wellcare eob explanation codes

If you are still unable to resolve the login problem, read the troubleshooting steps or report your issue. Claim Or Adjustment/reconsideration Request Should Include An Operative Or Pathology Report For This Procedure. Formal Speech Therapy Is Not Needed. Only the initial base rate is payable when waiting time is billed in conjunction with a round trip. Reimbursement for this procedure and a related procedure is limited to once per Date Of Service(DOS). Please Refer To The Original R&S. Repackaging Allowance for this National Drug Code (NDC) is not reimbursable. The procedure code has Family Planning restrictions. Personal Care Services Exceeding 30 Hours Per 12 Month Period Per Member Require Prior Authorization. The medical record request is coordinated with a third-party vendor. Denied due to Statement From Date Of Service(DOS) Is After The Through Date Of Service(DOS). Use The ICN which Is In An Allowed Or Paid Status When Filing An Adjustment/ReconsiderationRequest. If A Reporting Form Is Not Submitted Within 60 Days, The claim detail will be denied. Certifying Agency Verified Member Was Not Eligible for Dates Of Services. Medicare covered Codes Explanation Bill The Single Appropriate Code That Describes The Total Quantity Of Tests Performed. Watch FutureRemittance And Status Reports For Its Finalization Before Resubmitting. A valid Referring Provider ID is required. Claim Denied. This Service Is Covered Only In Emergency Situations. The Performing Or Billing Provider On The Claim Does Not Match The Billing Provider On Theprior Authorization File. An xray or diagnostic urinalysis is reimbursable only when performed on the same Date Of Service(DOS) and billed on the same claim as the initial office visit. Routine foot care Diagnoses must be billed with valid routine foot care Procedure Codes. Revenue Code 0001 Can Only Be Indicated Once. Good Faith Claim Denied For Timely Filing. Documentation Does Not Justify Fee For ServiceProcessing . Note: This PA Request Has Been Backdated A Maximum Of 3 Weeks Prior To Its First Receipt By EDS, Based Upon Difficulty In Obtaining The Physicians Written Prescription. For FQHCs, place of service is 50. Member eligibility file indicates that BadgerCare Plus Benchmark, CorePlan or Basic Plan member. Amount Paid On Detail By WWWP Is Less Than Billed Or Reimbursement Rate Due ToPrior Payment By Other Insurance. WellCare 5010 837P FFS Claims Companion Guide Claim Denied/Cutback. Pharmacuetical care limitation exceeded. Home Health, Personal Care And Private Duty Nursing Services Are Subject To A Monthly Cap. This Member Has Completed Intensive AODA Treatment Within The Past 12 Months and Documentation Provided Is Not Adequate To Justify Intensive Treatment at this time. A valid header Medicare Paid Date is required. Please Resubmit With The Costs For Sterilization Related Charges Identified As Non-covered Charges On The Claim. 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. The Primary Diagnosis Code is inappropriate for the Surgical Procedure Code. Critical care performed in air ambulance requires medical necessity documentation with the claim. Claim Denied For No Client Enrollment Form On File. The Surgical Procedure Code is not payable for Wisconsin Chronic Disease Program for the Date Of Service(DOS). Denials with solutions in Medical Billing; Denials Management - Causes of denials and solution in medical billing; Medical Coding denials with solutions The Procedure Code is not reimbursable for the Rendering Provider Type and/or Specialty. Active Treatment Dose Is Only Approved Once In Six Month Period. Purchase of additional DME/DMS item exceeding life expectancy rRequires Prior Authorization. Claim Denied Due To Absent Or Incorrect Discharge (to) Date. This Payment Is To Satisfy The Amount Owed For OBRA Level 1. Serviced Denied. Billing Tips - Wellcare NC Claims and Billing | NC Medicaid - NCDHHS Dispense Date Of Service(DOS) exceeds Prescription Date by more than one year. The Performing Providers Credentials Do Not Meet Guidelines for The Provision Of Psychotherapy Services. Member is enrolled in a commercial health insurance on the Dispense Date Of Service(DOS). This Mutually Exclusive Procedure Code Remains Denied. An Approved AODA Day Treatment Program Cannot Exceed A 6 Week Period. 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. Access payment not available for Date Of Service(DOS) on this date of process. Only One Panoramic Film Or Intraoral Radiograph Series, By The Same Provider, Per Year Allowed. Denied. Please Review Remittance And Status Report. HCPCS Procedure Code is required if Condition Code A6 is present. 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). The Service/procedure Proposed Is Not Supported By Submitted Documentation. Reimbursement For Training Is One Time Only. Contact Provider Services For Further Information. Day Treatment Services For Members With Inpatient Status Limited To 20 Hours. For Newly Certified CNAs, Date Of Inclusion Is T heir Test Date. Unable To Process This Request Because The Competency Test Date And TrainingCompletion Date Fields Are Blank. 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. The header total billed amount is required and must be greater than zero. Denied. CSHCN number The client's CSHCN Services Program number. 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. This Modifier has been discontinued by CMS or AMA for the Date Of Service(DOS)(s). Denied. Claim Denied. Member is not Medicare enrolled and/or provider is not Medicare certified. Denied/Cutback. Denied due to Diagnosis Not Allowable For Claim Type. WellCare Known Issues List EOP Denial Code or Rejection Reason Code Issue Description Impacted Provider Specialty . Unable To Process This Request Due To Either Missing, Invalid OrMismatched National Provider Identifier # (NPI)/Provider Name/POP ID. No Interim Billing Allowed On Or After 01-01-86. Documentation You Have Submitted Does Not Meet The Requirements Of HSS 107.09(4)(k). We update the Code List to conform to the most recent publications of CPT and HCPCS . The training Completion Date On This Request Is After The CNAs CertificationTest Date. Pricing Adjustment/ Medicare crossover claim cutback applied. Pricing Adjustment/ Traditional dispensing fee applied. A Total Charge Was Added To Your Claim. Two different providers cannot be reimbursed for the same procedure for the same member on the same Date Of Service(DOS). Intraoral Complete Series/comprehensive Oral Exam Limited To Once Every Three Years, Unless Prior Authorized. Dollar Amount Of Claim Was Adjusted To Correct Mathematical Error. Inpatient psychiatric services are not reimbursable for members age 21 65 (age 22 if receiving services prior to 21st birthday). Referral Codes Must Be Indicated For W7001, W7002, W7003, W7006, W7008 And W7013. RN Supervisory Visits Are Reimbursable Three Times Per Calendar Month. Dental service limited to twice in a six month period. A Less Than 6 Week Healing Period Has Been Specified For This PA. An antipsychotic drug has recently been dispensed for this member. This list was formerly published as Part 6 of the administrative and billing instructions in Subchapter 5 of your MassHealth provider manual. Claim Denied The Combined Medicare And Private Insurance Payments Equal Or Exceed The Lesser Of The And Medicare Allowable Amounts. Condition code 20, 21 or 32 is required when billing non-covered services. The Surgical Procedure Code is not payable for /BadgerCare Plus for the Date Of Service(DOS). Individual Test Paid. Resubmit Claim Once Election Form Requirements Are Met Per The Hospice Provider Handbook. Procedure Denied Per DHS Medical Consultant Review. The Clinical Profile/Diagnosis Makes This Member Ineligible For AODA Services. This Dental Service Limited To Once A Year. A valid Prior Authorization is required for non-preferred drugs. Claim Is Pended For 60 Days. Medicare Disclaimer Code invalid. Denied/Cutback. Please Clarify. The Primary Diagnosis Code is inappropriate for the Procedure Code. Member has commercial dental insurance for the Date(s) of Service. 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. Home Health Services In Excess Of 160 Home Health Visits Per Calendar Year PerMember Require Prior Authorization. The Revenue/HCPCS Code combination is invalid. Pricing Adjustment/ Payment amount increased based on hospital access paymentpolicies. Billing Provider is restricted from submitting electronic claims. Request Denied Because The Screen Date Is After The Admission Date. is unable to is process this claim at this time. Please Indicate Anesthesia Time For Services Rendered. Normal delivery payment includes the induction of labor. Consultation or surgical procedures are not reimbursable in conjuctions with Emergency Room services. Member has Medicare Managed Care for the Date(s) of Service. Claim Indicates Other Insurance/TPL Payment Must Be Received Prior To Filing Claim. Designated codes for conditions such as fractures, burns, ulcers and certain neoplasms require documentation of the side/region of the body where the condition occurs. These are EOB codes, revised for NewMMIS, that may appear on your PDF remittance advice. Code. The From Date Of Service(DOS) for the Second Occurrence Span Code is required. This Unbundled Procedure Code Remains Denied. Pricing Adjustment/ Provider Level of Care (LOC) pricing applied. Gastrointestinal Surgery For The Purpose Of Weight Control Is Covered Only As An Emergency Procedure. Please Resubmit Corr. Bilateral Surgeries Reimbursed At 150% Of The Unilateral Rate. Prior Authorization (PA) is required for this service. Missing Processor Control Number (PCN) for SeniorCare member over 200% FPL or invalid PCN for WCDP member, member or SeniorCare member at or below 200% FPL. This National Drug Code (NDC) is only payable as part of a compound drug. Claim or Adjustment received beyond 730-day filing deadline. A Photocopy Of The PA Request Form Has Been Mailed Separately Identifying the Reimbursement Rate For The Procedure Codes Authorized. Please Indicate Separately On Each Detail. The initial rental of a negative pressure wound therapy pump is limited to 90 days; member lifetime. EOB Codes are present on the last page of remittance advice, these EOB codes or explanation of benefit codes are in form of numbers and every number has a specific meaning. Strong knowledge of adjustment and denial reason codes from Electronic Remittance Advices (ERA/835 files) and from paper Explanation of benefits (EOB's) / Explanation of payments (EOP's), CPT and ICD10 codes; Excellent interpersonal and communication skills with professional demeanor and positive attitude The Total Number Of Hours Per Day Requested For AODA Day Treatment Exceeds Guidelines And The Request Has Been Adjusted Accordingly. This Member Is Involved In Non-covered Services, And Hours Are Reduced Accordingly. Surgical Procedure Code is not related to Principal Diagnosis Code. Procedure Code Used Is Not Applicable To Your Provider Type. Exceeds The 35 Treatment Days Per Spell Of Illness. If you are still unable to resolve the login problem, read the troubleshooting steps or report your issue. This Claim Is A Reissue of a Previous Claim. Timely Filing Deadline Exceeded. Avoiding denial reason code CO 22 FAQ Q: We received a denial with claim adjustment reason code (CARC) CO 22. . Healthcheck screenings or outreach is limited to six per year for members up to one year of age. Pregnancy Indicator must be "Y" for this aid code. Fifth Other Surgical Code Date is required. Services Can Only Be Authorized Through One Year From The Prescription Date. Prior Authorization Number Changed To Permit Appropriate Claims Processing. Your Adjustment/reconsideration Request For Additional Payment Has Been Denied, Request Was Received Beyond The 90 Day Requirement For Payment Reconsideration. Details Include Revenue/surgical/HCPCS/CPT Codes. Excessive height and/or weight reported on claim. Copyright 2023 Wellcare Health Plans, Inc. New Coding Integrity Reimbursement Guidelines. Default Prescribing Physician Number XX9999991 Was Indicated. WellCare 2016 NA_11_16 NA6PROGDE80121E_1116 . Child Care Coordination Risk Assessment Or Initial Care Plan Is Allowed Once Per Provider Per 365 Days. Denied. Payment For Immunotherapy Service Included In Reimbursement For Allergy Extract Injection. 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. Please Furnish A NDC Code And Corresponding Description. Determinations as to whether services are reasonable and necessary for an individual patient should be made on the same basis as all other such determinations: with reference to accepted standards of medical practice and the medical circumstances of the individual case. Billed Amount Is Equal To The Reimbursement Rate. 0300-0319 (Laboratory/Pathology). Denied due to NDC Is Not Allowable Or NDC Is Not On File. Emergency Services Indicator must be "Y" or Pregnancy Indicator must be "Y" for this aid code. Amount Recouped For Mother Baby Payment (newborn). More Than 5 Consecutive Calendar Days Of Continuous Care Are Not Payable. Prescriber must contact the Drug Authorization and Policy Override Center for policy override. Claims For Sterilization Procedures Must Reflect ICD-9 Diagnosis Code V25.2. EPSDT/healthcheck Indicator Submitted Is Incorrect. Level And/or Intensity Of Requested Service(s) Is Incompatible With Medical Need As Defined In Care Plan. Psych Evaluation And/or Functional Assessment Ser. Denied. Member has Medicare Supplemental coverage for the Date(s) of Service. Denied. Billing Provider is not certified for the detail From Date Of Service(DOS). Limited to once per quadrant per day. Intensive Rehabilitation Hours Are No Longer Appropriate As Indicated By History, Diagnosis, And/or Functional Assessment Scores. EOB Any EOB code that applies to the entire claim (header level) prints here. ACCOM REV CODE QTY BILLED NOT EQUAL TO DTL DOS. Reason Code: 234. Has Already Issued A Payment To Your NF For A Level I Screen With The Same Admission Date. This Member Has Completed Primary Intensive Services And Is Now Only Eligible For after Care/follow-up Hours. The Treatment Request Is Not Consistent With The Members Diagnosis. Pricing Adjustment/ Medicare benefits are exhausted. Continuous home care must be billed in an hourly quantity equal to or greater than eight hours, up to and including 24 hours. According to the American College of Emergency Physicians, the American Heart Association and the American College of Cardiology Foundation, CT, CTA, MRA, MRI should not be performed routinely for evaluation of syncope in the absence of related neurologic signs and symptoms. Medicare Id Number Missing Or Incorrect. Header To Date Of Service(DOS) is invalid. Please Resubmit. Please submit claim to HIRSP or BadgerRX Gold. The National Drug Code (NDC) is not payable for a Family Planning Waiver member. Please Indicate The Revenue Code/procedure Code/NDC Code For Which The Credit is To Be Applied. Capitation Payment Recouped Due To Member Disenrollment. Second Other Surgical Code Date is invalid. Copyright 2023 Wellcare Health Plans, Inc. Prior Authorization is required for manipulations/adjustments exceeding 20 perspell of illness. Anesthesia Modifying Services Must Be Billed Separately From The Charge For Anesthesia Base And Time Units. See Physicians Handbook For Details. This Request Can Only Be Backdated To The Date EDS First Receives The Request In The Mailroom. A Payment For The CNAs Competency Test Has Already Been Issued. Type of Bill is invalid for the claim type. Will Only Pay For One. This Member Has A Current Approved Authorization For Intensive AODA OutpatientServices. Once Therapy Is Prior Authorized, All Therapy Must Be Billed With A Valid Prior Authorization Number. 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. HMO Payment Equals Or Exceeds Hospital Rate Per Discharge. 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. AODA Day Treatment Is Not A Covered Service For Members Who Are Residents Of Nursing Homes or Who Are Hospital Inpatients. Denied due to Greater Than Four Dates Of Service Billed On One Detail. The Eighth Diagnosis Code (dx) is invalid. Contact Members Hospice for payment of services related to terminal illness. The total billed amount is missing or is less than the sum of the detail billed amounts. NDC- National Drug Code is invalid for the Dispense Date Of Service(DOS). Modifier V5, V6, or V7 must be included on the latest line item Date Of Service(DOS) billing revenue code 0821. Denied. No Complete WWWP Participation Agreement Is On File For This Provider. Our Records Indicate This Provider Is Not Certified For AODA Day Treatment. One or more Occurrence Code(s) is invalid in positions nine through 24. Inpatient Respite Care Is Not Covered For Hospice Members Residing In Nursing Homes. Please Review The Covered Services Appendices Of The Dental Handbook. Amount Recouped For Duplicate Payment on a Previous Claim. Services Denied. Dialysis/EPO treatment is limited to 13 or 14 services per calendar month. Procedure Code is allowed once per member per lifetime. Service Denied. Pricing Adjustment/ Ambulatory Surgery pricing applied. To access the training video's in the portal .