wellcare eob explanation codes
Services Requested Do Not Meet The Criteria for an Acute Episode. POS codes are required under the provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA). PLEASE RESUBMIT CLAIM LATER. Men. Amount Recouped For Duplicate Payment on a Previous Claim. Department of Health Services (DHS) Authorized Payment Is Being Withheld Due toa Department Of Justice Settlement. Denied. At Least One Of The Compounded Drugs Must Be A Covered Drug. Denied. Procedure not allowed for the CLIA Certification Type. This Procedure Code Is Not Valid In The Pharmacy Pos System. Claim Denied. Dental service limited to twice in a six month period. NDC was reimbursed at Employer Medical Assistance Contribution (EMAC) rate. If A CNA Obtains his/her Certification After Theyve Been Hired By A NF, A NF Has A Year From Their Certification, Test, Date To Submit A Reimbursement Request To . WellCare_Consult_ManagedProcedureCodeList_2023_20221222 Page 2 of 7 Remote afterloading high dose rate radionuclide interstitial or intracavitary brachytherapy, includes Was Unable To Process This Request. Submitted rendering provider NPI in the detail is invalid. The Surgical Procedure Code is not payable for the Date Of Service(DOS). Do not resubmit. One or more Diagnosis Code(s) in positions 10 through 25 is not on file. Correct And Resubmit. Member has Medicare Supplemental coverage for the Date(s) of Service. Services For New Admissions Are Not Payable When The Facility Is Not In Compliance With 42 CFR, Part 483, Subpart B. Denied. Inpatient mental health services performed by masters level psychotherapists or substance abuse counselors are not covered. Rendering Provider is not a certified provider for Wisconsin Well Woman Program. Reimbursement Is Limited To The Average Monthly Nursing Home Cost And Services Above That Amount Are Considered Non-covered Services. Service is not reimbursable for Date(s) of Service. Secondary Diagnosis Code (dx) is not on file. Denied. . Member is enrolled in a commercial health insurance on the Dispense Date Of Service(DOS). A Version Of Software (PES) Was In Error. This National Drug Code is not covered under the Core Plan or Basic Plan for the diagnosis submitted. Payment Reduced Due To Patient Liability. The Diagnosis Code is not payable for the member. Only One Date For EachService Must Be Used. The quantity billed of the NDC is not equally divisible by the NDC package size. Explanation of benefits. Do Not Indicate NS On The Claim When The NDC Billed Is For A Generic Drug. The Narrative History Does Not Indicate the Members Functioning is Impaired due To AODA Usage. Supervisory visits for Unskilled Cases allowed once per 60-day period. Transplant services not payable without a transplant aquisition revenue code. Wellcare Cvs Caremark Login - bwdkg.bluejeanblues.net The Members Gait Is Not Functional And Cannot Be Carried Over To Nursing. NDC- National Drug Code is not covered on a pharmacy claim. . Member is enrolled in Medicare Part B on the Date(s) of Service. Please Supply The Appropriate Modifier. The Travel component for this service must be billed on the same claim as the associated service. PDF Mississippi Medicaid Explanation of Benefits (EOB) Codes Discharge Diagnosis 2 Is Not Applicable To Members Sex. Prior Authorization (PA) is required for payment of this service. The revenue code has Family Planning restrictions. Original Payment/denial Processed Correctly. Crosswalk - Adjustment Reason Codes and Remittance Advice (RA) Remark Codes to PHC Explanation (EX) Codes Revised 11/16/2020 Page 1 Key: If RA has . Denied. Wellcare Explanation Of Payment Codes USA Health The Member Is School-age And Services Must Be Provided In The Public Schools. That is why we support our provider partners with quality incentive programs, quicker claims payments and dedicated market support. Additional Encounter Service(s) Denied. Day Treatment Services For Members With Inpatient Status Limited To 20 Hours. This Payment Is To Satisfy Amount Owed For A Drug Rebate Prior Quarter Correction. Value codes 48 Homoglobin Reading and 49 Hematocrit Reading, must have a zero in the far right position. Unable To Process Your Adjustment Request due to Provider Not Found. Reimbursement For HCPCS Procedure Code 58300 Includes IUD Cost. Adjustments To Correct Copayment Deductions On date Ranged Claims Are Not Payable. Please Clarify Services Rendered/provide A Complete Description Of Service. Procedure Code is not allowed on the claim form/transaction submitted. Claim Denied Due To Invalid Pre-admission Review Number. Good Faith Claim Denied. Please Correct And Resubmit. This Diagnosis Code Has Encounter Indicator restrictions. Default Prescribing Physician Number XX9999991 Was Indicated. Revenue code submitted is no longer valid. Third modifier code is invalid for Date Of Service(DOS). Explanation of Benefits (EOB) The four-digit explanation of benefits (EOB) codes and the corresponding narratives indicate that the submitted claim paid as billed or describe the reason the claim suspended, was denied, or did not pay in full. Denied. Revenue Codes 0110 (N6) And 0946 (N7) Are Not Payable When Billed On The Same Dateof Service As Bedhold Days. Member enrolled in Tuberculosis-Related Services Only Benefit Plan. Providers must ensure that the E&M CPT codes selected reflect the services furnished. The Member Was Not Eligible For On The Date Received the Request. The Procedure Requested Is Not Allowable For The Process Type Indicated On TheRequest. No Substitution Indicator Invalid For Non-innovator Drugs Not On The Current Wisconsin MAC List. Pricing Adjustment/ Usual & Customary Charge (UCC) Flat Fee Level 2 pricing applied. If it is medical necessary for more than 13 or 14 services per calendar month, submit an adjustment request with supporting documentation. Denied due to Per Division Review Of NDC. This Individual Is Either Not On The Registry Or The SSN On The Request D oesnt Match The SSN Thats Been Inputted On The Registry. Missing or invalid level of effort submitted and/or reason for service, professional service, or result of service code billed in error. subsequent hospital care (CPT 99231-99233) or inpatient consultations (CPT 99251-99255) in the previous week. The Primary Diagnosis Code is inappropriate for the Revenue Code. Description & Use Of Day RX Procedure Codes Based On Members Status-not the place Of Service Where Day Rx Service Performed. Claim Denied. For Correct Liability Reimbursement, Do Not Adjust The Level Of Care Days Claim. codes are provided per day by the same individual physician or other health care professional. The first occurrence span from Date Of Service(DOS) is after the to Date Of Service(DOS). This Incidental/integral Procedure Code Remains Denied. Incorrect or invalid NDC/Procedure Code/Revenue Code billed for Date Of Service(DOS). Diagnosis 635-635.92 May Only Be Used When Billing For Abortion Procedures. These same rules are used by most healthcare claims payers and enforced by the Centers for Medicare and Medicaid Services. Other Medicare Part B Response not received within 120 days for provider basedbill. Documentation Does Not Justify Fee For ServiceProcessing . TPA Certification Required For Reimbursement For This Procedure. This change to be effective 4/1/2008: Submission/billing error(s). 51.42 Board Directors Or Designees Statement & Signature Required OnThe Claim Form For Payment Of Functional Assessment. Claim Must Indicate A New Spell Of Illness And Date Of Onset. Member enrolled in QMB-Only Benefit plan. The member has no Level of Care (LOC) authorization on file or the LOC on filedoes not match the LOC on the claim. Supplemental Payment Authorized By Department of Health Services (DHS) Due to an Interim Rate Settlement. Other Therapies Currently Provide Sufficient Services To Meet The Members Needs. Drug Dispensed Under Another Prescription Number. Number On Claim Does Not Match Number On Prior Authorization Request. PDF How to read EOB codes - Washington This Procedure, When Billed With Modifier HK, Is Payable Only If The Member Is Under The Age Of 19. Multiple Prescriptions For Same Drug/ Same Fill Date, Not Allowed. A Less Than 6 Week Healing Period Has Been Specified For This PA. Invalid modifier removed from primary procedure code billed. Billing Provider Name Does Not Match The Billing Provider Number. Revenue code 082X is present on an ESRD claim which also contains revenue code088X (X frequency non equal to 9). The Tooth Is Not Essential To Maintain An Adequate Occlusion. Based on reimbursement guidelines it is not appropriate for providers to bill inpatient Evaluation and Management (E/M) services while the patient is in an observation status. Due To Miscellaneous Or Unspecified Reason, Adjustment/Resubmission was initiated by Provider, Adjustment/Resubmission was initiated by DHS, Adjustment/Resubmission was initiated by EDS, Adjustment Generated Due To Change In Patient Liability, Payout Processed Due To Disproportionate Share. Purchase of a blood glucose monitor includes the first 30 days of supplies for the monitor. Denied. An amount in the Gross Amount Due field and/or Usual and Customary Charge field is required. Excessive height and/or weight reported on claim. Not A WCDP Benefit. Service Denied. The initial rental of a negative pressure wound therapy pump is limited to 90 days; member lifetime. Multiple Providers Of Treatment Are Not Indicated For This Member. Cutback/denied. Therefore itIs Not Necessary To Wait The Full 6 Weeks After Extractions Before Taking Denture Impressions. 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 . Claim Denied. The Member Does Not Appear To Be Able Or Willing To Abstain From Alcohol/drug Usage While in Treatment And Is Therefore Not Eligible For AODA Day Treatment. BMN prior authorization may be submitted for Mental Health drugs for which a Core Plan transitioned member has been previously grandfathered. Previously Paid Individual Test May Be Adjusted Under a Panel Code. Non-covered Charges Are Missing Or Incorrect. The Timeframe Between Certification, Test, Date And Hire Date Exceeds A Year. You Must Adjust The Nursing Home Coinsurance Claim. These Supplies/items Are Included In The Purchase Of The Dme Item Billed On The Same Date Of Service(DOS). Reason Code 234 | Remark Codes N20 - JD DME - Noridian Medicare RA/EOMB And Claim Dates And/or Charges Do Not Match. The Information Provided Is Not Consistent With The Intensity Of Services Requested. CNAs Eligibility For Training Reimbursement Has Expired. Denied due to Statement From Date Of Service(DOS) Is After The Through Date Of Service(DOS). Third Diagnosis Code (dx) (dx) is not on file. A valid procedure code is required on WWWP institutional claims. 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). From Date Of Service(DOS) is before Admission Date. Reason/Remark Code Lookup To better assist you, please first select your state. The National Drug Code (NDC) is not on file for the Dispense Date Of Service(DOS). The Requested Transplant Is Not Covered By . Billing or Rendering Provider certification is cancelled for the From Date Of Service(DOS). These are EOB codes, revised for NewMMIS, that may appear on your PDF remittance advice. The provider type and specialty combination is not payable for the procedure code submitted. Separate reimbursement for drugs included in the composite rate is not allowed. Established in 1975 and incorporated in 1987, WPC is widely recognized as a leading expert in supporting the development, publishing, and licensing of complex . Accommodation Days Missing/invalid. Please adjust quantities on the previously submitted and paid claim. Claim paid according to Medicares reimbursement methodology. Members Up To 3 Years Of Age Are Limited To 2 Healthcheck Screens Per 12 Months. An approved PA was not found matching the provider, member, and service information on the claim.