Compound drugs not covered under this program. Members Age 3 And Older Must Have An Oral Assessment And Blood Pressure Check.With Appropriate Referral Codes, For Payment Of A Screening. 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. Hospice Member Services Related To The Terminal Illness Must Be Billed By Hospice Or Attending Physician. trevor lawrence 225 bench press; new internal . NDC was reimbursed at State Maximum Allowable Cost (SMAC) rate. The Procedure Code has Diagnosis restrictions. Revenue code is not valid for the type of bill submitted. Inpatient psychiatric services are not reimbursable for members age 21 65 (age 22 if receiving services prior to 21st birthday). Member eligibility file indicates that BadgerCare Plus Benchmark, CorePlan or Basic Plan member. Only Medicare Crossover claims are reimbursed for coinsurance, copayment, and deductible. For Revenue Code 0820, 0821, 0825 or 0829, HCPCS Code 90999 or Modifier G1-G6 must be present. Reimburse Is Limited To Average Monthly NHCost And Services Above That Amount Are Consider non-Covered Services. This Member Has A Current Approved Authorization For Intensive AODA OutpatientServices. This level not only validates the code sets , but also ensures the usage is appropriate for any HMO Payment Equals Or Exceeds Hospital Rate Per Discharge. Lab Procedures Billed In Conjunction With Family Planning Pharmacy Visit Denied as not a Benefit. Prior Authorization is required for service(s) exceeding mental health and/or substance abuse benefit guidelines. PleaseResubmit Charges For Each Condition Code On A Separate Claim. Requires A Unique Modifier. Wis Adm Code 106.04(3)(b) Requires Providers To Reimburse The Person/party (eg, County) That Previously. Please Refer To The Original R&S. 2004-79 For Instructions. The Member Has Shown No Ability Within 6 Months To Carry Over Abilities GainedFrom Treatment In A Facility To The Members Place Of Residence. Quantity indicated for this service exceeds the maximum quantity limit established by the National Correct Coding Initiative. The Service Requested Was Performed Less Than 5 Years Ago. Prescription limit of five Opioid analgesics per month. Due To Non-covered Services Billed, The Claim Does Not Meet The Outlier Trim Point. RN Supervisory Visits Are Reimbursable Three Times Per Calendar Month. This Payment Is A Refund For An Overpayment Of A Provider Assessment, Thank You For Your Assessment Payment By Check, In Accordance With Your Request, EDS Has Deducted Your Assessment From This Payment. The revenue code and HCPCS code are incorrect for the type of bill. Services restricted to EPSDT clients valid only with a Full Scope, EPSDT-eligible Aid Code. Denied. Service Denied. Benefit Payment Determined By DHS Medical Consultant Review. Denied. The Revenue/HCPCS Code combination is invalid. Denied. Superior HealthPlan News. Denied/Cutback. Please Indicate Computation For Unloaded Mileage. Please Resubmit using A Approved CPT Or HCPCS Procedure Code. Denied. Rinoplastia; Blefaroplastia Pricing Adjustment/ Inpatient Per-Diem pricing. When billing multiple diagnosis codes, the recoding is based on the highest level of service associated to one or more of the diagnosis codes billed. Denied. Denied. Dispense Date Of Service(DOS) is after Date of Receipt of claim. Billed Procedure Not Covered By WWWP. Other Coverage Code is missing or invalid. Dates Of Service For Purchased Items Cannot Be Ranged. 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. This Revenue Code has Encounter Indicator restrictions. Canon R-FRAME-EB 84 Eb Home care ongoing assessments are allowed once every sixty days per member.nt, But Arepayable Every Fifty-fourth Day For Flexibility In Scheduling. Diagnosis Indicated Is Not Allowable For Procedures Designated As Mycotic Procedures. Reduction To Maintenance Hours. Supplemental tests billed on the same Date Of Service(DOS) as vision examination are not payable. Submitted rendering provider NPI in the detail is invalid. Timely Filing Deadline Exceeded. NDC- National Drug Code is invalid for the Dispense Date Of Service(DOS). Denied. First modifier code is invalid for Date Of Service(DOS). Contact. 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. WI Can Not Issue A NAT Payment Without A Valid Hire Date. Denied. . Compound Ingredient Quantity must be greater than zero. Claims may deny when reported with incompatible ICD-10-CM Laterality policy for Diagnosis-to-Modifier comparison. Previously Denied Claims Are To Be Resubmitted As New Day Claims. Billing or Rendering Provider certification is cancelled for the From Date Of Service(DOS). CO/204. Denied. Because a claim can have edits and audits at both the header and detail levels, EOB codes are listed . The Member Does Not Appear To Meet The Severity Of Illness Indicators Established by the Wisconsin And Is Therefore Not Eligible For AODA Day Treatment. Procedure not allowed for the CLIA Certification Type. To better assist you, please first select your state. Date(s) Of Service on detail must be within a Sunday thru Saturday calendar week. Training Completion Date Must Be Within A Year Of The CNAs Certification, Test, Date. The Services Requested Do Not Meet Criteria For An Acute Episode. Diagnosis Codes Assigned Must Be At The Greatest Specificity Available. Services are not payable. Documentation Does Not Justify Fee For ServiceProcessing . Adjustment Requested Member ID Change. Denied due to Take Home Drugs Not Billable On UB92 Claim Form. This National Drug Code (NDC) is not covered. Documentation Does Not Justify Medically Needy Override. Requests For Training Reimbursement Denied Due To Late Billing. Please Resubmit Corr. When Billing For Basic Screening Package, Charge Must Be Indicated Under Procedure W7000. Critical care in non-air ambulance is not covered. Billing/performing Provider Indicated On Claim Is Not Allowable. Fifth Other Surgical Code Date is invalid. Only Healthcheck Modifiers Can Be Billed With Healthcheck Services. Reason Code 160: Attachment referenced on the claim was not received. Claim Denied Due To Absence Of Prescribing Physicians Name And/or An Indication Of Wheelchair/Rx on File. Service Denied/cutback. WellCare Known Issues List EOP Denial Code or Rejection Reason Code Issue Description Impacted Provider Specialty . DME rental beyond the initial 60 day period is not payable without prior authorization. If you have questions regarding your remittance advice, please contact our Provider Call Center at 1-888-FIDELIS (1-888-343-3547) or your . Header To Date Of Service(DOS) is required. Denial Codes. This Member is enrolled in Wisconsin or BadgerCare Plus for Date(s) of Service. Hearing aid repairs are limited to once per six months, per provider, per hearing aid. Understanding your TRICARE explanation of benefits Denied. 51.42 Board Directors Or Designees Statement & Signature Required OnThe Claim Form For Payment Of Functional Assessment. One or more Surgical Code(s) is invalid in positions six through 23. This claim has been adjusted because a service on this claim is not payable inconjunction with a separate paid service on the same Date Of Service(DOS) due to National Correct Coding Initiative. Medicare Paid The Total Allowable For The Service. Denied. An Approved AODA Day Treatment Program Cannot Exceed A 6 Week Period. Summarize Claim To A One Page Billing And Resubmit. Payspan's Core Payment Network comes with a feature that allows payers to send members an electronic version of their Explanation of Benefits (eEOB). Services For Members With Medical Status Code TR, SH, SJ, TS Or ST NotAllowed For Your Provider Type, Or For Your Provider Type without a TB Diagnosis. Wellcare By Fidelis Care - New Explanation Codes on Dual Access Assistant Surgery Must Be Billed Separately By The Assistant Surgeon With Modifier 80. Eighth Diagnosis Code (dx) is not on file. Other Therapies Currently Provide Sufficient Services To Meet The Members Needs. Denied due to Member Not Eligibile For All/partial Dates. Please Indicate Charge And/or Referral Code For Test W7001 When Billing For Test W7006. Denied. CO 197 Denial Code - Authorization or Pre-Certification missing Additional services mustbe billed as treatment services and count towards the Mental Health and/or substance abuse treatment policy for prior authorization. Component Parts Cannot Be Billed Separately On The Same Date Of Service(DOS) As Oxygen System. Denied. Discharge Diagnosis 3 Is Not Applicable To Members Sex. 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. One or more Diagnosis Code(s) in positions 10 through 25 is not on file. Admission Date is on or after date of receipt of claim. According to CMS policy and the American College of Radiology, a chest X-ray (CPT codes 71045, 71046) should not be performed for screening purposes in the absence of pertinent signs, symptoms or diseases. Referring Provider ID is invalid. Child Care Coordination services are reimbursable only if both the member and provider are located in Milwaukee County. These Urinalysis Procedures Reimbursed Collectively At The Maximum For Routine Urinalysis With Microscopy. Billed Amount Is Greater Than Reimbursement Rate. Name And Complete Address Of Destination. The Second Other Provider ID is missing or invalid. Speech Therapy Evaluations Are Limited To 4 Hours Per 6 Months. Dispensing Two Lens Replacements On Same Date Of Service(DOS) Not Allowed. NDC was reimbursed at brand WAC (Wholesale Acquisition Cost) (Wholesale Acquisition Cost) rate. Complete Medicare Denial Codes List - Billing Executive The Request May Only Be Back-dated Two Weeks Prior To Receipt By EDS. Use This Claim Number For Further Transactions. Participant Is Enrolled In Medicare Part D. Beginning 09/01/06, Providers AreRequired To Bill Part D And Other Payers Prior To Seniorcare Or Seniorcare WillDeny The Claim. Purchase of additional DME/DMS item exceeding life expectancy rRequires Prior Authorization. Two different providers cannot be reimbursed for the same procedure for the same member on the same Date Of Service(DOS). Reimbursement limit for all adjunctive emergency services is exceeded. Start: 01/01/2000 | Last Modified: 03/06/2012 Notes: (Modified 2/28/03, 3/6/2012) N5: Hospital And Nursing Home Stays Are Not Payable For The Same DOS Unless The Nursing Home Claim Indicated Hospital Bedhold Days. Medicare Part A Services Must Be Resubmitted. Claims may deny when DXA bone density studies (CPT 77080 or 77081) are billed and the only diagnosis on the claim is osteoporosis screening (ICD-10 code Z13.820) for a woman who is under age 65 or for a man who is under age 70. Training Completion Date Must Be Prior To And Within A Year Of The CNAs Certification Date. Header Rendering Provider number is not found. No Action Required on your part. Denied. Room And Board Is Only Reimbursable If Member Has A BQC Nursing Home Authorization. 191. The Number In The National Provider Identifier (NPI) Section On This Request IsNot A Number Assigned To A Certified Nursing Facility For This Date Of Service(DOS). Diagnosis Treatment Indicator is invalid. Reason Code 161: Attachment referenced on the claim was not received in a timely fashion. Men. Claim Corrected. The Service Requested Does Not Correspond With Age Criteria. Pricing Adjustment/ Maximum Flat Fee pricing applied. BMN prior authorization may be submitted for Mental Health drugs for which a Core Plan transitioned member has been previously grandfathered. Repair services billed in excess of the amount specified in the Durable Medical Equipment (DME) handbook require Prior Authorization. Please Contact The Hospital Prior Resubmitting This Claim. PDF Mississippi Medicaid Explanation of Benefits (EOB) Codes Other Medicare Part A Response not received within 120 days for provider basedbill. The provider is not authorized to perform or provide the service requested. The Performing Provider Id, Member Id, And Date Of Service(DOS) Must Match The Completion Certificate Received From Ddes. Condition code 70-76 is required on an ESRD claim when Influenza/PPV/HEP B HCPCS codes are the only codes being billed with condition code A6. Procedure Code is not payable for SeniorCare participants. Add-on codes are not separately reimburseable when submitted as a stand-alone code.