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. Purchase Only Allowed; Medical Need For Rental Has Not Been Documented. Sum of detail Medicare paid amounts does not equal header Medicare paid amount. The initial rental of a negative pressure wound therapy pump is limited to 90 days; member lifetime. Accommodation Days Missing/invalid. Gastrointestinal Surgery For The Purpose Of Weight Control Is Covered Only As An Emergency Procedure. The Request Has Been Approved To The Maximum Allowable Level. Additional servcies may be billed with H0046 and will count toward mental health and/or substance abuse treatment policy limits for prior authorization. It Must Be In MM/DD/YY FormatAnd Can Not Be A Future Date. Claim or Adjustment received beyond 365-day filing deadline. One or more Date(s) of Service is missing for Occurrence Span Codes in positions 9 through 24. Next step verify the application to see any authorization number available or not for the services rendered. 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. Only One Panel Code Within Same Category (CBC Or Chemistry) Maybe Performed Per Member/Provider/Date Of Service. Medicare Part A Services Must Be Resubmitted. The To Date Of Service(DOS) for the Second Occurrence Span Code is invalid. The Service/procedure Proposed Is Not Supported By Submitted Documentation. Principal Diagnosis 9 Not Applicable To Members Sex. Only non-innovator drugs are covered for the members program. Each month you fill a prescription, your Medicare Prescription Drug Plan mails you an "Explanation of Benefits" (EOB). Home | WPC Surgical Procedure Code billed is not appropriate for members gender. 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. Unable To Process Your Adjustment Request due to A Different Adjustment Is Pending For This Claim. Denied/recouped. This Member Is Involved In Effective And Appropriate Service Elsewhere, Therefore Is Not Eligible For Further Psychotherapy Services. The information on the claim isinvalid or not specific enough to assign a DRG. Denied. Denied due to Service Is Not Covered For The Diagnosis Indicated. Supplemental tests billed on the same Date Of Service(DOS) as vision examination are not payable. Anesthesia and moderate sedation services billed with pain management services for a patient age 18 or older may deny unless a surgical procedure CPT code range 10021-69990 (other than pain management procedures) is also billed on the claim. Prescribing Provider UPIN Or Provider Number Missing From Claim And Attachment. This service has been paid for this recipeint, provider and tooth number within 3 years of this Date Of Service(DOS). Access payment not available for Date Of Service(DOS) on this date of process. Submit copy of the dated and signed evaluation and indicate if this is an initial Evaluation. Claim paid according to Medicares reimbursement methodology. This Diagnosis Code Has Encounter Indicator restrictions. Submit Claim To For Reimbursement. Home Health, Personal Care And Private Duty Nursing Services Are Subject To A Monthly Cap. These are EOB codes, revised for NewMMIS, that may appear on your PDF remittance advice. NFs Eligibility For Reimbursement Has Expired. One or more Diagnosis Code(s) is invalid for the Date(s) of Service. Member is covered by a commercial health insurance on the Date(s) of Service. Rendering Provider may not submit claims for reimbursement as both the Surgeonand Assistant Surgeon For The Same Member On The Same DOS. Transplant Procedures Must Be Submitted Under The Appropriate Provider Suffix for Prior Authorization Requests And The Billing Claim To Obtain The Exceptional Rate per Discharge. Payment Recouped. . 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. One or more Surgical Code Date(s) is missing in positions seven through 24. Revenue Code 082X is present on an ESRD claim which also contains revenue codes 083X, 084X, or 085X. 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. Member first name does not match Member ID. Prior Authorization (PA) is required for payment of this service. Based on these reimbursement guidelines, claims may deny when the following revenue codes are billed without the appropriate HCPCS code: BMN prior authorization may be submitted for Mental Health drugs for which a Core Plan transitioned member has been previously grandfathered. Request Denied Due To Late Billing. Pricing Adjustment/ Pharmacy dispensing fee applied. Admission Date does not match the Header From Date Of Service(DOS). If you haven't created an account yet, register now. Description & Use Of Day RX Procedure Codes Based On Members Status-not the place Of Service Where Day Rx Service Performed. We have created a list of EOB reason codes for the help of people who are . Only one antipsychotic drug is allowed without an Attestation to Prescribe More Than One Antipsychotic Drug for a Member 16 Years of Age or Younger. Occurrence Codes 50 And 51 Are Invalid When Billed Together. We encourage you to take advantage of this easy-to-use feature. Denied. Note: The Group, Reason and Remark Codes are HIPAA EOB codes and are cross-walked to L&I's EOB codes. Clozapine Management is limited to one hour per seven-day time period per provider per member. This claim has been adjusted due to a change in the members enrollment. The condition code is not allowed for the revenue code. Indiana Medicaid: Providers: Explanation of Benefits (EOB) 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. Please Select A Procedure Code In The 58980-58988 Range That Best Describes The Procedure Being Performed. A code with no Trip Modifier billed on same day as a code with Modifier U1 are considered the same trip. The Members Demonstrated Response To Current Therapy Does Not Warrant The Intense Freqency Requested. Verify billed amount and quantity billed. By continuing to use our site, you agree to our Privacy Policy and Terms of Use. Please Obtain A Valid Number For Future Use. This claim is eligible for electronic submission. The Processor Control Number (PCN) for SeniorCare member over 200% FPL is missing, or the PCN is invalid for a WCDP member, member or SeniorCare member at or below 200% FPL. Please Use This Claim Number For Further Transactions. CO/204/N30. Denied. This Payment Is To Satisfy The Amount Owed For OBRA Nurse Aid Training. Use This Claim Number For Further Transactions. Adjustment To Crossover Paid Prior To Aim Implementation Date. Only Medicare Crossover claims are reimbursed for coinsurance, copayment, and deductible. Reimbursement For IUD Insertion Includes The Office Visit. 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 . Please Attach Copy Of Medicare Remittance. PDF How to read EOB codes - Washington Adjustment/reconsideration Request Denied Due To Incorrect/insufficient Information. Rebill Using Correct Procedure Code. The sum of the Medicare paid, deductible(s), coinsurance, copayment and psychiatric reduction amounts does not equal the Medicare allowed amount. Please submit claim to HIRSP or BadgerRX Gold. Dispense Date Of Service(DOS) is after Date of Receipt of claim. Denied. Billing or Rendering Provider certification is cancelled for the From Date Of Service(DOS). WI Can Not Issue A NAT Payment Without A Valid Hire Date. Service(s) exceeds four hour per day prolonged/critical care policy. Reimbursement For This Certification, Test, Segment Has Already Been Issued ToYour NF. Payspan's Core Payment Network comes with a feature that allows payers to send members an electronic version of their Explanation of Benefits (eEOB). Routine Foot Care Procedures Must Be Billed With Valid Routine Foot Care Diagnosis. NDC was reimbursed at AWP (Average Wholesale Price) (Average Wholesale Price) rate. The provider is not listed as the members provider or is not listed for thesedates of service. The Ninth Diagnosis Code (dx) is invalid. Out Of State Billing Provider Not Enrolled For Entire Detail DOS Span. Member has commercial dental insurance for the Date(s) of Service. All The Teeth Do Not Meet Generally Accepted Criteria Requiring Gingivectomy. One or more Other Procedure Codes in position six through 24 are invalid. Once you register and have access to the provider portal, you will find a variety of video training available in the Resources section of the portal. The Medical Need For Some Requested Services Is Not Supported By Documentation. Ninth Diagnosis Code (dx) is not on file. Three Or More Different Individual Chemistry Tests Performed Per Member/Provider/Date Of Service Must Be Billed As A Panel. Denied due to Claim Contains Future Dates Of Service. Valid group codes for use on Medicare remittance advice are:. Procedure Code 59420 Must Be Used For 5 Or More Prenatal Visits With One Charge. Language Comprehension And Language Production Are Equivalent To Cognition, Thus Formal Speech Therapy Is Not Needed. The Service(s) Requested Could Be Adequately Performed With Local Anesthesia In The Dental Office. Unable To Process This Request Due To Either Missing, Invalid OrMismatched National Provider Identifier # (NPI)/Provider Name/POP ID. Additional Reimbursement Is Denied. Please correct and resubmit. Member is assigned to an Inpatient Hospital provider. Second Other Surgical Code Date is required. Denied. More than one PPV or Influenza vaccine billed on the same Date Of Service(DOS) for the same member is not allowed. These Urinalysis Procedures Reimbursed Collectively At The Maximum For Routine Urinalysis With Microscopy. The Services Requested Are Not Reasonable Or Appropriate For The AODA-affectedmember. is unable to is process this claim at this time. 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. This service or a related service performed on this date has already been billed by another provider and paid. Unable To Process Your Adjustment Request due to Claim ICN Not Found. The Medicare copayment amount is invalid. Ability to proficiently use Microsoft Excel, Outlook and Word. Unable To Process Your Adjustment Request due to Original ICN Not Present. Service Denied. An Alert willbe posted to the portal on how to resubmit. Please Resubmit Your Non-healthcheck Services Using The Appropriate Claim SortIndicator Or Electronic Format. Claim Reduced Due To Member/participant Spenddown. Vision Diagnostic Services Limited To 1 Of These: Vision Exam, Diagnostic Review, Supplemental Test Or Contact Lens Therapy. MCR - 835 Denial Code List | Medicare Payment, Reimbursement, CPT code Wis Adm Code 106.04(3)(b) Requires Providers To Reimburse The Person/party (eg, County) That Previously. A New Prior Authorization Number Has Been Assigned To This Request In Order ToProcess. Concurrent Services Are Not Appropriate. The To Date Of Service(DOS) for the Second Occurrence Span Code is required. Adequate Justification For Starting Member In AODA Day Treatment Prior To Authorization being Obtained Has Not Been Provided. Repackaging allowance is not allowed for unit dose NDCs. An ICD-9-CM Diagnosis Code of greater specificity must be used for the Ninth Diagnosis Code. Speech Therapy Is Not Warranted. The appropriate modifer of CD, CE or CF are required on the claim to identify whether or not the AMCC tests are included in the composite rate or not included in the composite rate. A Primary Occurrence Code Date is required. The Date Of The Screening Request Or The Date Of Screening Is Invalid Or Missing. CSHCN number The client's CSHCN Services Program number. Denied/Cutback. Copayment Should Not Be Deducted From Amount Billed. Claim Is Being Reprocessed, No Action On Your Part Required. PleaseResubmit Charges For Each Condition Code On A Separate Claim. Claim contains an unclassified drug HCPCS procedure code or a drug HCPCS procedure code included in the composite rate. Admission Date is on or after date of receipt of claim. Fifth Other Surgical Code Date is invalid. One or more Surgical Code(s) is invalid in positions six through 23. Claim Number Given Is Not The Most Recent Number. Third Diagnosis Code (dx) (dx) is not on file. This member is eligible for Medication Therapy Management services. Resubmit Claim Through Regular Claims Processing. The Member Has Received A 93 Day Supply Within The Past Twelve Months. Day Treatment Exceeding 5 Hours/day Not Payable Regardless Of Prior Authorization. Please Contact Your District Nurse To Have This Corrected. The Sixth Diagnosis Code (dx) is invalid. Procedure Not Payable for the Wisconsin Well Woman Program. Resubmit Using Valid Rn/lpn Procedure Codes And A Valid PA Number. Medicare RA/EOMB And Claim Dates And/or Charges Do Not Match.