This Claim HasBeen Manually Priced Using The Medicare Coinsurance, Deductible, And Psyche RedUction Amounts As Basis For Reimbursement. The Third Occurrence Code Date is invalid. Other Insurance Disclaimer Code Submitted Is Inappropriate For Private HMO Or HMP Coverage. The Surgical Procedure Code is not payable for Wisconsin Chronic Disease Program for the Date Of Service(DOS). Claims may deny when tympanometry/impedance testing (CPT 92567) is billed with a preventive medicine service (CPT 99381-99397) or wellness visit (CPT G0438-G0439) without appropriate modifier appended to the E&M service to identify a separately identifiable procedure; tympanometry/impedance testing will be considered part of the office visit. Claim Denied. If you are having difficulties registering please . Claim Denied For No Consent And/or PA. Revenue Code Required. 690 Canon Eb R-FRAME-EB According to the AMA CPT Manual and our policy, an initial inpatient admission (CPT 99221-99223) is allowed once every seven days. Pharmaceutical care reimbursement for tablet splitting is limited to three permonth, per member. A new set of Generic Reason codes and statements for Part A, Part B and DME have been added and approved for use across all Prior Authorization (PA), Claim reviews . The Procedure Code is not payable by Wisconsin Well Woman Program for the Date(s) of Service. Amount Paid Reduced By Amount Of Other Insurance Payment. The Hearing Aid Recommended Is Not Necessary; The Member Could Be Adequately Fitted With A Conventional Aid. Medicare Coinsurance Amount Was Not Provided On Crossover Claim. Please Disregard Additional Information Messages For This Claim. Claim contains duplicate segments for Present on Admission (POA) indicator. Denied. Number On Claim Does Not Match Number On Prior Authorization Request. Previously Paid Individual Test May Be Adjusted Under a Panel Code. Service Denied/cutback. Indicated Diagnosis Is Not Applicable To Members Sex. Invalid Service Facility Address. The Performing Provider Id, Member Id, And Date Of Service(DOS) Must Match The Completion Certificate Received From Ddes. The Billing Providers taxonomy code is missing. The condition code is not allowed for the revenue code. This claim did not include the Plan ID, therefore we assigned TXIX as the Plan ID for this claim. Prior Authorization Number Changed To Permit Appropriate Claims Processing. Do Not Bill Intraoral Complete Series Components Separately. Refer To Provider Handbook. Please Disregard Additional Messages For This Claim. This drug/service is included in the Nursing Facility daily rate. Please Resubmit A New Adjustment/reconsideration Request Form And Indicate TheMost Recent Cclaim Number Where Payment Was Made Or Allowed. NDC- National Drug Code is restricted by member age. Claim or adjustment/reconsideration request must have both a Revenue Code and either a HCPCS Code or CPT Code. Home Health, Personal Care And Private Duty Nursing Services Are Subject To A Monthly Cap. A valid Level of Effort is also required for pharmacuetical care reimbursement. Intraoral Complete Series/comprehensive Oral Exam Limited To Once Every Three Years, Unless Prior Authorized. Claim Denied Due To Absent Or Incorrect Discharge (to) Date. Claim or line denied. NCTracks AVRS. Reimbursement limits for Community Care Services for the calendar year are close to being exceeded. Service(s) Denied/cutback. Effective With Claims Received On And After 10/01/03 , Occurrence Codes 50 And 51 Are Invalid. Additional services mustbe billed as treatment services and count towards the Mental Health and/or substance abuse treatment policy for prior authorization. No Financial Needs Statement On File. The diagnosis code on the claim requires Condition code A6 be present on the Type of Bill. Please Refer To The Original R&S. The billing provider number is not on file. Claim Denied. Please Bill Medicare First. Denied. Please Re-submit This Claim With The Insurance EOB Showing A Denial OrPartial Payment. Dialysis/EPO treatment is limited to 13 or 14 services per calendar month. An exception will apply for anesthesia services billed with modifiers indicating severe systemic disease (Physical status modifiers P3, P4 or monitored anesthesia care modifier G9). 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. Pricing Adjustment/ Payment amount decreased based on Pay for Performance policies. Claim Number Given On The Adjustment/reconsideration Request Form Does Not Match Services Originally Billed. Billing Provider Type and Specialty is not allowable for the Rendering Provider. Denied. Please Review The Covered Services Appendices Of The Dental Handbook. Refill Indicator Missing Or Invalid. Nursing Home Visits Limited To One Per Calendar Month Per Provider. Supplemental Payment Authorized By Department of Health Services (DHS) Due to aAudit. The service was previously paid for this Date Of Service(DOS). Modification Of The Request Is Necessitated By The Members Minimal Progress. Service Denied A Physician Statement (including Physical Condition/diagnosis) Must Be Affixed To Claims For Abortion Services Refer To Physician Handbook. A Hospital Stay Has Been Paid For DOS Indicated. The sum of all Value Code amounts must be numeric and less than or equal to 999.999.999. Member does not have commercial insurance for the Date(s) of Service. If The Proc Code Does Not Require A Modifier, Please Remove The Modifier. Timeframe Between The CNAs Training Date And Test Date Exceeds 365 Days. Prior authorization is required for Advair or Symbicort if no other Glucocorticoid Inhaled product has been reimbursed within 90 days. Service Denied. wellcare explanation of payment codes and comments. Denied due to Provider Is Not Certified To Bill WCDP Claims. Services Requested Do Not Meet The Criteria for an Acute Episode. No Action On Your Part Required. Date Of Service Must Fall Between The Prior Authorization Grant Date And Expiration Date. Claim Is Pended For 60 Days. Pricing Adjustment/ Payment reduced due to benefit plan limitations. The Service Requested Does Not Correspond With Age Criteria. The Other Payer ID qualifier is invalid for . Service(s) paid in accordance with program policy limitation. Multiple Referral Charges To Same Provider Not Payble. 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. Member Is Eligible For Champus. Reimbursement Is At The Unilateral Rate. Services restricted to EPSDT clients valid only with a Full Scope, EPSDT-eligible Aid Code. There is no action required. Please Resubmit As A Regular Claim If Payment Desired. This revenue code requires value code 68 to be present on the claim. Billed Procedure Not Covered By WWWP. No Action On Your Part Required. Seventh Diagnosis Code (dx) is not on file. For Revenue Code 0820, 0821, 0825 or 0829, HCPCS Code 90999 or Modifier G1-G6 must be present. No Complete Program Enrollment Form Is On File For This Client Or The Client Is Not Eligible For The Date Of Service(DOS) On The Clai im. Pricing Adjustment/ Resource Based Relative Value Scale (RBRVS) pricing applied. The Procedure Code is not reimbursable for the Rendering Provider Type and/or Specialty. Other Medicare Managed Care Response not received within 120 days for providerbased bill. Speech Therapy Limited To 45 Treatment Days Per Spell Of Illness W/o Prior Authorization. The Member Is Involved In group Physical Therapy Treatment. Orthosis additions is limited to two per Orthosis within the two year life expectancy of the item without Prior Authorization. Pricing Adjustment/ Third party liability deducible amount applied. Claim Or Adjustment/reconsideration Request Should Include An Operative Or Pathology Report For This Procedure. Providers must ensure that the E&M CPT codes selected reflect the services furnished. A Second Surgical Opinion Is Required For This Service. Recd Beyond 90 Days Special Filing Deadline FOr System Generated Adjmts/Medicare X-overs/Other Insurance Reconsideration/Cou rt Order/Fair Hearing. Billing Provider ID is missing or unidentifiable. A: This denial is received when Medicare records indicate that Medicare is the beneficiary's secondary payer. The Primary Diagnosis Code is inappropriate for the Revenue Code. CO - Contractual Obligations: This group code is used when a contractual agreement between the payer and payee, or a regulatory requirement, resulted in an adjustment.These adjustments are considered a write off for the provider and are not billed to . Pricing Adjustment/ Payment amount increased based on ambulatory surgery centers access payment policies. When diagnoses 800.00 through 999.9 are present, an etiology (E-code) diagnosis must be submitted in the E-code field. That is why we support our provider partners with quality incentive programs, quicker claims payments and dedicated market support. Member ID has changed. Req For Acute Episode Is Denied. Dispensing replacement parts and complete appliance on same Date Of Service(DOS) not Allowed. Denied due to Statement Covered Period Is Missing Or Invalid. Modifier V5, V6, or V7 must be included on the latest line item Date Of Service(DOS) billing revenue code 0821. Submitclaim to the appropriate Medicare Part D plan. A Payment Has Already Been Issued For This SSN. Purchase of additional DME/DMS item exceeding life expectancy rRequires Prior Authorization. Billed Amount Is Greater Than Reimbursement Rate. Principal Diagnosis 8 Not Applicable To Members Sex. Principle Surgical Procedure Code Date is missing. The Diagnosis Code Is Not Valid On This Date Of Service(DOS). Service is covered only during the first month of enrollment in the Home and Community Based Waiver. Only One Date For EachService Must Be Used. Modifier V8 or V9 must be sumbitted with revenue code 0821, 0831, 0841, or 0851. Claim Denied. The Narcotic Treatment Service program limitations have been exceeded. Members Are Limited To 45 Dates Of Service Per Therapy/spell Of Illness without Prior Authorization. No Reimbursement Rates on file for the Date(s) of Service. A National Provider Identifier (NPI) is required for the Performing Provider listed in the header. An ICD-9-CM Diagnosis Code of greater specificity must be used for the Second Diagnosis Code. One or more Diagnosis Codes are not applicable to the members gender. Case Plan and/or assessment reimbursment is limited to one per calendar year.Calendar Year. No Separate Payment For IUD. Providers May Only Bill For Assessments And Care Plans Twice Per Calendar Year. Reimbursement rate is not on file for members level of care. A National Drug Code (NDC) is required for this HCPCS code. This Procedure Is Limited To Once Per Day. Condition code must be blank or alpha numeric A0-Z9. Service Allowed Once Per Lifetime, Per Tooth. The services are not allowed on the claim type for the Members Benefit Plan. the patient (or parent or guardian) at the address noted on the claim, be sure your doctor has updated your records with your current address. HMO Extraordinary Claim Denied. Does not reimburse both the global service and the individual component parts of the service for the same Date Of Service(DOS). 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. At least one Remark Code must be provided (may be comprised of either the Remittance Advice Remark Code or NCPDP Reject Reason Code.) See Physicians Handbook For Details. The respiratory care services billed on this claim exceed the limit. We encourage you to take advantage of this easy-to-use feature. Purchase Only Allowed; Medical Need For Rental Has Not Been Documented. A National Provider Identifier (NPI) is required for the Billing Provider. Denied. Denied. Supervisory visits for Unskilled Cases allowed once per 60-day period. Out of State Billing Provider not certified on the Dispense Date. Please Correct And Resubmit. Pricing Adjustment/ Usual & Customary Charge (UCC) rate pricing applied. The Surgical Procedure Code is not payable for /BadgerCare Plus for the Date Of Service(DOS). To Continue Treatment With Two Anti-ulcer Drugs Beyond Authorized Limit Please Submit Request On Paper With Clinical Documentation Clearly Indicating medical necessity. The Value Code and/or value code amount is missing, invalid or incorrect. To Date Of Service(DOS) Precedes From Date Of Service(DOS). This Is A Manual Increase To Your Accounts Receivable Balance. The Skills Of A Therapist Are Not Required To Maintain The Member. This Procedure Code Not Approved For Billing. Claim Paid Under DRG Reimbursement, Except For Transplants Billed Using Suffixes 05 Through 09. Please Contact The Hospital Prior Resubmitting This Claim. The first position of the attending UPIN must be alphabetic. Incidental modifier was added to the secondary procedure code. The member has no Level of Care (LOC) authorization on file or the LOC on filedoes not match the LOC on the claim. According to the American Society of Anesthesiologists and the International Spine Intervention Society, minor pain procedures such as epidural steroid injections, epidural blood patch, trigger point injections, sacroiliac joint injection, bursal injections, occipital nerve block and facet injections under most routine circumstances, require only local anesthesia. 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. Thank You For Your Assessment Interest Payment. Pricing Adjustment/ Spenddown deductible applied. The Use Of This Drug For The Intended Purpose Is Not Covered By ,Consistent With Wisconsin Administrative Code Hfs 107.10(4) And 1396r-8(d). This Dental Service Limited To Once Every Six Months, Unless Prior Authorized. Department of Health Services (DHS) Authorized Payment Is Being Withheld Due toan Audit. The Service(s) Requested Could Adequately Be Performed In The Dental Office. Cannot bill for both Assay of Lab and other handling/conveyance of specimen. To access the training video's in the portal, please register for an account and request access to your contract or medical group. WellCare_Consult_ManagedProcedureCodeList_2023_20221222 Page 2 of 7 Remote afterloading high dose rate radionuclide interstitial or intracavitary brachytherapy, includes Reimbursement also may be subject to the application of These Services Paid In Same Group on a Previous Claim. 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. CSHCN number The client's CSHCN Services Program number. 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. Please Indicate The Dollar Amount Requested For The Service(s) Requested. DX Of Aphakia Is Required For Payment Of This Service. Reimbursement For This Certification, Test, Segment Has Already Been Issued ToYour NF. Ulcerations Of The Skin Do Not Warrant A New Spell Of Illness. It Must Be In MM/DD/YY FormatAnd Can Not Be A Future Date. Annual Nursing Home Member Oral Exam Is Allowed Once Per 355 Days Per Recip Per Prov. When a provider submits an E&M level of service that exceeds the maximum level of E&M service level based on the diagnosis submitted, the E&M code is recoded (and allowed to pay) to match the maximum level of E&M service allowed based on the severity of the medical diagnosis submitted. Denied due to Member Is Eligible For Medicare. Information inadequate to establish medical necessity of procedure performed.Please resubmit with additional supporting documentation. Pharmaceutical Care Code must be billed with a payable drug detail or if a prescription was not filled, the quantity dispensed must be zero. Out-of-State non-emergency services require Prior Authorization. Supervising Nurse Name Or License Number Required. Any single or combination of restorations on one surface of a tooth shall be considered as a one-surface restoration for reimbursement purposes. Prior Authorization Is Required For Payment Of Hospital Exceptional Claims. Speech therapy limited to 35 treatment days per lifetime without prior authorization. Prior authorization requests for this drug are not accepted. This Procedure, When Billed With Modifier HK, Is Payable Only If The Member Is Under The Age Of 19. Service Denied. You Must Either Be The Designated Provider Or Have A Referral. A valid header Medicare Paid Date is required. Will Not Authorize New Dentures Under Such Circumstances. The Competency Test Date On The Request Does Not Match The CNAs Test Date OnThe WI Nurse Aide Registry.
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