Different Drug Benefit Programs. Claim Denied Due To Invalid Pre-admission Review Number. An ICD-9-CM Diagnosis Code of greater specificity must be used for the First Diagnosis Code. Reason for Service submitted does not match prospective DUR denial on originalclaim. By continuing to use our site, you agree to our Privacy Policy and Terms of Use. For RHCs, place of service is 72, however, you can bill lab services with a place of service 11. 1. 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. Req For Acute Episode Is Denied. CO/96/N216. Service Denied. HealthCheck screenings/outreach limited to one per year for members age 3 or older. CO/204. The Rendering Providers taxonomy code in the header is invalid. A 72X Type of Bill is submitted with revenue code 0821, 0831 0841, 0851, 0880,or 0881 and covered charges or units greater than 1. Denied. 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. To access the training video's in the portal . Speech Therapy Is Not Warranted. Claim Is Being Special Handled, No Action On Your Part Required. Payment may be reduced due to submitted Present on Admission (POA) indicator. this Procedure Code Is Denied As Mutually Exclusive To Another Code Billed On This Claim. Claims may deny for audiology screening (CPT 92551, 92560, V5008) may be denied when a provider bills for auditory screening services at the same time as a preventive medicine visit (CPT 99381-99397) or wellness visit (CPT G0438-G0439), without appropriate modifier appended to the E&M service to identify a separately identifiable procedure. Prior Authorization Is Required For Payment Of This Service With This Modifier. The Reimbursement Code Assigned To This Certification Segment Does Not Authorize a Training Payment. Denied/recouped. Denied. Benefit Payment Determined By DHS Medical Consultant Review. The revenue accomodation billing code on the claim does not match the revenue accomodation billing code on the member file or does not match for these dates of service. Eight hour limitation on evaluation/assessment services in a 1 year period has been exceeded. Service(s) Denied. Diag Restriction On ICD9 Coverage Rule edit. This claim must contain at least one specified Surgical Procedure Code. Do not insert a period in the ICD-9-CM or ICD-10-CM codes. Speech Therapy Evaluations Are Limited To 4 Hours Per 6 Months. Has Processed This Claim With A Medicare Part D Attestation Form. Denied. Head imaging in the form of CT scans, MRI or MRA is allowed only when the service is medically reasonable and necessary. Dental service is limited to once every six months. Please Do Not Resubmit Your Claim. Discharge Date is before the Admission Date. First Other Surgical Code Date is required. One or more Diagnosis Code(s) in positions 10 through 25 is not on file. Details Include Revenue/surgical/HCPCS/CPT Codes. The first position of the attending UPIN must be alphabetic. Service(s) paid in accordance with program policy limitation. A Qualified Provider Application Is Being Mailed To You. Code. Superior HealthPlan News. Previously Paid Individual Test May Be Adjusted Under a Panel Code. Denied. 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). Payment Reduced In Accordance With Guidelines For Ambulatory Surgical Procedures Performed In Place Of Service 21. Prescription Drug Plan (PDP) payment/denial information required on the claim to WCDP. Please Do Not Resubmit Your Claim, And Disregard Additional Informational Messages for this claim. Please verify billing. Services Not Payable When Rendered To An Individual Aged 21-64 Who Is A Resident Of A Nursing Home Imd. Please Resubmit With The Costs For Sterilization Related Charges Identified As Non-covered Charges On The Claim. Pricing Adjustment. One or more Diagnosis Code(s) is invalid in positions 10 through 25. Unable To Process This Request Due To Either Missing, Invalid OrMismatched National Provider Identifier # (NPI)/Provider Name/POP ID. Insufficient Info On Unlisted Med Proc; Submit Claim Or Attachment With A Complete Description Of The Procedure As Described In History and Physical Exam Report, Med Progress, anesthesia or Op Report. Good Faith Claim Denied. Amount Indicated In Current Processed Line On R&S Report Is The Manual Check You Recently Received. Other Insurance/TPL Indicator On Claim Was Incorrect. Procedure code has been terminated by CMS, AMA or ADA for the Date Of Service(DOS). Pharmaceutical care reimbursement for tablet splitting is limited to three permonth, per member. Panel And Individual Test Not Payable For Same Member/Provider/ Date Of Service(DOS). A SeniorCare drug rebate agreement is not on file for this drug for the Date Of Service(DOS). Denied. Denied due to Claim Or Adjustment Received After The Late Billing Filing Limit. Admission Denied In Accordance With Pre-admission Review Criteria. The Comprehensive Community Support Program reimbursement limitations have been exceeded. This claim has been adjusted due to Medicare Part D coverage. The code next to this was 264, which was described on the back of Frank's EOB as "Over What Medicare Allows" Total Patient Cost: $15.00 - Frank's office visit copayment; Amount Paid to the Provider: $50.00 - the amount of money that Frank's Medicare Advantage Plan sent to Dr. David T. Denied due to Services Billed On Wrong Claim Form. Denied. Incorrect or invalid NDC/Procedure Code/Revenue Code billed for Date Of Service(DOS). Service is not reimbursable for Date(s) of Service. Hospital discharge must be within 30 days of from Date Of Service(DOS). Duplicate Item Of A Claim Being Processed. MedicalBillingRCM.com is a participant in the Amazon Services LLC Associates Program, an affiliate advertising program designed to provide a means for sites to earn advertising fees by advertising and linking to Amazon.com. For example, a claim from a physician provider with place of service 11 (Office) would be considered incorrectly coded when a claim from an outpatient facility (e.g. Denied due to Quantity Billed Missing Or Zero. This ProviderMay Only Bill For Coinsurance And Deductible On A Medicare Crossover Claim. The Revenue Code is not payable for the Date Of Service(DOS). This Claim Is Being Reprocessed As An Adjustment On This R&s Report. Compound drugs not covered under this program. Permanent Tooth Restoration/sealant, Limited To Once Every 3 Years Unless Narrative Documents Medical Necessity. Case Planning And/or On-going Monitoring For Both Targeted Case Managementand Child Care Coordination Are Not Allowed In The Same Month. Medically Unbelievable Error. A Payment For The CNAs Competency Test Has Already Been Issued. An ICD-9-CM Diagnosis Code of greater specificity must be used for the Diagnosis Code in posistion 10 through 24. Fifth Other Surgical Code Date is required. Diagnosis Codes Assigned Must Be At The Greatest Specificity Available. Outside Lab Indicator Must Be Y For The Procedure Code Billed. (National Drug Code). Submit copy of the dated and signed evaluation and indicate if this is an initial Evaluation. Condition code 80 is present without condition code 74. This National Drug Code Has Diagnosis Restrictions. The Member Is Only Eligible For Maintenance Hours. One or more To Date(s) of Service is invalid for Occurrence Span Codes in positions three through 24. Payment Authorized By Department of Health Services (DHS) To Be Recouped at a Later Date. In addition, when distinct service modifier 59 or modifier XE is not appended to auditory screening services and tympanometry/impedance testing, these services may be denied. WellCare Known Issues List EOP Denial Code or Rejection Reason Code Issue Description Impacted Provider Specialty . Routine foot care is limited to no more than once every 61days per member. Claim contains duplicate segments for Present on Admission (POA) indicator. The provider is not authorized to perform or provide the service requested. The Clinical Profile And Narrative History Indicate Day Treatment Is Neither Appropriate Nor A Medical Necessity For This Member. Payment Subject To Pharmacy Consultant Review. Revenue Code 0001 Can Only Be Indicated Once. See Provider Handbook For Good Faith Billing Instructions. Pricing Adjustment/ Claim has pricing cutback amount applied. Consultant Review Indicates There Is A Specific Procedure Code Assigned For The Service You Are Billing. For Newly Certified CNAs, Date Of Inclusion Is T heir Test Date. Multiple Screens Performed Within A Fifteen Day Time Frame For This SSN. This notice gives you a summary of your prescription drug claims and costs. The Value Code(s) submitted require a revenue and HCPCS Code. Crossover Claims/adjustments Must Be Received Within 180 Days Of The Medicare Paid Date. A Rendering Provider is not required but was submitted on the claim. Description. RN And LPN Subsequent Care Visits Limited To 6 Hrs Per Day/per Member/per Provider. Denied. This service or a related service performed on this date has already been billed by another provider and paid. A dispense as written indicator is not allowed for this generic drug. Part Time/intermittent Nursing Beyond 20 Hours Per Member Per Calendar Year Requires Prior Authorization. If the KT/V reading was not performed, then the value code D5 with 9.99 must be present without the occurrence code 51. Reimb Is Limited to the Average Monthly NH Cost and Services Above that Amount Are Considered non-Covered Services. Quantity Billed is restricted for this Procedure Code. Occupational therapy limited to 35 treatment days per lifetime without prior authorization. Benefit code These codes are submitted by the provider to identify state programs. Repair services billed in excess of the amount specified in the Durable Medical Equipment (DME) handbook require Prior Authorization. Partial Payment Withheld Due To Previous Overpayment. See Physicians Handbook For Details. The condition code is not allowed for the revenue code. NDC was reimbursed at Employer Medical Assistance Contribution (EMAC) rate. No Action On Your Part Required. 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. Prior authorization is required for Advair or Symbicort if no other Glucocorticoid Inhaled product has been reimbursed within 90 days. PleaseResubmit Charges For Each Condition Code On A Separate Claim. Annual Nursing Home Member Oral Exam Is Allowed Once Per 355 Days Per Recip Per Prov. Denied. Quantity indicated for this service exceeds the maximum quantity limit established by the National Correct Coding Initiative. WellCare_Consult_ManagedProcedureCodeList_2023_20221222 Page 2 of 7 Remote afterloading high dose rate radionuclide interstitial or intracavitary brachytherapy, includes Submitted rendering provider NPI in the detail is invalid. A Payment Has Already Been Issued For This SSN. Service(s) exceeds four hour per day prolonged/critical care policy. NDC- National Drug Code is not allowed for the member on the Date Of Service(DOS). A Total Charge Was Added To Your Claim. A valid procedure code is required on WWWP institutional claims. Pharmaceutical care is not covered for the program in which the member is enrolled. Request Denied. Unable To Process This Request Because The Competency Test Date And TrainingCompletion Date Fields Are Blank. Claims may deny for the initial inpatient admission E&M if a provider from the same provider group and same specialty bills any other inpatient E&M visit, i.e. Pricing Adjustment/ Maximum Allowable Fee pricing used. Claim Denied. Value Code 48 And 49 Must Have A Zero In The Far Right Position. Unable To Process Your Adjustment Request due to A Different Adjustment Is Pending For This Claim. Service Denied. Ulcerations Of The Skin Do Not Warrant A New Spell Of Illness. The Surgical Procedure Code is restricted. It is a duplicate of another detail on the same claim. If A Reporting Form Is Not Submitted Within 60 Days, The claim detail will be denied. Services are not payable. All services should be coordinated with the Inpatient Hospital provider. Prescriber must contact the Drug Authorization and Policy Override Center for policy override. A Primary Occurrence Code Date is required. HTTP Status Code Connect Time (ms) Result; 2023-03-01 04:10:52: 200: 255: Page Active: Activities To Promote Diversion Or General Motivation Are Non-covered Services. Claim Number Given Is Not The Most Recent Number. The Service(s) Requested Could Be Adequately Performed With Local Anesthesia In The Dental Office. Supply The Place Of Service Code On The Request Form (the Place Of Service Where The Service/procedure Would Be Performed). For Revenue Code 0820, 0821, 0825 or 0829, HCPCS Code 90999 or Modifier G1-G6 must be present. A Second Occurrence Code Date is required. Denied. The Date Of The Screening Request Or The Date Of Screening Is Invalid Or Missing. 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. Additional Psychotherapy Is Not Considered Appropriate Or Inline With More Effective, Available Services. Purchase of additional DME/DMS item exceeding life expectancy rRequires Prior Authorization. This Diagnosis Code Has Encounter Indicator restrictions. Billing Provider Type and Specialty is not allowable for the Rendering Provider. 1 PC Dispensing Fee Allowed Per Date Of Service(DOS). Header From Date Of Service(DOS) is invalid. Modifiers are required for reimbursement of these services. Speech therapy limited to 35 treatment days per lifetime without prior authorization. Resubmit Your Services Using The Appropriate Modifier After YouReceive A Update Providing Additional Billing Information. Reading your EOB. Please note that the submission of medical records is not a guarantee of payment. Normal delivery reimbursement includes anesthesia services. Adequate Justification For Starting Member In AODA Day Treatment Prior To Authorization being Obtained Has Not Been Provided. Cannot Be Reprocessed Unless There Is Change In Eligibility Status. Claim reduced to fifteen Hospital Bedhold Days for stays exceeding fifteen days. This detail is denied. Provider Must Have A CLIA Number To Bill Laboratory Procedures. Invalid Procedure Code For Dx Indicated. Medicare Claim Copy And EOMB Have Been Submitte d For Processing Of Coinsurance And Deductible. NDC was reimbursed at generic WAC (Wholesale Acquisition Cost) rate. Denied due to Medicare Allowed Amount Is Greater Than Total Billed Amount. If it is medical necessary for more than 13 or 14 services per calendar month, submit an adjustment request with supporting documentation. Prosthodontic Services Appear To Have Started After Member EligibilityLapsed. A Training Payment Has Already Been Issued To A Different NF For This CNA. Claim Or Adjustment/reconsideration Request Should Include An Operative Or Pathology Report For This Procedure. Previously Denied Claims Are To Be Resubmitted As New-day Claims. Questionable Long Term Prognosis Due To Gum And Bone Disease. Header Rendering Provider number is not found. Denied due to Detail Billed Amount Missing Or Zero. Denied due to Take Home Drugs Not Billable On UB92 Claim Form. 0; Edentulous Alveoloplasty Requires Prior Authotization. Escalations. Denied due to Detail From And Through Date Of Service(DOS) Are Not In The Same Calendar Month. Surgical Procedure Code billed is not appropriate for members gender. DME rental beyond the initial 180 day period is not payable without prior authorization. Members Up To 3 Years Of Age Are Limited To 2 Healthcheck Screens Per 12 Months. Secondary Diagnosis Code (dx) is not on file. A Less Than 6 Week Healing Period Has Been Specified For This PA. Claim cannot contain both Condition Codes A5 and X0 on the same claim. Recd Beyond 90 Days Special Filing Deadline FOr System Generated Adjmts/Medicare X-overs/Other Insurance Reconsideration/Cou rt Order/Fair Hearing. Duplicate ingredient billed on same compound claim. Review Billing Instructions. Billing Provider is not certified for the Dispense Date. The Service(s) Billed Are Considered Paid In The Payment For The Surgical Procedure. Denied. Claim Denied. Procedure not allowed for the CLIA Certification Type. Training Reimbursement DeniedDue To late Billing. HMO Payment Equals Or Exceeds Hospital Rate Per Discharge. Normal delivery payment includes the induction of labor. CPT Code And Service Date For Member Is Identical To Another Claim Detail On File For Provider On Claim. Plan options will be available in 25 states, including plans in Missouri . Please Refer To The Original R&S. Services Billed On This Claim/adjustment Have Been Split to Facilitate Processing. WellCare Known Issues List Please be advised: Claims that have either rejected or denied . Prescriptions Or Services Must Be Billed As ASeparate Claim. Additional servcies may be billed with H0046 and will count toward mental health and/or substance abuse treatment policy limits for prior authorization. ICD-9-CM Diagnosis code in diagnosis code field(s) 1 through 9 is missing or incorrect. Please Correct And Resubmit. The taxonomy code for the attending provider is missing or invalid. Backdating Allowed Only In Cases Of Retroactive Member/provider Eligibility. Denied due to Procedure Billed Not A Covered Service For Dates Indicated. Denied due to The Members Last Name Is Incorrect. No More Than 2 Medication Check Services (30 Minutes) Are Payable Per Date Of Service(DOS). Member Name Missing. The Procedure Code/Modifier combination is not payable for the Date Of Service(DOS). 2434. Men. Reimbursement For Training Is One Time Only. Prior Authorization Required For Day Treatment Services If Members FunctionalAssessment Negative. Please Use This Claim Number For Further Transactions. Refill Indicator Missing Or Invalid. Anesthesia Modifying Services Must Be Billed Separately From The Charge For Anesthesia Base And Time Units. Secondary Diagnosis Code(s) in positions 2-9 cannot duplicate the Primary Discharge Diagnosis. The Second Other Provider ID is missing or invalid. 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. 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. Annual Physical Exam Limited To Once Per Year By The Same Provider. Additional information is needed for unclassified drug HCPCS procedure codes. The Information Provided Indicates Regression Of The Member. Please Correct And Resubmit. Other Insurance Disclaimer Code Used Is Inappropriate For This Members Insurance Coverage. The Service Requested Was Performed Less Than 5 Years Ago. Provider Not Eligible For Outlier Payment. Invalid Admission Date. Assessment Is Not A Covered Service Unless All Four Components Of Skilled Nursing Are Present: Assessment, Planning, Intervention And Evaluation. Independent Nurses, Please Note Payable Services May Not Exceed 12 Hours/dayOr 60 Hours/week. Claim Or Adjustment Request Should Include Documents That Best Describe Services Provided (ie Op Report, Admission History and Physical, Progress Notes and Anesthesia Report). Paid In Accordance With Dental Policy Guide Determined By DHS. Occurance code or occurance date is invalid. Please Resubmit Medicares Nursing Home Coinsurance Days As A New Claim RatherThan An Adjustment/reconsideration Request. Timeframe Between The CNAs Training Date And Test Date Exceeds 365 Days. 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. Drugs Prescribed and Filled on the Same Day, Cannot have a Refill Greater thanZero. Initial Visit/Exam limited to once per lifetime per provider. Suspend Claims With DOS On Or After 7/9/97. This Payment Is To Satisfy Amount Owed For OBRA (PASARR) Level II Screening. NCPDP Format Error Found On Medicare Drug Claim. A traditional dispensing fee may be allowed for this claim. The sum of the Accommodation Days is not equal to the sum of Covered plus Non-Covered Days, or the From and To Dates of Service cannot be the same. The Member Does Not Meet The Criteria For Binaural Amplification; One Hearing Aid Is Authorized. Patient Status Code is incorrect for Long Term Care claims. Denied. The Service Requested Is Inappropriate For The Members Diagnosis. Medical record number If a medical record number is used on the provider's claim, that number appears here. Claim Denied. The Information Provided Indicates This Member Is Not Willing Or Able To Participate Inaftercare/continuing Care Services And Is Therefore Not Eligible For AODA Day Treatment. This claim is eligible for electronic submission. Wk. Individual Test Paid. PleaseReference Payment Report Mailed Separately. The National Drug Code (NDC) is not a benefit for the Date Of Service(DOS). Claim Denied. Subsequently hospital care services (CPT 99221-99223 or 99231-99233) will be denied when billed for the same date of service as observation services (CPT G0378, 99218-99220 or 99224-99226) for Bill Type 0130-013Z (hospital outpatient). Prior Authorization is required for service(s) exceeding mental health and/or substance abuse benefit guidelines. Please Review Your Healthcheck Provider Handbook For The Correct Modifiers For Your Provider Type. A Trading Partner Agreement/profile Form(s) Authorizing Electronic Claims Submission Is Required. The Service Requested Is Covered By The HMO. All ESRD clinical diagnostic laboratory tests must be billed individually to ensure that automated multi-chanel chemistry tests are paid in accordance with the Medicare Provider Reimbursement Manual (PRM) 2711. Fourth Other Surgical Code Date is required. Timely Filing Deadline Exceeded. Denied. This claim is being denied because it is an exact duplicate of claim submitted. Denied. No Separate Payment For IUD. Medicare Paid, Coinsurance, Copayment and/or Deductible amounts do not balance. The Members Clinical Profile/diagnosis Is Not Within Diagnostic Limitations for Psychotherapy Services.