Detail From Date Of Service(DOS) is after the ICN Date. Amount Recouped For Duplicate Payment on a Previous Claim. The following table outlines the new coding guidelines. WellCare Known Issues List Please be advised: Claims that have either rejected or denied . The Member Has Shown No Ability Within 6 Months To Carry Over Abilities GainedFrom Treatment In A Facility To The Members Place Of Residence. Reimb Is Limited To The Average Montly NH Cost And Services Above that Amount Are Considered non-Covered Services. Reimbursement For This Certification, Test, Segment Has Been Issued To AnotherNF. Services Included In The Inpatient Hospital Rate Are Not Separately Reimbursable. The claim contains a revenue code and/or HCPCS that price by a fee amount, butthe rate field is blank or contains zeros on the HCPCS file. The Rendering Providers taxonomy code is missing in the header. Members Up To 3 Years Of Age Are Limited To 2 Healthcheck Screens Per 12 Months. Denied. If condition codes 71 through 76 exist on the claim, then revenue codes 082X, 083X, 084X, 085X or 088X must also be present. Payment may be reduced due to submitted Present on Admission (POA) indicator. The Total Number Of Sessions Requested Exceeds Quarterly Guidelines. DRG cannotbe determined. Principal Diagnosis 9 Not Applicable To Members Sex. Please Obtain A Valid Number For Future Use. Claims Edit Guideline: Reimbursement (Maximum Edit Units) - WellCare Multiple Service Location Found For the Billing Provider NPI. The member is locked-in to a pharmacy provider or enrolled in hospice. Psych Evaluation And/or Functional Assessment Ser. 1. The Medical Need For This Service Is Not Supported By The Submitted Documentation. The value code 48 (Hemoglobin reading) or 49 (Hematocrit) is required for the revenue code/HCPCS code combination. An ICD-9-CM Diagnosis Code of greater specificity must be used for the Ninth Diagnosis Code. Denied due to Procedure Is Not Allowable For Diagnosis Indicated. The likelihood of a central nervous system (CNS) cause of the event is extremely low, and patient outcomes are not improved with brain imaging studies. Assessment Is Not A Covered Service Unless All Four Components Of Skilled Nursing Are Present: Assessment, Planning, Intervention And Evaluation. Refer To Provider Handbook. One or more From Date Of Service(DOS) (DOS) is invalid for Occurrence Span Codes in positions three through 24. Ninth Diagnosis Code (dx) is not on file. TPA Certification Required For Reimbursement For This Procedure. Denied. Revenue code 0850 thru 0859 is not allowed when billed with revenue codes 0820thru 0829, 0830 thru 0839, or 0840 thru 0849. The Revenue code on the claim requires Condition code 70 to be present for this Type of Bill. Medicare Disclaimer Code invalid. The National Drug Code (NDC) is not on file for the Dispense Date Of Service(DOS). Please Correct And Resubmit. Claim Detail Pended As Suspect Duplicate. Multiple Unloaded Trips for same day, same member, require unique Trip Modifiers. These Supplies/items Are Included In The Purchase Of The Dme Item Billed On The Same Date Of Service(DOS). Denied. You can even print your chat history to reference later! Denied due to Member Not Eligibile For All/partial Dates. Service Billed Limited To Three Per Pregnancy Per Guidelines. To better assist you, please first select your state. Billed Amount Is Greater Than Reimbursement Rate. Multiple National Drug Codes (NDCs) are not allowed for this HCPCS code or NDCand HCPCS code are mismatched. 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. Revenue Code Required. The Performing Or Billing Provider On The Claim Does Not Match The Billing Provider On Theprior Authorization File. Condition code 20, 21 or 32 is required when billing non-covered services. Third Other Surgical Code Date is required. Training Completion Date Is Not A Valid Date. Eighth Diagnosis Code (dx) is not on file. Ability to proficiently use Microsoft Excel, Outlook and Word. Amount Paid By Other Insurance Exceeds Amount Allowed By . An Approved AODA Day Treatment Program Cannot Exceed A 6 Week Period. The Billing Providers taxonomy code is missing. Remark Codes: N20. CO/204/N30. This Claim Is Being Reprocessed As An Adjustment On This R&s Report. Please Attach Copy Of Medicare Remittance. Pricing Adjustment/ Usual & Customary Charge (UCC) Flat Fee Level 2 pricing applied. Was Unable To Process This Request Due To Illegible Information. This Is Not A Preadmission Screen And Is Not Reimbursable. Default Prescribing Physician Number XX9999991 Was Indicated. Dental service limited to twice in a six month period. No Supporting Documentation. The Procedure Code has Diagnosis restrictions. This National Drug Code (NDC) has been terminated by CMS for the Date Of Service(DOS). First Other Surgical Code Date is required. Pricing Adjustment/ Payment amount decreased based on Pay for Performance policies. Please Clarify. Denied due to Medicare Allowed Amount Required. Member is enrolled in Medicare Part A and/or Part B on the on the Dispense Dateof Service. Reason Code 161: Attachment referenced on the claim was not received in a timely fashion. Member enrolled in QMB-Only Benefit plan. Rendering Provider is not a certified provider for . The Fourth Occurrence Code Date is invalid. According to the American College of Radiology and the International Society for Clinical Densitometry, dual-energy X-ray absorptiometry (DXA) bone density screening (77080 or 77081) is not indicated for women under age 65 or men under age 70 without risk factors for osteoporosis. Please Refer To The Original R&S. Payment(s) For Capital Or Medical Education Are Generated By EDS And May Not Be Billed By The Provider. EOB: Claims Adjustment Reason Codes List Questionable Long-term Prognosis Due To Apparent Root Infection. Individual Test Paid. The following are the most common reasons HCFA/CMS-1500 and UB/CMS-1450 paper claims for Veteran care are rejected: Requires the 17 alpha-numeric internal control number (ICN) [format: 10 digits + "V" + 6 digits] or 9-digit social security number (SSN) with no special characters. Reimburse Is Limited To Average Monthly NHCost And Services Above That Amount Are Consider non-Covered Services. Second Other Surgical Code Date is invalid. Admit Diagnosis Code is invalid for the Date(s) of Service. Condition codes 71, 72, 73, 74, 75, and 76 cannot be present on the same ESRD claim at the same time. Other Therapies Currently Provide Sufficient Services To Meet The Members Needs. Adjustment To Crossover Paid Prior To Aim Implementation Date. The Services Requested Are Not Reasonable Or Appropriate For The AODA-affectedmember. This diabetic supply has been paid under an equivalent code on this Date Of Service(DOS). Documentation Indicates That Client Is Able To Direct Cares And Can Safely Direct A PCW. Denied. Admission Denied In Accordance With Pre-admission Review Criteria. Members Age 3 And Older Must Have An Oral Assessment And Blood Pressure Check.With Appropriate Referral Codes, For Payment Of A Screening. Reason/Remark Code Lookup Service(s) Billed Are Included In The Total Obstetrical Care Fee. Claim Previously/partially Paid. The sum of all Value Code amounts must be numeric and less than or equal to 999.999.999. Care Does Not Meet Criteria For Complex Case Reimbursement. This Surgical Code Has Encounter Indicator restrictions. What to Expect with WellCare CMS (UPDATED-60 days in) Records Indicate This Tooth Has Previously Been Extracted. The Member Is Enrolled In An HMO. The National Drug Code (NDC) has an age restriction. The Member Has At Least 4 Posterior Teeth, Including Bicuspids On Each Side, which Can Be Used For Chewing. Explanation of benefits. A Training Payment Has Already Been Issued To Your NF For This CNA. The Member Has Been Totally Without Teeth And An Appliance For 5 Years. Claim Explanation Codes. No Action On Your Part Required. Condition Code 73 for self care cannot exceed a quantity of 15. Providers will find a list of all EOB codes used with the corresponding description on the last page of the Remittance Advice. Member is enrolled in a State-contracted managed care program for the Date(s) of Service. Denied. 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. A Hospital Stay Has Been Paid For DOS Indicated. Your latest EOB will be under Claims on the top menu. Benefit code These codes are submitted by the provider to identify state programs. Billing Provider is not certified for the Dispense Date. All The Teeth Do Not Meet Generally Accepted Criteria Requiring Gingivectomy. (part JHandbook). Service Denied. Procedure Code 59420 Must Be Used For 5 Or More Prenatal Visits With One Charge. Dispensing fee denied. FACIAL. Do not resubmit. Anesthesia and Moderate Sedation Services CPTs 00300, 00400, 00600, 01935-01936, 01991-01992, 99152-99153, 99156-99157, Pain Management Services CPTs 20552, 20553, 27096, 62273, 62320-62323, 64405, 64479, 64480, 64483, 64484, 64490-64495, 0228T, 0229T, 0230T, 0231T, G0260, Nerve Conduction Studies CPT 95907-95913, Needle electromyography (EMG)-CPT 95885, 95886. No More Than 2 Medication Check Services (30 Minutes) Are Payable Per Date Of Service(DOS). Service billed is bundled with another service and cannot be reimbursed separately. Please verify the accuracy of the procedure code and the presence of the appropriate procedure code modifier before cont acting ACS for assistance. These services are not allowed for members enrolled in Tuberculosis-Related Services Only Benefit Plan. CPT Code And Service Date For Member Is Identical To Another Claim Detail On File For Provider On Claim. One BMI Incentive payment is allowed per member, per renderingprovider, per calendar year. Referring Provider is not currently certified. Learns to use professional . The number of treatments/days reflected by the units entered with revenue code0821, 0831, 0841, 0851, 0880, 0881 exceeds the number of days included in the FROM and TO dates entered on this claim. Pricing Adjustment/ Pharmacy pricing applied. Requests For Training Reimbursement Denied Due To Late Billing. Electronic Explanation of Benefits (eEOB) - Payspan | Payspan Denied. Hospital And Nursing Home Stays Are Not Payable For The Same DOS Unless The Nursing Home Claim Indicated Hospital Bedhold Days. The Documentation Submitted Does Not Indicate Medically Oriented Tasks Are Medically Necessary, Therefore Personal Care Services Have Been Approved. The condition code is not allowed for the revenue code. Please submit future claims with the appropriate NPI, taxonomy and/or Zip +4 Code. Service(s) Denied/cutback. Revenue Code 0001 Can Only Be Indicated Once. The Procedure Code has Encounter Indicator restrictions. A more specific Diagnosis Code(s) is required. Accommodation Days Missing/invalid. Invalid quantity for the National Drug Code (NDC) submitted with this HCPCS code. The Rendering Providers taxonomy code in the detail is not valid. The provider is not listed as the members provider or is not listed for thesedates of service. Fifth Diagnosis Code (dx) is not on file. The Service Performed Was Not The Same As That Authorized By . Denied. Quantity submitted matches original claim. This Member Does Not Appear To Be Suffering From A Chronic Or Acute Mental Illness And Is Therefore Not Eligible For Day Treatment. Tooth number or letter is not valid with the procedure code for the Date Of Service(DOS). 0001: Member's . Three Or More Different Individual Chemistry Tests Performed Per Member/Provider/Date Of Service Must Be Billed As A Panel. Service Denied. Reimbursement For Training Is One Time Only. Computed tomography (CT) of the head or brain (CPT 70450, 70460, 70470), Computed tomographic angiography (CTA) of the head (CPT 70496), Magnetic resonance angiography (MRA) of the head (CPT 70544, 70545, 70546), Magnetic resonance imaging (MRI) of the brain (CPT 70551, 70552, 70553), Duplex scan of extracranial arteries (CPT 93880,93882), Computed tomographic angiography (CTA) of the neck(CPT 70498), Magnetic resonance angiography (MRA) of the neck(CPT 70547, 70548, 70549), ICD-10 Diagnosis codes G43.009, G43.109, G43.709, G43.809, G43.829, G43.909.