An approved PA was not found matching the provider, member, and service information on the claim. For 2020, WellCare is adding 68 new Medicare Advantage plans for a total of 261 plans with $0 or low monthly plan premiums.
Login - WellCare Denied due to Member Is Eligible For Medicare. Back-up dialysis sessions are limited to three per lifetime. Please Supply Modifier Code(s) Corresponding To The Procedure Code Description. 191. Scope Aid Code and an EPSDT Aid Code. Referral Codes Must Be Indicated For W7001, W7002, W7003, W7006, W7008 And W7013. Claims may be denied if an advanced imaging procedure is billed with a diagnosis of syncope and there is no history of a 12-lead EKG being performed/billed the same date or in the previous 90 days. Services restricted to EPSDT clients valid only with a Full Scope, EPSDT-eligible Aid Code. Claimchecks Editing And Your Supporting Documentation Was Reviewed By The DHS Medical Consultant. Intermittent Peritoneal Dialysis hours must be entered for this revenue code. Denied due to Statement Covered Period Is Missing Or Invalid. The Services Requested Are Not Reasonable Or Appropriate For The AODA-affectedmember. No Reimbursement Rates on file for the Date(s) of Service. Denied. The Service/procedure Proposed Is Not Supported By Submitted Documentation. Revenue Code 082X is present on an ESRD claim which also contains revenue codes 083X, 084X, or 085X. 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). Surgical Procedures May Only Be Billed With A Whole Number Quantity. Denied. Pricing Adjustment/ Medicare crossover claim cutback applied. Prior Authorization (PA) required for payment of this service. Member Name Missing. You can choose to receive only your EOBs online, eliminating the paper . The Quantity Allowed Was Reduced To A Multiple Of The Products Package Size. Superior HealthPlan News. Rqst For An Acute Episode Is Denied. Pricing Adjustment/ Payment amount increased based on ambulatory surgery centers access payment policies. A Pharmaceutical Care Code (PCC) must include a valid diagnosis code.
PDF Claim Adjustment Reason Codes (CARCs) and Enclosure 1 - California CPT Code 88305 (Level IV Surgical pathology, gross and microscopic examination) includes different types of biopsies. To access the training video's in the portal . Case Plan and/or assessment reimbursment is limited to one per calendar year.Calendar Year. Basic knowledge of CPT and ICD-codes. They are used to provide information about the current status of . Here are just a few of them: EOB CODE. Header and/or Detail Dates of Service are missing, incorrect or contain futuredates. Goals Are Not Realistic To The Members Way Of Life Or Home Situation, And Serve No Functional Or Maintenance Service. Amount Recouped For Duplicate Payment on a Previous Claim. Pap Smears, Hematocrit, Urinalysis Are Not Reimbursable Separately In Conjunction With Family Planning Medical Visits. Rimless Mountings Are Not Allowable Through . Claim Denied. Unable To Process Your Adjustment Request due to This Claim Is In Post Pay Billing For Third Party Liability Payment. The Surgical Procedure Code is not payable for /BadgerCare Plus for the Date Of Service(DOS). Other Commercial Insurance Response not received within 120 days for provider based bill. Partial Payment Withheld Due To Previous Overpayment. . A Training Payment Has Already Been Issued For This Cna. Physical Therapy Treatment Limited To One Modality, One Procedure, One Evaluation Or One Combination Per Day. The disposable medical supply Procedure Code has a quantity limit as indicated in the DMS Index. Denied due to Diagnosis Not Allowable For Claim Type. Fifth Other Surgical Code Date is invalid. Effective With Claims Received On And After 10/01/03 , Occurrence Codes 50 And 51 Are Invalid. 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. Pharmaceutical Care Codes Are Billable On Non-compound Drug Claims Only. Claim Detail Is Pended For 60 Days. For FQHCs, place of service is 50. Reimbursement For This Detail Does Not Include Unit DoseDispensing Fee. Claim Or Adjustment/reconsideration Request Should Include An Operative Or Pathology Report For This Procedure. This service was previously paid under an equivalent Procedure Code. The Service Requested Was Performed Less Than 3 Years Ago. Thank You For The Payment On Your Account. Pricing Adjustment/ Prescription reduction applied. Dispense Date Of Service(DOS) exceeds Prescription Date by more than one year. Day Treatment Exceeding 5 Hours/day Not Payable Regardless Of Prior Authorization. Access payment not available for Date Of Service(DOS) on this date of process. Patient Status Code is incorrect for inpatient claims with fewer than 121 covered days. One or more Condition Code(s) is invalid in positions eight through 24. Please Supply The Appropriate Modifier. Member Expired Prior To Date Of Service(DOS) On Claim. Transplant services not payable without a transplant aquisition revenue code. Denied. OA 12 The diagnosis is inconsistent with the provider type. Up to a $1.10 reduction has been applied to this claim payment. Compound drugs require a minimum of two components with at least one payable FowardHealth covered drug. Denied. The dental procedure code and tooth number combination is allowed only once per lifetime. Example: Diagnosis code 285.21 is entered as 28521, without a period or space. FL 44 HCPCS/Rates/HIPPS Rate Codes Required. This National Drug Code (NDC) has Encounter Indicator restrictions. and other medical information at your current address. Service(s) paid in accordance with program policy limitation. Denied. Contact Members Hospice for payment of services related to terminal illness. Please Do Not File A Duplicate Claim. Effective 1/1: Electronic Prescribing of Controlled Substances Required. DME rental is limited to 90 days without Prior Authorization. Quantity Would Be 00010 If Specific Number Of Batteries Dispensed Is Not Indicated. Multiple Service Location Found For the Billing Provider NPI. Denied/recouped. Detail Quantity Billed must be greater than zero. Duplicate Item Of A Claim Being Processed. Denied/cutback. Requires A Unique Modifier. Unable To Process Your Adjustment Request due to Claim ICN Not Found. Claim Is Being Special Handled, No Action On Your Part Required. Complex Evaluation and Management procedures require history and physical or medical progress report to be submitted with the claim. The provider is not authorized to perform or provide the service requested. Claim Denied/Cutback. Denied. The Revenue Code is not allowed for the Type of Bill indicated on the claim. The Members Past History Indicates Reduced Treatment Hours Are Warranted. Out Of State Billing Provider Not Enrolled For Entire Detail DOS Span. One or more To Date(s) of Service is missing for Occurrence Span Codes in positions three through 24. For Revenue Code 0820, 0821, 0825 or 0829, HCPCS Code 90999 or Modifier G1-G6 must be present. 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. The relationship between the Billed and Allowed Amounts exceeds a variance threshold. Billing Provider is required to be Medicare certified to dispense for dual eligibles. Bilateral Surgeries Reimbursed At 150% Of The Unilateral Rate. Documentation Does Not Justify Reconsideration For Payment. (Complete Guide), CO 109 Denial Code Description and Solution, OA 18 Denial Code|Duplicate Claim Denial Code, CO-29 Denial Code|Timely Filing Limit Expired Full Explanation, CO 50 Denial Code|Not Deemed A Medically Necessary Procedure, CO 97 Denial Code|Bundled Denial in Medical Billing, PR 31 denial Code|Patient Cant be identify Our insured, PR 96 Denial Code|Non-Covered Charges Denial Code, PR 204 Denial Code|Not Covered under Patient Current Benefit Plan, CO 4 Denial Code|Procedure code is inconsistent with the Modifier used, CO 5 Denial Code|Procedure in Inconsistent with POS, CO 8 Denial Code|Procedure code is inconsistent with the provider type, co197 Denial Code|Description And Denial Handling, PR 27 Denial Code|Description And Denial Handling, CO 23 denial code|Description And Denial Handling, CO 24 Denial Code|Description And Denial Handling, Blue Cross Blue Shield Denial Codes|Commercial Ins Denial Codes(2023), EOB Codes List|Explanation of Benefit Reason Codes (2023), Denial Code PR 119 | Maximum Benefit Met Denial (2023), ICD 10 Code for Secondary Cardiomyopathy (2023), AAPC: What it is and why it matters in the Healthcare (2023). Pricing Adjustment/ Medicare Pricing information. Condition Code 73 for self care cannot exceed a quantity of 15. Does not reimburse both the global service and the individual component parts of the service for the same Date Of Service(DOS). Denied/Cutback. One or more From Date Of Service(DOS) (DOS) is invalid for Occurrence Span Codes in positions three through 24. This drug is limited to a quantity for 100 days or less. Claim cannot contain both Condition Codes A5 and X0 on the same claim. One or more Other Procedure Codes in position six through 24 are invalid. Adjustment To Eyeglasses Not Payable As A Repair Service. If Required Information Is Not Received Within 60 Days,the claim will be denied. The Clinical Profile And Narrative History Indicate Day Treatment Is Neither Appropriate Nor A Medical Necessity For This Member. Four X-rays are allowed per spell of illness per provider. Vision Diagnostic Services Limited To 1 Of These: Vision Exam, Diagnostic Review, Supplemental Test Or Contact Lens Therapy. Denied due to Provider Is Not Certified To Bill WCDP Claims. Professional Service code is invalid. Please Request Prior Authorization For Additional Days. Prescriber ID Qualifier must equal 01. Claim Generated An Informational ProDUR Alert, Drug-Drug Interaction prospective DUR alert, Drug-Disease (reported) prospective DUR alert, Drug-Disease (inferred) prospective DUR alert, Therapeutic Duplication prospective DUR alert, Suboptimal Regiment prospective DUR alert, Insufficient Quantity prospective DUR alert. Denied. Calls are recorded to improve customer satisfaction. Third Other Surgical Code Date is invalid. Prescription limit of five Opioid analgesics per month. Please Correct And Submit. Well-baby visits are limited to 12 visits in the first year of life. This Is Not A Good Faith Claim. Rebill Using Correct Procedure Code. PDN Codes W9045/w9046 Are Not Payable On The Same Date As PDN Codes W9030/W9031 For The Same Provider And Member.