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An ICD-9-CM Diagnosis Code of greater specificity must be used for the First Diagnosis Code. Rimless Mountings Are Not Allowable Through . These codes provide additional explanation for an adjustment already described by a Claim Adjustment Reason Code (CARC) or convey information about remittance processing. These materials include the HPMS memorandum titled, "Updates Regarding Final Part C EOB Model Templates and Implementation of the Part C EOB," the final templates and instructions, and Frequently Asked Questions regarding the Part C EOB requirements for Medicare Advantage . An approved PA was not found matching the provider, member, and service information on the claim. 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. Intensive Multiple Modality Treatment Is Not Consistent With The Information Provided. Claim Denied. trevor lawrence 225 bench press; new internal . Claim Is Being Reprocessed Through The System. HTTP Status Code Connect Time (ms) Result; 2023-03-01 04:10:52: 200: 255: Page Active: Will Not Authorize New Dentures Under Such Circumstances. The header total billed amount is required and must be greater than zero. Medicare Copayment Out Of Balance. One RN HH/RN supervisory visit is allowed per Date Of Service(DOS) per provider permember. If laboratory costs exceed reimbursement, submit a claim adjustment request with lab bills for reconsideration. Provider Is Responsible For Averaging Costs During Cal Year Not To Exceed YrlyTotal (12 x $2325.00). 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. The Billing Providers taxonomy code is missing. Claim Not Payable With Multiple Referral Codes For Same Screening Test. Denied by Claimcheck based on program policies. Services Requiring Prior Authorization Cannot Be Submitted For Payment On A Claim In Conjunction With Non Prior Authorized Services. Check Your Current/previous Payment Reports forPayment. Eighth Diagnosis Code (dx) is not on file. Detail To Date Of Service(DOS) is invalid. Seventh Occurrence Code Date is required. PLEASE RESUBMIT CLAIM LATER. Reimbursement determination has been made under DRG 981, 982, or 983. Please Supply The Appropriate Modifier. Denied. Has Processed This Claim With A Medicare Part D Attestation Form. Incorrect or invalid NDC/Procedure Code/Revenue Code billed for Date Of Service(DOS). Speech Therapy Limited To 45 Treatment Days Per Spell Of Illness W/o Prior Authorization. This claim has been adjusted due to a change in the members enrollment. Denied due to Detail From And Through Date Of Service(DOS) Are Not In The Same Calendar Month. This claim has been adjusted due to Medicare Part D coverage. The maximum number of details is exceeded. Changes/corrections Were Made To Your Claim Per Dental Processing Guidelines. One or more Diagnosis Code(s) is not payable by Wisconsin Chronic Disease Program for the Date Of Service(DOS). OA 12 The diagnosis is inconsistent with the provider type. Please Correct And Resubmit. If it is medically necessary to exceed the limitation, submit an Adjustment/Reconsideration request with supporting documentation. By continuing to use our site, you agree to our Privacy Policy and Terms of Use. Documentation You Have Submitted Does Not Meet The Requirements Of HSS 107.09(4)(k). Prior Authorization Required For Day Treatment Services If Members FunctionalAssessment Negative. This Payment Is A Refund For An Overpayment Of A Provider Assessment, Thank You For Your Assessment Payment By Check, In Accordance With Your Request, EDS Has Deducted Your Assessment From This Payment. 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 Functional Assessment Indicates This Member Has Less Than A 50% Likelihoodof Benefit, Therefore Day Treatment Is Not Appropriate. Additional Psychotherapy Is Not Considered Appropriate Or Inline With More Effective, Available Services. Please Submit With Completed timely Filing Form In The All Provider Handbook And Supporting Documentation. Inpatient Respite Care Is Not Covered For Hospice Members Residing In Nursing Homes. Due To Non-covered Services Billed, The Claim Does Not Meet The Outlier Trim Point. wellcare eob explanation codes. Denied. Procedimientos. The detail From or To Date Of Service(DOS) is missing or incorrect. Services Requested Do Not Meet The Criteria for an Acute Episode. Occupational Therapy Limited To 45 Treatment Days Per Spell Of Illness w/o Prior Authorization. Well-baby visits are limited to 12 visits in the first year of life. A Photocopy Of The PA Request Form Has Been Mailed Separately Identifying the Reimbursement Rate For The Procedure Codes Authorized. This Is A Manual Decrease To Your Accounts Receivable Balance. The Value Code and/or value code amount is missing, invalid or incorrect. Reconsideration With Documentation Warranting More X-rays. A WCDP drug rebate agreement for this drug is not on file for the Date Of Service(DOS). Reimbursement Based On Members County Of Residence. Please Correct And Resubmit. Denied due to Procedure Or Revenue Code(s) Are Missing On The Claim. Denied. The detail From Date Of Service(DOS) is invalid. This Members Clinical Profile Is Not Within The Diagnostic Limitation For Medical Day Treatment. This is a duplicate claim. Payment Authorized By Department of Health Services (DHS) To Be Recouped at a Later Date. Assistant Surgery Must Be Billed Separately By The Assistant Surgeon With Modifier 80. Member In TB Benefit Plan. We Have Determined There Were (are) Several Home Health Agencies Willing To Provide Medically Necessary Skilled Nursing Services To This Member. No Reimbursement Rates on file for the Date(s) of Service. WI Can Not Issue A NAT Payment Without A Valid Hire Date. Pricing Adjustment/ Repackaging dispensing fee applied. 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. A HCPCS code is required when condition code A6 is included on the claim. Denied. More Than 5 Consecutive Calendar Days Of Continuous Care Are Not Payable. Initial Visit/Exam limited to once per lifetime per provider. Prescriptions Or Services Must Be Billed As ASeparate Claim. Per Information From Insurer, Claims(s) Was (were) Paid. Reason Code 161: Attachment referenced on the claim was not received in a timely fashion. Principle Surgical Procedure Code Date is missing. 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 . Use Of Therapy Equipment Alone Is Not Sufficient To Justify Maintenance Therapy. 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. Rendering Provider is not a certified provider for . Panel And Individual Test Not Payable For Same Member/Provider/ Date Of Service(DOS). Valid Numbers Are Important For DUR Purposes. The Date Of The Screening Request Or The Date Of Screening Is Invalid Or Missing. The Narrative History Does Not Indicate the Members Functioning is Impaired due To AODA Usage. Ninth Diagnosis Code (dx) is not on file. The Fourth Occurrence Code Date is invalid. 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). Payment reduced. More than 6 hours of evaluation/assessment in a 2 year period must be billed astreatment services and count toward the MH/SA policy limits for prior authorization. Service(s) Denied By DHS Transportation Consultant. Reason Code 159: State-mandated Requirement for Property and Casualty, see Claim Payment Remarks Code for specific explanation. Denied. Ancillary Billing Not Authorized By State. Only Medicare crossover claims are reimbursable. Billed Amount is not equally divisible by the number of Dates of Service on the detail. Acute Care General And Specialty Hospitals Are Subject To Pre-admission Requirements Or The Pre-admission Review Number Indicated Is Invalid. Secondary Diagnosis Code (dx) is not on file. Effective 5/31/2019, we will introduce new Coding Integrity Reimbursement Guidelines. Learn more about Ezoic here. Refer To Notice From DHS. These case coordination services exceed the limit. Occupational therapy limited to 35 treatment days per lifetime without prior authorization. Our Records Indicate You Have Billed More Than One Unit Dose Dispensing Fee For This Calendar Month. Claims may deny the chest X-ray billed when the only diagnoses is one of the following routine screening diagnoses: General medical exam (ICD-10 codes Z00.0-Z00.01, Z00.5, Z00.6, Z00.8), Pre-admission/administrative exam (ICD-10 codes Z02.0-Z02.6, Z02.8-Z02.89, Z04.6), Pre-operative exam (ICD-10 codes Z01.810-Z01.811, Z01.818), FL 42 Revenue Code Required. A Google Certified Publishing Partner. An Individual CBC Or Chemistry Test With A CBC Or Chemistry Panel, Performed Per Member/Provider/Date Of Service Must Be Billed w/ Appropriate Panel Code. In the above example the claim was denied with two codes, the Adjustment Reason Code of 16 and then the explanatory Remark Code of N329 (Missing/incomplete/invalid patient birth date). Rental Only Allowed; Medical Need For Purchase Has Not Been Documented. The Value Code(s) submitted require a revenue and HCPCS Code. Medical record number If a medical record number is used on the provider's claim, that number appears here. Request was not submitted Within A Year Of The CNAs Hire Date. Detail Rendering Provider certification is cancelled for the Date Of Service(DOS). Please Correct And Resubmit. SMV Mileage Exceeding 40 Miles In Urban Counties Or 70 Miles In Rural CountiesRequires Prior Authorization. Bill The Single Appropriate Code That Describes The Total Quantity Of Tests Performed. Pricing Adjustment/ Maximum Flat Fee pricing applied. 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. Documentation Provided Indicates A Less Elaborate Procedure Should Be Considered. It is a duplicate of another detail on the same claim. One or more Diagnosis Codes has a gender restriction. Approved. CO/204/N182 . Submit Claim To Other Insurance Carrier. Reimbursement limit for all adjunctive emergency services is exceeded. Multiple Tooth Extract On Same Date Of Service(DOS) Must Be Billed As Single And Additional Tooth Extract In Same Quadrant. This Claim Has Been Denied Due To A POS Reversal Transaction. This service is not covered under the ESRD benefit. Reimbursement for this procedure and a related procedure is limited to once per Date Of Service(DOS). Submitted rendering provider NPI in the header is invalid. Pediatric Community Care is limited to 12 hours per DOS. For RHCs, place of service is 72, however, you can bill lab services with a place of service 11. The Performing Or Billing Provider On The Claim Does Not Match The Billing Provider On Theprior Authorization File. Surgical Procedure Code billed is not appropriate for members gender. Valid Numbers AreImportant For DUR Purposes. Medicare Id Number Missing Or Incorrect. 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. The training Completion Date On This Request Is After The CNAs CertificationTest Date. PleaseResubmit Charges For Each Condition Code On A Separate Claim. Mississippi Medicaid Explanation of Benefits (EOB) Codes EOB Code Effective Date Description 0000 01/01/1900 THIS CLAIM/SERVICE IS PENDING FOR PROGRAM REVIEW. Outside Lab Indicator Must Be Y For The Procedure Code Billed. Unable To Process Your Adjustment Request due to Member ID Number On The Claim And On The Adjustment Request Do Not Match. ICD-9-CM Diagnosis code in diagnosis code field(s) 1 through 9 is missing or incorrect. This Member Appears To Continue To Abuse Alcohol And/or Other Drugs And Is Therefore Not Eligible For Day Treatment. Diag Restriction On ICD9 Coverage Rule edit. Denied. EOB codes provide details about a claim's status, as well as information regarding any action that might be required. Procedure Code and modifiers billed must match approved PA. 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. ACTION TYPE LEGEND: If some of the services were previously paid, submit an adjustment/reconsideration request for the paid claim. Referring Provider is not currently certified. Physical Therapy, Occupational Therapy Or Speech Therapy Limited To 90 Min PerDay. qatar to toronto flight status. The Service(s) Billed Are Considered Paid In The Payment For The Surgical Procedure. 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 procedure code and modifier combination is not payable for the members benefit plan. Medicare paid amount(s) have been incorrectly applied to both the claim headerand details. Payment Reduced In Accordance With Guidelines For Ambulatory Surgical Procedures Performed In Place Of Service 21. Original Payment/denial Processed Correctly. Always bill the correct place of service. This Member is enrolled in Wisconsin or BadgerCare Plus for Date(s) of Service. Description. Fourth Other Surgical Code Date is invalid. This Program Does Not Appear To Meet The Minimum Requirement For AODA Day Treatment Programming (10hrs) And Does Not Qualify For Aoda Day Treatment. 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. The Materials/services Requested Are Principally Cosmetic In Nature. Area of the Oral Cavity is required for Procedure Code. NDC was reimbursed at brand WAC (Wholesale Acquisition Cost) (Wholesale Acquisition Cost) rate. Denied. The Diagnosis Code is not payable for the member. Supervisory visits for Unskilled Cases allowed once per 60-day period. Denied. Denied. Discharge Diagnosis 3 Is Not Applicable To Members Sex. You should receive it within 30 to 60 days of services provided, but it's not an official bill. Denied. The Medical Need For This Service Is Not Supported By The Submitted Documentation. The Primary Occurrence Code Date is invalid. Personal Care Services Exceeding 30 Hours Per 12 Month Period Per Member Require Prior Authorization. The National Drug Code (NDC) submitted with this HCPCS code is CMS terminated or not covered by the program. Serviced Denied. Our Records Indicate This Provider Is Not Certified For AODA Day Treatment. Services billed are included in the nursing home rate structure. Value codes 48 Homoglobin Reading and 49 Hematocrit Reading, must have a zero in the far right position. Physical Therapy Treatment Limited To One Modality, One Procedure, One Evaluation Or One Combination Per Day. Services Not Payable When Rendered To An Individual Aged 21-64 Who Is A Resident Of A Nursing Home Imd. The Procedure Code Indicated Is For Informational Purposes Only. Admit Diagnosis Code is invalid for the Date(s) of Service. Correct And Resubmit. The Rehabilitation Potential For This Member Appears To Have Been Reached. Suspend Claims With DOS On Or After 7/9/97. Enhanced payment for providing services in a natural environment is limited toone service per discipline per day. Supplemental Payment Authorized By Department of Health Services (DHS) Due to a Department Of Justice Settlement. Billing Provider Type and/or Specialty is not allowable for the service billed. Revenue code 082X is present on an ESRD claim which also contains revenue code088X (X frequency non equal to 9). Procedure Code Modifier(s) Invalid For Date Of Service(DOS) Or For Prior Authorization Date Of Receipt. A more specific Diagnosis Code(s) is required. Non-preferred Drug Is Being Dispensed. According to the AMA CPT Manual and our policy, an initial inpatient admission (CPT 99221-99223) is allowed once every seven days. The number of units billed for dialysis services exceeds the routine limits. Continuous home care and routine home care may not be billed for the same member on the same Date Of Service(DOS). Dialysis/EPO treatment is limited to 13 or 14 services per calendar month. The Evaluation Was Received By Fiscal Agent More Than Two Weeks After The Evaluation Date. Individual Replacements Reimbursed As Dispensing A Complete Appliance. The Rendering Providers taxonomy code in the detail is not valid. Oral exams or prophylaxis is limited to once per year unless prior authorized. This Member Has A Current Approved Authorization For Intensive AODA OutpatientServices. EOB Codes List|Explanation of Benefit Reason Codes (2023) February 7, 2022 by medicalbillingrcm. If you have questions regarding your remittance advice, please contact our Provider Call Center at 1-888-FIDELIS (1-888-343-3547) or your . This Service Is Not Payable Without A Modifier/referral Code. The Service Requested Is Not Medically Necessary. Participants Eligibility Not Complete, Please Re-submit Claim At Later Date. Please submit claim to BadgerRX Gold. . Purchase Of A DME/DMS Item Exceeding One Per Month Requires Prior Authorization. Pricing Adjustment/ Payment amount increased based on hospital access paymentpolicies. Total Rental Payments For This Item Have Exceeded The Maximum Allowable Forthe Purchase Of This Item. The Member Has Received A 93 Day Supply Within The Past Twelve Months. Modifier invalid for Procedure Code billed. When diagnoses 800.00 through 999.9 are present, an etiology (E-code) diagnosis must be submitted in the E-code field. Exceeds The 35 Treatment Days Per Spell Of Illness. Pricing Adjustment/ Ambulatory Surgery pricing applied. The Billing Providers taxonomy code is invalid. Non-covered Charges Are Missing Or Incorrect. Header From Date Of Service(DOS) is after the date of receipt of the claim. Multiple Unloaded Trips For Same Day/same Recip. Training Reimbursement DeniedDue To late Billing. Superior HealthPlan News. Pricing Adjustment/ The submitted charge exceeds the allowed charge. The Members Reported Diagnosis Is Not Considered Appropriate For AODA Day Treatment. Prior Authorization is required to exceed this limit. Abortion Dx Code Inappropriate To This Procedure. Denied. Claims may deny when reported with incompatible ICD-10-CM Laterality policy for Diagnosis-to-Modifier comparison. Claim Denied. Claim paid according to Medicares reimbursement methodology. Medicare Paid The Total Allowable For The Service. This Procedure Code Is Denied As Incidental/Integral To Another Procedure CodeBilled On This Claim. Denied. Use the most current year's ICD-9-CM or ICD-10-CM codes, depending on the date(s) of service. One or more To Date(s) of Service is invalid for Occurrence Span Codes in positions three through 24. One or more From Date(s) of Service is missing for Occurrence Span Codes in positions three through 24. All Outpatient Services/or Accommodations And Ancillaries Are Denied, Therefore The Total Charge Is Denied. The Existing Appliance Has Not Been Worn For Three Years. Resubmit Complete And/or Second Page Of Medicares EOMB Showing All Total And Payments. No Separate Payment For IUD. If it is medical necessary for more than 13 or 14 services per calendar month, submit an adjustment request with supporting documentation. Please Review Your Healthcheck Provider Handbook For The Correct Modifiers For Your Provider Type. "Laterality" (side of the body affected) is a coding convention added to relevant ICD-10 codes to increase specificity. Detail Quantity Billed must be greater than zero. The Service Billed Does Not Match The Prior Authorized Service. Prescriber ID Qualifier must equal 01. Default Prescribing Physician Number XX9999991 Was Indicated. This is a same-day claim for bill types 13X, 14X, 71X, or 83X and there are multiple units or combination of chemistry/hemotology tests. Missing Or Invalid Level Of Effort And/or Reason For Service Code, Professional Service Code, Result Of Service Code Billed In Error. Service Provided Before Prior Authorization Was Obtained Is Not Allowable. Activities To Promote Diversion Or General Motivation Are Non-covered Services. Condition Code 73 for self care cannot exceed a quantity of 15. The Header and Detail Date(s) of Service conflict. This procedure is limited to once per day. Hearing Aid Batteries Are Limited To 12 Monaural/24 Binaural Batteries Per 30-day Period, Per Provider, Per Hearing Aid. An ICD-9-CM Diagnosis Code of greater specificity must be used for the Fourth Diagnosis Code. Reimbursement For This Certification, Test, Segment Has Already Been Issued ToYour NF. 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. Claim Is Being Special Handled, No Action On Your Part Required. Services Submitted On Improper Claim Form. Billing provider number was used to adjudicate the service(s). Denied. A National Provider Identifier (NPI) is required for the Rendering Provider listed in the header. Based on these reimbursement guidelines, claims may deny when the following revenue codes are billed without the appropriate HCPCS code: More than 50 hours of personal care services per calendar year require prior authorization. Service Denied. Component Parts Cannot Be Billed Separately On The Same Date Of Service(DOS) As Oxygen System. Ancillary Codes Dates Of Service And/or Quantity Billed Do Not Match Level Of Care authorized Dates. Denied. An Approved AODA Day Treatment Program Cannot Exceed A 6 Week Period. Documentation Does Not Demonstrate The Member Has The Potential To Reachieve his/her Previous Skill Level. SeniorCare member enrolled in Medicare Part D. Claim is excluded from Drug Rebate Invoicing. Plan options will be available in 25 states, including plans in Missouri . Use The ICN which Is In An Allowed Or Paid Status When Filing An Adjustment/ReconsiderationRequest. Claim Or Adjustment/reconsideration Request Should Include An Operative Or Pathology Report For This Procedure. This Claim Is Being Reprocessed As An Adjustment On This R&s Report. Other Coverage Code is missing or invalid. Information Required For Claim Processing Is Missing. The Maximum Prior Authorized Service Limitation Or Frequency Allowance Has Been Exceeded. Dispense Date Of Service(DOS) is invalid. 51.42 Board Stamp Required On All Outpatient Specialty Hospital Claims For Dates Of Service On Or After January 1, 1986. Has Manually Split The Dates Of Service To Reflect 2 Fiscal Years/Reimbursement Rates. Please Furnish Length Of Time For Services Rendered. Resubmit the Claim with the Appropriate Modifier for Provider Type andSpecialty. Two different providers cannot be reimbursed for the same procedure for the same member on the same Date Of Service(DOS). Unable To Process Your Adjustment Request due to A Different Adjustment Is Pending For This Claim. A National Provider Identifier (NPI) is required for the Performing Provider listed in the header. Denied. Do Not Indicate A Hcpcs Or Cpt Procedure Code On An Inpatient Claim. The Submission Clarification Code is missing or invalid. Services not allowed for your Provider Type or for your Provider Type without a TB diagnosis. It Must Be In MM/DD/YY Format AndCan Not Be A Future Date. Indicated Diagnosis Is Not Applicable To Members Sex. External Cause Diagnosis May Not Be The Single Or Primary Diagnosis. Pricing Adjustment/ Medicare pricing cutbacks applied. Additional servcies may be billed with H0046 and will count toward mental health and/or substance abuse treatment policy limits for prior authorization. Outside Lab,element 20 On CMS 1500 Claim Form Must Be Checked Yes When Handling Charges Are Billed. Claim Must Indicate A New Spell Of Illness And Date Of Onset. The Clinical Profile/Diagnosis Makes This Member Ineligible For AODA Services. LTC hospital bedhold quantity must be equal to or less than occurrence code 75span date range(s). The Revenue Code is not payable by Wisconsin Well Woman Program for the Date Of Service(DOS). As a result, providers experience more continuity and claim denials are easier to understand. 1. Quantity indicated for this service exceeds the maximum quantity limit established by the National Correct Coding Initiative. Remark Codes: N20. 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 . You can choose to receive only your EOBs online, eliminating the paper . Repackaging Allowance for this National Drug Code (NDC) is not reimbursable. Reference: Transmittal 477, change request 3720 issued February 18, 2005. Claim/adjustment Received Beyond The 455 Day Resubmission Deadline. Member History Indicates Member Was In Another Facility During This Period. 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 . Additional Encounter Service(s) Denied. 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). Pricing Adjustment/ Payment reduced due to the inpatient or outpatient deductible. Less Expensive Alternative Services Are Available For This Member. Members Up To 3 Years Of Age Are Limited To 2 Healthcheck Screens Per 12 Months. The Request May Only Be Back-dated Two Weeks Prior To Receipt By EDS. Pricing Adjustment/ Prior Authorization pricing applied. Submitted referring provider NPI in the detail is invalid. The service requested is not allowable for the Diagnosis indicated. Review Patient Liability/paid Other Insurance, Medicare Paid. The National Drug Code (NDC) is not on file for the Dispense Date Of Service(DOS). The Service Requested Does Not Correspond With Age Criteria. Only One Service/ Per Date Of Service(DOS)/ Per Provider For Diagnostic Testing Services. Accident Related Service(s) Are Not Covered By WCDP. Billing Provider indicated is not certified as a billing provider. Personal Care In Excess Of 250 Hrs Per Calendar Year Requires Prior Authorization. Detail Denied. WellCare Known Issues List Please be advised: Claims that have either rejected or denied . Prescription Drug Plan (PDP) payment/denial information is required on the claim to SeniorCare. Denial Codes. Dates Of Service Must Be Itemized. For dates of service on or after 7/1/10 for TOB 72X an occurrence code 51 and value code D5 are required when the KT/V reading was performed. The Clinical Profile And Narrative History Indicate Day Treatment Is Neither Appropriate Nor A Medical Necessity For This Member. Date Of Service Must Fall Between The Prior Authorization Grant Date And Expiration Date. Denied due to Prescription Number Is Missing Or Invalid. Submit copy of the dated and signed evaluation and indicate if this is an initial Evaluation. Split Decision Was Rendered On Expansion Of Units. Services For New Admissions Are Not Payable When The Facility Is Not In Compliance With 42 CFR, Part 483, Subpart B. To access the training video's in the portal, please register for an account and request access to your contract or medical group. Revenue Code 0001 Can Only Be Indicated Once. A National Drug Code (NDC) is required for this HCPCS code. Comprehension And Language Production Are Age-appropriate. This Member Has Completed Primary Intensive Services And Is Now Only Eligible For after Care/follow-up Hours. Capitation Payment Recouped Due To Member Disenrollment. Per Information From Insurer, Claim(s) Was (were) Not Submitted. This drug has been paid under an equivalent code within seven days of this Date Of Service(DOS). Claim Currently Being Processed. If this is your first visit, be sure to check out the FAQ & read the forum rules.To view all forums, post or create a new thread, you must be an AAPC Member.If you are a member and have already registered for member area and forum access, you can log in by clicking here.If you've forgotten your username or password use our . Excessive height and/or weight reported on claim.