The maximum number of details is exceeded. Pricing Adjustment/ Prescription reduction applied. Reimburse Is Limited To Average Monthly NHCost And Services Above That Amount Are Consider non-Covered Services. Our Records Indicate This Provider Is Not Certified For AODA Day Treatment. Rendering Provider is not a certified provider for . The National Drug Code (NDC) has an age restriction. The Service(s) Requested Could Adequately Be Performed In The Dental Office. Denied. The medical record request is coordinated with a third-party vendor. Amount Paid By Other Insurance Exceeds Amount Allowed By . Denied. Rendering Provider is not a certified provider for Wisconsin Well Woman Program. Provider signature and/or date is required. Resubmit The Original Medicare Determination (EOMB) Along With Medicares Reconsideration. Please Resubmit. Services Included In The Inpatient Hospital Rate Are Not Separately Reimbursable. Secondary Diagnosis Code (dx) is not on file. Denied due to Service Is Not Covered For The Diagnosis Indicated. Submitclaim to the appropriate Medicare Part D plan. This Is Not A Reimbursable Level I Screen. This claim has been adjusted because a service on this claim is not payable inconjunction with a separate paid service on the same Date Of Service(DOS) due to National Correct Coding Initiative. CO/204. Please Indicate Computation For Unloaded Mileage. Member has Medicare Supplemental coverage for the Date(s) of Service. Claim Paid In Accordance With Family Planning Contraceptive Services Guidelines. Rimless Mountings Are Not Allowable Through . Service Fails To Meet Program Requirements. An ICD-9-CM Diagnosis Code of greater specificity must be used for the Third Diagnosis Code. PDN services billed on this claim exceed 12 hours/day per nurse, PDN services billed on this claim exceed 60 hours/week per nurse, PDN services billed on this claim exceed 24 hours/day per member. Pricing Adjustment/ Prior Authorization pricing applied. Denied. Second And Subsequent Cerebral Evoked Response Tests Paid At A Reduced Rate Per Guidelines. 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. The Members Clinical Profile/diagnosis Is Not Within Diagnostic Limitations for Psychotherapy Services. Money Will Be Recouped From Your Account. This service is payable at a frequency of once per 12-month period, per provider, per hearing aid. Denied due to Procedure Or Revenue Code(s) Are Missing On The Claim. For Revenue Code 0820, 0821, 0825 or 0829, HCPCS Code 90999 or Modifier G1-G6 must be present. Denied. NDC- National Drug Code billed is not appropriate for members gender. Another PNCC Has Billed For This Member In The Last Six Months. Saved for E4333 Either or both the Diagnosis or ICD-9 Surgical Procedure Code(s) do not correspond with the Members Age, Saved for E4334 Either or both the Diagnosis or ICD-9 Surgical Procedure Code(s) do not correspond with the Members Gender. Please Provide Copy Of Medicare Explanation Of Benefits/medicare Remittance Advice Attached To Claim. Charges Paid At Reduced Rate Based Upon Your Usual And Customary Pricing Profile. Please Refer To The PDL For Preferred Drugs In This Therapeutic Class. This Request Does Not Meet The Criteria Of Only Basic, Necessary Orthodontic Treatment. This Report Was Mailed To You Separately. The Member Is School-age And Services Must Be Provided In The Public Schools. Denied due to Detail Add Dates Not In MM/DD Format. Covered By An HMO As A Private Insurance Plan. The Members Reported Diagnosis Is Not Considered Appropriate For AODA Day Treatment. Remittance Advice Remark Codes (RARCs) are used to provide additional explanation for an adjustment already described by a Claim Adjustment Reason Code (CARC) or to convey information about remittance processing. Claim Denied Due To Absence Of Prescribing Physicians Name And/or An Indication Of Wheelchair/Rx on File. Claim contains an unclassified drug HCPCS procedure code or a drug HCPCS procedure code included in the composite rate. Denied/Cutback. Fifth Other Surgical Code Date is invalid. Services Are Covered For Medically Needy Members Only When Healthcheck Referral is Indicated On Claim. A Primary Occurrence Code Date is required. Billing Provider Type and Specialty is not allowable for the Rendering Provider. Once 50 Initial Visits/year Has Been Reached Within Any One Discipline All Home Health Services Require Pa. Denied. PleaseReference Payment Report Mailed Separately. Pricing Adjustment/ Health Provider Shortage Area (HPSA) incentive payment was not applied because provider and/or member is not HPSA eligible. Summarize Claim To A One Page Billing And Resubmit. This Diagnosis Code Has Encounter Indicator restrictions. All services should be coordinated with the Inpatient Hospital provider. Default Prescribing Physician Number XX9999991 Was Indicated. 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. The Other Payer ID qualifier is invalid for . This Check Automatically Increases Your 1099 Earnings. Plan options will be available in 25 states, including plans in Missouri . The Diagnosis Code is not payable for the member. The Surgical Procedure Code is not payable for /BadgerCare Plus for the Date Of Service(DOS). One or more To Date(s) of Service is missing for Occurrence Span Codes in positions three through 24. Medicare accepts any National Uniform Billing Committee (NUBC) approved revenue codes. Denied. An explanation of benefits is a document from your insurance company outlining the services you received and how much they cost. This Adjustment Was Initiated By . Req For Acute Episode Is Denied. Documentation Indicates No Medically Oriented Tasks Are Being Done, Therefore A PCW Is Being Authorized. Quantity Would Always Be 00010 If Number Of Pounds Not Indicated. Denied. Please Submit Charges Minus Credit/discount. Services Must Be Submitted On Proper Claim/adjustment/reconsiderationRequest Form. Claim Denied. This member is eligible for Medication Therapy Management services. NCTracks Contact Center. Refer to the DME area of the Online Handbook for claims submission requirements for compression garments. The Lens Formula Does Not Justify Replacement. Amount Paid On Detail By WWWP Is Less Than Billed Or Reimbursement Rate Due ToPrior Payment By Other Insurance. Rebill On Pharmacy Claim Form. Physical Therapy Limited To 45 Treatment Days Per Spell Of Illness W/o Prior Authorization. The provider enters the appropriate revenue codes to identify specific accommodation and/or ancillary charges. Non-Reimbursable Service. NDC was reimbursed at Employer Medical Assistance Contribution (EMAC) rate. 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 . ambulatory surgical center, outpatient hospital) exists for the same member, same date of service and the same procedure or service. Submitted rendering provider NPI in the header is invalid. Service is not reimbursable for Date(s) of Service. Continue ToUse Appropriate Codes On Billing Claim(s). Other Medicare Part A Response not received within 120 days for provider basedbill. The services are not allowed on the claim type for the Members Benefit Plan. The Revenue/HCPCS Code combination is invalid. Denied. (National Drug Code). Original Payment/denial Processed Correctly. A Previously Submitted Adjustment Request Is Currently In Process. Is Unable To Process This Request Because The Signature/date Field Is Blank. Please Disregard Additional Informational Messages For This Claim. Billing Provider ID is missing or unidentifiable. Denied/Cutback. The Member Does Not Meet The Criteria For Binaural Amplification; One Hearing Aid Is Authorized. Activities To Promote Diversion Or General Motivation Are Non-covered Services. The Requested Procedure Is Cosmetic In Nature, Therefore Not Covered By . Amount Paid Reduced By Amount Of Other Insurance Payment. Payment Is Limited To One Unit Dose Service Per Calendar Month, Per Legend Drug, Per Member. Pricing Adjustment/ Anesthesia pricing applied. Claim reimbursement has been cutback to reimbursement limits for denture repairs performed within 6 months. Dialysis/EPO treatment is limited to 13 or 14 services per calendar month. DRG cannotbe determined. Psych Evaluation And/or Functional Assessment Ser. Unable To Process Your Adjustment Request due to Provider ID Not Present. Third modifier code is invalid for Date Of Service(DOS). Please File With Champus Carrier. The statement coverage FROM date on a hemodialysis ESRD claim (revenue code 0821, 0880, or 0881) was greater than the hemodialysis termination date in the provider file. Please Furnish A Breakdown Of Your Procedure Code And Charge In Question GivenOn The Adjustment/reconsideration Request. Election Form Is Not On File For This Member. Please Indicate The Dollar Amount Requested For The Service(s) Requested. Prescriber Number Supplied Is Not On Current Provider File. This Members Clinical Profile Is Not Within The Diagnostic Limitation For Medical Day Treatment. Services In Excess Of This Cap Are Not Reimbursable for this Member. Consultation or surgical procedures are not reimbursable in conjuctions with Emergency Room services. Services restricted to EPSDT clients valid only with a Full Scope, EPSDT-eligible Aid Code. Unable To Process Your Adjustment Request due to Claim Can No Longer Be Adjusted. 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. This drug/service is included in the Nursing Facility daily rate. Claim Is Pended For 60 Days. Out Of State Billing Provider Not Enrolled For Entire Detail DOS Span. Claim Denied For Invalid Diagnosis Code Or Diagnosis Code/CPT Combination. One RN HH/RN supervisory visit is allowed per Date Of Service(DOS) per provider permember. 100 Days Supply Opportunity. EOB Any EOB code that applies to the entire claim (header level) prints here. This drug is limited to a quantity for 34 days or less. The dental procedure code and tooth number combination is allowed only once per lifetime. Member Is Eligible For Champus. BMN prior authorization may be submitted for Mental Health drugs for which a Core Plan transitioned member has been previously grandfathered. Newsroom. Pricing Adjustment/ The submitted charge exceeds the allowed charge. Lenses Only Are Approved; Please Dispense A Contracted Frame. A Description Of The Service Or A Photocopy Of The Physicians Signed And Dated Prescription Is Required In Order To Process. Incorrect or invalid NDC/Procedure Code/Revenue Code billed. Documentation Indicates That Client Is Able To Direct Cares And Can Safely Direct A PCW. Men. Copyright 2023 Wellcare Health Plans, Inc. New Coding Integrity Reimbursement Guidelines. Principal Diagnosis 8 Not Applicable To Members Sex. HMO Capitation Claim Greater Than 120 Days. Speech Therapy Evaluations Are Limited To 4 Hours Per 6 Months. This Claim Is A Reissue of a Previous Claim. According To Our Records, The Surgeon For This Sterilization Procedure Has NotSubmitted The Members Consent Form. Claim Corrected. Claims may deny when a procedure defined as requiring an anatomical modifier is billed without an associated anatomical modifier. Training Completion Date Is Not A Valid Date. Pricing Adjustment/ Pharmacy dispensing fee applied. Medication checks by a Psychiatrist and/or Registered Nurse are limited to four services per calendar month. Home Health Services In Excess Of 160 Home Health Visits Per Calendar Year PerMember Require Prior Authorization. Resubmit the Claim with the Appropriate Modifier for Provider Type andSpecialty. One Visit Allowed Per Day, Service Denied As Duplicate. Requests For Training Reimbursement Denied Due To Late Billing. Billed Amount Is Greater Than Reimbursement Rate. The Surgical Procedure Code is not payable for Wisconsin Chronic Disease Program for the Date Of Service(DOS). The Insurance EOB Does Not Correspond To The Dates Of Service/servicesBeing Billed. Denied. Denied. According to the AMA CPT Manual and our policy, an initial inpatient admission (CPT 99221-99223) is allowed once every seven days. Calls are recorded to improve customer satisfaction. Modifiers submitted are invalid for the Date Of Service(DOS) or are missing.. An ICD-9-CM Diagnosis Code of greater specificity must be used for the Sixth Diagnosis Code. Was Unable To Process This Request Due To Illegible Information. 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.