wellcare eob explanation codes

Please Indicate One Prior Authorization Number Per Claim. Research Has Determined That The Member Does Not Qualify For Retroactive Eligibility According To Hfs 106.03(3)(b) Of The Wisconsin Administrative Code. Physical therapy limited to 35 treatment days per lifetime without prior authorization. Accommodation Days Missing/invalid. Routine foot care Diagnoses must be billed with valid routine foot care Procedure Codes. The procedure code has Family Planning restrictions. Invalid Provider Type To Claim Type/Electronic Transaction. Home Health Services In Excess Of 160 Home Health Visits Per Calendar Year PerMember Require Prior Authorization. One or more Diagnosis Code(s) in positions 10 through 25 is not on file. Per Information From Insurer, Prior Authorization Was Not Requested/approved Prior To Providing Services. Secondary Diagnosis Code(s) in positions 2-9 cannot duplicate the Primary Discharge Diagnosis. If correct, special billing instructions apply. Cannot bill for both Assay of Lab and other handling/conveyance of specimen. NCPDP Format Error Found On Medicare Drug Claim. 51.42 Board Stamp Required On All Outpatient Specialty Hospital Claims For Dates Of Service On Or After January 1, 1986. Our Records Indicate This Provider Is Not Certified For AODA Day Treatment. CSHCN number The client's CSHCN Services Program number. This Member is enrolled in Wisconsin or BadgerCare Plus for Date(s) of Service. This Claim HasBeen Manually Priced Using The Medicare Coinsurance, Deductible, And Psyche RedUction Amounts As Basis For Reimbursement. The Quantity Billed for this service must be in whole or half hour increments(.5) Increments. Services billed are included in the nursing home rate structure. One or more Diagnosis Codes has an age restriction. Effective 04/01/09, the BadgerCare Plus Core Plan will limit coverage for Brochodilators-Beta Agonists to Proventil HFA and Serevent. Claim Detail Denied. The Value Code and/or value code amount is missing, invalid or incorrect. If Required Information Is not received within 60 days, the claim detail will be denied. Header From Date Of Service(DOS) is after the header To Date Of Service(DOS). An ICD-9-CM Diagnosis Code of greater specificity must be used for the Second Diagnosis Code. Emergency Services Indicator must be "Y" or Pregnancy Indicator must be "Y" for this aid code. Surgical Procedures May Only Be Billed With A Whole Number Quantity. The Diagnosis Does Not Indicate A Significant Change In the Members Condition. Rendering Provider is not certified for the From Date Of Service(DOS). You Must Either Be The Designated Provider Or Have A Refer. If A Reporting Form Is Not Submitted Within 60 Days, The claim detail will be denied. Per Information From Insurer, Claims(s) Was (were) Paid. Prior Authorization is required for service(s) exceeding mental health and/or substance abuse benefit guidelines. Procedure Code Changed To Permit Appropriate Claims Processing. Speech Therapy Limited To 45 Treatment Days Per Spell Of Illness W/o Prior Authorization. Service Not Covered For Members Medical Status Code. Denied. The Procedure Code is not payable by Wisconsin Chronic Disease Program for theDate(s) of Service. Providers should submit adequate medical record documentation that supports the claim (services) billed. Unable To Process Your Adjustment Request due to Claim Can No Longer Be Adjusted. Health (3 days ago) Webwellcare explanation of payment codes and comments. For over 40 years, Washington Publishing Company (WPC) has specialized in managing and distributing data integration information through publications, training, and consulting services. Multiple Referral Charges To Same Provider Not Payble. Please adjust quantities on the previously submitted and paid claim. Claim Explanation Codes View Fee Schedules Electronic Payments and Remittances Submit Behavioral Health Claim Durable Medical Equipment - Rental/Purchase Grid Claims Submission Process Procedure Code Modifiers Submitting Medical Records Submitting Medicare Part D Claims . Good Faith Claim Has Previously Been Denied By Certifying Agency. Revenue code billed with modifier GL must contain non-covered charges. The Procedure(s) Requested Are Not Medical In Nature. 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. Referring Provider is not currently certified. 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 Bill Your Medicare Intermediary Prior To Submitting To . Medicare Coinsurance Amount Was Not Provided On Crossover Claim. Day Treatment exceeding 120 hours per month is not payable regardless of PriorAuthorzation. NDC- National Drug Code is not allowed for the member on the Date Of Service(DOS). Information inadequate to establish medical necessity of procedure performed.Please resubmit with additional supporting documentation. Immunization Questions A And B Are Required For Federal Reporting. Correct And Resubmit. Has Already Issued A Payment To Your NF For This Level L Screen. This Payment Is To Satisfy Amount Owed For A Drug Rebate Prior Quarter Correction. Only One Outpatient Claim Per Date Of Service(DOS) Allowed. Claims may deny when a nerve conduction study is billed without a needle EMG, or a needle EMG is billed without a Nerve conduction study, and the only diagnosis is radiculopathy (ICD-10 codes M50.1-M50.23, M51.1-M51.27, M51.9, M53.80, M54.10-M54.18, M54.30-M54.42, and M79.2). Bill The Single Appropriate Code That Describes The Total Quantity Of Tests Performed. Member is enrolled in Medicare Part B on the Date(s) of Service. Two different providers cannot be reimbursed for the same procedure for the same member on the same Date Of Service(DOS). Hearing aid repairs are limited to once per six months, per provider, per hearing aid. Pharmaceutical care indicates the prescription was not filled. Once medical records are received, medical review professionals will review the documentation to determine whether the claim is supported as submitted and pay or deny accordingly. Review Has Determined No Adjustment Payment Allowed. 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. The submitted claim contains value code 68 and 48 or 49 but does not contain revenue code 0634 or 0635 and HCPCS Q4055. Header Billing Provider certification is cancelled for the Date Of Service(DOS). 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. Valid Numbers AreImportant For DUR Purposes. Personal Care Services Exceeding 30 Hours Per 12 Month Period Per Member Require Prior Authorization. LTC hospital bedhold quantity must be equal to or less than occurrence code 75span date range(s). Denied. Whenever claim denied with CO 197 denial code, we need to follow the steps to resolve and reimburse the claim from insurance company: First step is to verify the denial reason and get the denial date. Principal Diagnosis 8 Not Applicable To Members Sex. Please Correct And Resubmit. The Functional Assessment And/or Progress Status Report Does Not Indicate Any Change, and/or Positive Rehabilitation Potential. Denials with solutions in Medical Billing; Denials Management - Causes of denials and solution in medical billing; Medical Coding denials with solutions Denied. A National Provider Identifier (NPI) is required for the Performing Provider listed in the header. The From Date Of Service(DOS) for the Second Occurrence Span Code is required. If authorization number available . Services on this claim have been split to facilitate processing.on On Your Part Is Required. A code with no Trip Modifier billed on same day as a code with Modifier U1 are considered the same trip. Denied. Insufficient Documentation To Support The Request. This service was previously paid under an equivalent Procedure Code. 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. Continuous home care must be billed in an hourly quantity equal to or greater than eight hours, up to and including 24 hours. A NAT Reimbursement Request Must Be Submitted To WI Within A Year Of The CNAs Hire Date. Denied. Rendering Provider may not submit claims for reimbursement as both the Surgeonand Assistant Surgeon For The Same Member On The Same DOS. Errors in one of the following data elements exceed their field size: Statement covered FROM Date, Admission date, Date Of Service(DOS), Revenue code. Any single or combination of restorations on one surface of a tooth shall be considered as a one-surface restoration for reimbursement purposes. Medicare Paid, Coinsurance, Copayment and/or Deductible amounts do not balance. Backdating Allowed Only In Cases Of Retroactive Member/provider Eligibility. Physical Therapy Limited To 45 Treatment Days Per Spell Of Illness W/o Prior Authorization. Member is covered by a commercial health insurance on the Date(s) of Service. Detail To Date Of Service(DOS) is invalid. Occupational therapy limited to 35 treatment days per lifetime without prior authorization. Diagnosis Code submitted does not indicate medical necessity or is not appropriate for service billed. 1 PC Dispensing Fee Allowed Per Date Of Service(DOS). Dispense as Written indicator is not accepted by . Claim Denied Due To Incorrect Accommodation. Fourth Other Surgical Code Date is required. The Performing Provider Id, Member Id, And Date Of Service(DOS) Must Match The Completion Certificate Received From Ddes. Please Resubmit As A Regular Claim If Payment Desired. These coding rules are published within the Medicare Claims Processing Manual, Current Procedural Terminology (CPT) by the American Medical Association (AMA) and ICD-10-CM guidelines governed by Medicare and Medicaid Services (CMS) and the National Center for Health Statistics (NCHS). Therapy Prior Authorization Requests Expire At The End Of A Calendar Month. It is a duplicate of another detail on the same claim. Claims adjustments. Claim or adjustment/reconsideration request must have both a Revenue Code and either a HCPCS Code or CPT Code. Part A Reason Codes are maintained by the Part A processing system. Benefit Payment Determined By DHS Medical Consultant Review. This National Drug Code (NDC) has Encounter Indicator restrictions. Rendering Provider is not a certified provider for Wisconsin Chronic Disease Program. Correction Made Per Medical Consultant Review. Wellcare uses cookies. All services should be coordinated with the primary provider. This National Drug Code (NDC) is only payable as part of a compound drug. Third Other Surgical Code Date is required. Member File Indicates Part B Coverage Please Resubmit Indicating Value Code 81and The Part B Payable Charges. This drug is a Brand Medically Necessary (BMN) drug. Use This Claim Number For Further Transactions. Care Does Not Meet Criteria For Complex Case Reimbursement. Claimchecks Editing And Your Supporting Documentation Was Reviewed By The DHS Medical Consultant. NFs Eligibility For Reimbursement Has Expired. No Action Required. Denied. These Urinalysis Procedures Reimbursed Collectively At The Maximum For Routine Urinalysis With Microscopy. Real time pharmacy claims require the use of the NCPDP Plan ID. Service(s) paid in accordance with program policy limitation. Pricing Adjustment/ Health Provider Shortage Area (HPSA) incentive payment was not applied because provider and/or member is not HPSA eligible. Prescription Drug Plan (PDP) payment/denial information is required on the claim to SeniorCare. The Maximum Prior Authorized Service Limitation Or Frequency Allowance Has Been Exceeded. Unable To Reach Provider To Correct Claim. Member Is Enrolled In A Family Care CMO. Compound Ingredient Quantity must be greater than zero. Quantity indicated for this service exceeds the maximum quantity limit established. Non-preferred Drug Is Being Dispensed. The Information Provided Is Not Consistent With The Intensity Of Services Requested. OA 14 The date of birth follows the date of service. Please Indicate Anesthesia Time For Services Rendered. Claim paid at program allowed rate. The billing provider number is not on file. Other Payer Coverage Type is missing or invalid. Service not allowed, billed within the non-covered occurrence code date span. Diagnosis V25.2 May Only Be Used When Billing For Sterilization Procedures. If The Proc Code Does Not Require A Modifier, Please Remove The Modifier. Duplicate Item Of A Claim Being Processed. SMV Or Prescribing Provider Description Code(s) Missing OrInvalid. The taxonomy code for the attending provider is missing or invalid. Out Of State Billing Provider Not Enrolled For Entire Detail DOS Span. Hospice Member Services Related To The Terminal Illness Must Be Billed By Hospice Or Attending Physician. WellCare Known Issues List Please be advised: Claims that have either rejected or denied . Payment Is Limited To One Unit Dose Service Per Calendar Month, Per Legend Drug, Per Member. The Reimbursement Code Assigned To This CNA Does Not Authorize A NAT Payment. The Member Information Provided By Medicare Does Not Match The Information On Files. Recip Does Not Meet The Reqs For An Exempt. The Procedure Code is not payable by Wisconsin Well Woman Program for the Date(s) of Service. Pharmaceutical Care Codes Are Billable On Non-compound Drug Claims Only. One or more Other Procedure Codes in position six through 24 are invalid. Copyright 2023 Wellcare Health Plans, Inc. New Coding Integrity Reimbursement Guidelines. Services Are Covered For Medically Needy Members Only When Healthcheck Referral is Indicated On Claim. 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. BMN prior authorization may be submitted for Mental Health drugs for which a Core Plan transitioned member has been previously grandfathered. Outside Lab,element 20 On CMS 1500 Claim Form Must Be Checked Yes When Handling Charges Are Billed. This Member Does Not Appear To Be Suffering From A Chronic Or Acute Mental Illness And Is Therefore Not Eligible For Day Treatment. Denied. Service Denied. Claim Has Been Adjusted Due To Previous Overpayment. The Service Performed Was Not The Same As That Authorized By . Contact Wisconsin s Billing And Policy Correspondence Unit. Dates Of Service For Purchased Items Cannot Be Ranged. To better assist you, please first select your state. Reimbursement For Training Is One Time Only. A Third Occurrence Code Date is required. No Private HMO Or HMP On File. CORE Plan Members are limited to 25 non-emergency outpatient hospital visits per enrollment year. wellcare explanation of payment codes and comments. Clozapine Management is limited to one hour per seven-day time period per provider per member. Copayment Should Not Be Deducted From Amount Billed. Combine Like Details And Resubmit. A valid Referring Provider ID is required. The first occurrence span from Date Of Service(DOS) is after the to Date Of Service(DOS). Member Is Eligible For Champus. Verify billed amount and quantity billed. Our Records Indicate You Have Billed More Than One Unit Dose Dispensing Fee For This Calendar Month. (part JHandbook). Claim Reduced Due To Member/participant Spenddown. Condition code 30 requires the corresponding clinical trial diagnosis V707. Revenue Code 082X is present on an ESRD claim which also contains revenue codes 083X, 084X, or 085X. There are many different remittance adjustment reason codes (RARCs) established for Medicare and we understand their explanations may be "generic" and confusing, so we have provided a listing in the table below of the most commonly used denial messages and RARCs utilized by Medical Review Part B during medical record review. Quantity Would Always Be 00010 If Number Of Pounds Not Indicated. and other medical information at your current address. PDN Codes W9045/w9046 Are Not Payable On The Same Date As PDN Codes W9030/W9031 For The Same Provider And Member. Level, Intensity Or Extent Of Service(s) Requested Has Been Modified Consistent With Medical Need As Defined In The Plan Of Care. Single Bitewing X-rays Limited To Once Per Day And No More Than Two InA Six Month Period. The Service Billed Does Not Match The Prior Authorized Service. Pricing Adjustment/ Spenddown deductible applied. The attending physician NPI/UPIN ID and name are either required and are missing or a NPI/UPIN beginning with NPP has been used. Only non-innovator drugs are covered for the members program. Total billed amount is less than the sum of the detail billed amounts. Good Faith Claim Denied For Timely Filing. Competency Test Date Is Not A Valid Date. Private Duty Nursing Beyond 30 Hrs /Member Calendar Year Requires Prior Authorization. A WCDP drug rebate agreement for this drug is not on file for the Date Of Service(DOS). Description. The Service Requested Was Performed Less Than 5 Years Ago. Value codes 48 Homoglobin Reading and 49 Hematocrit Reading, must have a zero in the far right position. CNAs Eligibility For Nat Reimbursement Has Expired. This claim did not include the Plan ID, therefore we assigned TXIX as the Plan ID for this claim. Billing Provider is not certified for Substance Abuse Day Treatment for the Date(s) of Service. Good Faith Claim Correctly Denied. Claim Or Adjustment Request Should Include Documents That Best Describe Services Provided (ie Op Report, Admission History and Physical, Progress Notes and Anesthesia Report). These are EOB codes, revised for NewMMIS, that may appear on your PDF remittance advice. Service Provided Before Prior Authorization Was Obtained Is Not Allowable. One or more Date(s) of Service is missing for Occurrence Span Codes in positions 9 through 24. Services have been determined by DHCAA to be non-emergency. Reconsideration With Documentation Warranting More X-rays. wellcare eob explanation codes. The From Date Of Service(DOS) for the Second Occurrence Span Code is invalid. The Member Is Involved In group Physical Therapy Treatment. A quantity dispensed is required. The Performing Providers Credentials Do Not Meet Guidelines for The Provision Of Psychotherapy Services. Service not payable with other service rendered on the same date. Service Denied. Anesthesia Modifying Services Must Be Billed Separately From The Charge For Anesthesia Base And Time Units. Denied/Cutback. Cutback/denied. Please Resubmit. Member is not enrolled for the detail Date(s) of Service. Other Medicare Managed Care Response not received within 120 days for providerbased bill. Payment Authorized By Department of Health Services (DHS) To Be Recouped at a Later Date. Pricing Adjustment/ Repackaging dispensing fee applied. Effective September 1, 2021: Benefit Changes to Total Disc Arthroplasty for Medicaid and CHIP. The Insurance EOB Does Not Correspond To The Dates Of Service/servicesBeing Billed. Procedure Code 59420 Must Be Used For 5 Or More Prenatal Visits With One Charge. Medicare Deductible Is Paid In Full. Personal care subsequent and/or follow up visits limited to seven per Date Of Service(DOS) per member. Payspan's Core Payment Network comes with a feature that allows payers to send members an electronic version of their Explanation of Benefits (eEOB). The Tooth Is Not Essential To Maintain An Adequate Occlusion. Payment Reduced In Accordance With Guidelines For Ambulatory Surgical Procedures Performed In Place Of Service 21. The Medical Need For Some Requested Services Is Not Supported By Documentation. Preventive Medicine Code Billed Is Allowed For Health Check Agencies Only With The Appropriate Healthcheck Modifier. Service Fails To Meet Program Requirements. Individual Vaccines And Combination Vaccine Code May Not Be Billed For The Same Dates Of ervice. Please Refer To Update No. Denied. Denied. CPT Code And Service Date For Memberis Identical To Another Claim Detail On File For Another WWWP Provider.