Home, Would Be Sufficient To Maintain Healthy Gums. Private Duty Nursing Beyond 30 Hrs /Member Calendar Year Requires Prior Authorization. This service is not payable for the same Date Of Service(DOS) as another service included on this claim. Please Bill Appropriate PDP. No Reimbursement Rates on file for the Date(s) of Service. Annual Nursing Home Member Oral Exam Is Allowed Once Per 355 Days Per Recip Per Prov. Diagnosis 635-635.92 May Only Be Used When Billing For Abortion Procedures. This National Drug Code Has Diagnosis Restrictions. A Payment Has Already Been Issued To A Different Nf. The header total billed amount is invalid. Medicare Part A Or B Charges Are Missing Or Incorrect. Invalid Provider Type To Claim Type/Electronic Transaction. Request Denied Because The Screen Was Done More Than 90 Days Prior To The Admission Date. As a provider, you have access to a portal that streamlines your work, keeps you up-to-date more than ever before and provides critical information. Payspan's Core Payment Network comes with a feature that allows payers to send members an electronic version of their Explanation of Benefits (eEOB). Member is enrolled in Medicare Part A and/or Part B on the on the Dispense Dateof Service. An ICD-9-CM Diagnosis Code of greater specificity must be used for the Second Diagnosis Code. Explanation . Phone: 800-723-4337. The detail From Date Of Service(DOS) is invalid. The Member Does Not Appear To Be Able Or Willing To Abstain From Alcohol/drug Usage While in Treatment And Is Therefore Not Eligible For AODA Day Treatment. Member first name does not match Member ID. Please Provide Copy Of Medicare Explanation Of Benefits/medicare Remittance Advice Attached To Claim. The To Date Of Service(DOS) for the First Occurrence Span Code is required. Please Correct And Resubmit. Claims With Dollar Amounts Greater Than 9 Digits. Pricing Adjustment/ Pharmacy pricing applied. To allow for Medicare Pricing correct detail denials and resubmit. Service(s) Denied. Medicare Disclaimer Code Used Inappropriately. Please Reference Payment Report Mailed Separately. 0001: Member's . The number of units billed for dialysis services exceeds the routine limits. Multiple Unloaded Trips For Same Day/same Recip. Was Unable To Process This Request. EDI TRANSACTION SET 837P X12 HEALTH CARE . Please Resubmit. The Maximum Prior Authorized Service Limitation Or Frequency Allowance Has Been Exceeded. Please Verify That Physician Has No DEA Number. Member is enrolled in Medicare Part D for the Dispense Date Of Service(DOS). Treatment With More Than One Drug Per Class Of Ulcer Treatment Drug At The Same Time Is Not Allowed Through Stat PA. Two Informational Modifiers Required When Billing This Procedure Code. Pricing Adjustment/ Resource Based Relative Value Scale (RBRVS) pricing applied. To Date Of Service(DOS) Precedes From Date Of Service(DOS). Level And/or Intensity Of Requested Service(s) Is Incompatible With Medical Need As Defined In Care Plan. All The Teeth Do Not Meet Generally Accepted Criteria Requiring Gingivectomy. Denied due to Discharge Diagnosis 1 Missing Or Invalid, Denied due to Diagnosis Pointer To Diagnosis Code 1 Invalid, Denied due to Diagnosis Pointer To Diagnosis Code 2 Invalid, Denied due to Diagnosis Pointer To Diagnosis Code 3 Invalid, Denied due to Diagnosis Pointer To Diagnosis Code 4 Invalid, Denied due to Diagnosis Pointer To Diagnosis Code 5 Invalid, Denied due to Diagnosis Pointer(s) Are Invalid. An ICD-9-CM Diagnosis Code of greater specificity must be used for the SeventhDiagnosis Code. A NAT Reimbursement Request Must Be Submitted To WI Within A Year Of The CNAs Hire Date. Denied. Member Expired Prior To Date Of Service(DOS) On Claim. Claim Detail Denied For Invalid CPT, Invalid CPT/modifier Combination, Or Invalid Type Of Quantity Billed. CPT is registered trademark of American Medical Association. Denied. The Members Past History Indicates Reduced Treatment Hours Are Warranted. Denied. Service Fails To Meet Program Requirements. PleaseResubmit Charges For Each Condition Code On A Separate Claim. Pharmacuetical care limitation exceeded. The Travel component for this service must be billed on the same claim as the associated service. Staywell is committed to continually improving its claims review and payment processes. This Member Is Receiving Concurrent AODA/Psychotherapy Services And Is Therefore Only Eligible For Maintenance Hours. Department of Health Services (DHS) Authorized Payment Is Being Withheld Due toa Final Rate Settlement. Do not leave blank fields between the multiple occurance codes. Denied. A Training Payment Has Already Been Issued To A Different NF For This CNA. Denied as duplicate claim. Please Correct And Resubmit. DX Of Aphakia Is Required For Payment Of This Service. Valid Numbers AreImportant For DUR Purposes. Early Refill Alert. Duplicate Item Of A Claim Being Processed. Service(s) exceeds four hour per day prolonged/critical care policy. The Diagnosis Does Not Indicate A Significant Change In the Members Condition. Prior Authorization Is Required For Payment Of This Service With This Modifier. This Claim Is A Reissue of a Previous Claim. This Payment Is To Satisfy Amount Owed For A Drug Rebate Prior Quarter Correction. Reimbursement rate is not on file for members level of care. Result of Service submitted indicates the prescription was filled witha different quantity. 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. The Value Code(s) submitted require a revenue and HCPCS Code. Denied/Cuback. Unable To Process Your Adjustment Request due to Claim ICN Not Found. Please Supply The Appropriate Modifier. Less Expensive Alternative Services Are Available For This Member. Research Has Determined That The Member Does Not Qualify For Retroactive Eligibility According To Hfs 106.03(3)(b) Of The Wisconsin Administrative Code. This Claim HasBeen Manually Priced Using The Medicare Coinsurance, Deductible, And Psyche RedUction Amounts As Basis For Reimbursement. Paid In Accordance With Dental Policy Guide Determined By DHS. View the Part C EOB materials in the Downloads section below. One or more Occurrence Code Date(s) is invalid in positions nine through 24. Denied. Invalid modifier removed from primary procedure code billed. The sum of the Medicare paid, deductible(s), coinsurance, copayment and psychiatric reduction amounts does not equal the Medicare allowed amount. wellcare eob explanation codes. Reimbursement For This Service Has Been Approved. Please Indicate Computation For Unloaded Mileage. Auditory Screening with Preventive Medicine Visits. Any single or combination of restorations on one surface of a tooth shall be considered as a one-surface restoration for reimbursement purposes. 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. If you are still unable to resolve the login problem, read the troubleshooting steps or report your issue. Please submit claim to BadgerRX Gold. Patient Status Code is incorrect for Long Term Care claims. Discharge Date is before the Admission Date. Service Denied. The Surgical Procedure Code is not payable for the Date Of Service(DOS). Referring Provider ID is not required for this service. Laboratory Is Not Certified To Perform The Procedure Billed. 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. Either The Date Was Not In MM/DD/CCYY Format Or Its AFuture Date. LTC hospital bedhold quantity must be equal to or less than occurrence code 75span date range(s). EOB Code: EOB Description: 0000: This claim/service is pending for program review. Health (3 days ago) Webwellcare explanation of payment codes and comments. Pharmaceutical care indicates the prescription was not filled. Medicare Deductible Is Paid In Full. The Reimbursement Code Assigned To This Certification Segment Does Not Authorize a NAT Payment. The Medical Need For Some Requested Services Is Not Supported By Documentation. 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. If You Have Already Obtained SSOP, Please Disregard This Message. Pricing Adjustment/ Traditional dispensing fee applied. TPA Certification Required For Reimbursement For This Procedure. Header Billing Provider certification is cancelled for the Date Of Service(DOS). The Automated Voice Response System is encouraged to obtain claims status using a touch-tone phone. Reason Code 234 | Remark Codes N20. You can choose to receive only your EOBs online, eliminating the paper . Members Aged 3 Through 21 Years Old Are Limited To One Healthcheck Screening per 12 months. Day Treatment exceeding 120 hours per month is not payable regardless of PriorAuthorzation. Please Contact Your District Nurse To Have This Corrected. This Member Has Prior Authorization For Therapy Services. Wellcare uses cookies. Reimbursement for this procedure and a related procedure is limited to once per Date Of Service(DOS). A National Provider Identifier (NPI) is required for the Billing Provider. Claim Denied For Invalid Billing Type Frequency Code, Claim Type, Or SubmittedAdjustment Provider Number Does Not Match Original Claims Provider Number. Reason Code: 234. Goals Are Not Realistic To The Members Way Of Life Or Home Situation, And Serve No Functional Or Maintenance Service. Adjustment Denied For Insufficient Information. Members do not have to wait for the post office to deliver their EOB in a paper format. Edentulous Alveoloplasty Requires Prior Authotization. Please Resubmit Using Newborns Name And Number. Start: 01/01/2000 | Last Modified: 03/06/2012 Notes: (Modified 2/28/03, 3/6/2012) N5: More Than 5 Consecutive Calendar Days Of Continuous Care Are Not Payable. Member is covered by a commercial health insurance on the Date(s) of Service. Prescribing Provider UPIN Or Provider Number Missing. All Home Health Services Exceeding 8 Hours Per Day Or 40 Or More Hours Per Week Require Prior Authorization. Lenses Only Are Approved; Please Dispense A Contracted Frame. Member is assigned to a Hospice provider. All services should be coordinated with the primary provider. The Dispense As Written (Daw) Indicator Is Not Allowed For The National Drug Code. Denied due to Diagnosis Not Allowable For Claim Type. Members age does not fall within the approved age range. According To Our Records, The Surgeon For This Sterilization Procedure Has NotSubmitted The Members Consent Form. Good Faith Claim Denied For Timely Filing. The To Date Of Service(DOS) for the Second Occurrence Span Code is invalid. Payment has been reduced or denied because the maximum allowance of this ESRD service has been reached. Denied. Inpatient psychiatric services are not reimbursable for members age 21 65 (age 22 if receiving services prior to 21st birthday). Only Four Dates Of Service Are Allowed Per Line Item (detail) For Each Procedure. Pricing Adjustment/ Long Term Care pricing applied. CO/204. Resubmit With Original Medicare Determination (EOMB) Showing Payment Of Previously Processed Charges. Unable To Process This Request Due To Either Missing, Invalid OrMismatched National Provider Identifier # (NPI)/Provider Name/POP ID. Pricing Adjustment/ Provider Level of Care (LOC) pricing applied. Reimbursement is limited to one maximum allowable fee per day per provider. Claim Denied For Invalid Diagnosis Code Or Diagnosis Code/CPT Combination. Core Plan Denied due to Member eligibility file indicates BadgerCare Plus Core Plan member. Denied due to Provider Number Missing Or Invalid. The Service Requested Was Performed Less Than 5 Years Ago. This Is Not A Preadmission Screen And Is Not Reimbursable. Only One Panoramic Film Or Intraoral Radiograph Series, By The Same Provider, Per Year Allowed. Please Review The Covered Services Appendices Of The Dental Handbook. Principal Diagnosis 7 Not Applicable To Members Sex. A New Prior Authorization Number Has Been Assigned To This Request In Order ToProcess. Assistant Surgery Must Be Billed Separately By The Assistant Surgeon With Modifier 80. The Insurance EOB Does Not Correspond To The Dates Of Service/servicesBeing Billed. Denied. This Service Is Included In The Hospital Ancillary Reimbursement. Rqst For An Acute Episode Is Denied. Department of Health Services (DHS) Authorized Payment Is Being Withheld Due toan Interim Rate Settlement. NCTracks AVRS. Claim Corrected. Second And Subsequent Cerebral Evoked Response Tests Paid At A Reduced Rate Per Guidelines. The Related Surgical Procedure is not a covered service under Wisconsin Medicaid or BadgerCare Plus. Performed After Therapy/dayTreatment Have Begun Must Be Billed As Therapy Or Limit-exceed Psych/aoda/func. The From Date Of Service(DOS) for the First Occurrence Span Code is required. Claim Explanation Codes. ACTION DESCRIPTION: ACTION TYPE. Definitions and text of all the Claim Adjustment Reason Codes and the Remittance Advice Remark Codes used on the claim will be printed on the last page of the RA. Documentation Does Not Justify Reconsideration For Payment. Wis Adm Code 106.04(3)(b) Requires Providers To Reimburse The Person/party (eg, County) That Previously. Reconsideration With Documentation Warranting More X-rays. Billed amount exceeds prior authorized amount. Verify billed amount and quantity billed. Denied. The Service Requested Is Covered By The HMO. Condition code 80 is present without condition code 74. Denied due to Greater Than Four Dates Of Service Billed On One Detail. Valid Numbers Are Important For DUR Purposes. This claim has been adjusted due to Medicare Part D coverage. Member does not have commercial insurance for the Date(s) of Service. Procedure Code is allowed once per member per lifetime. 51.42 Board Directors Or Designees Statement & Signature Required OnThe Claim Form For Payment Of Functional Assessment.