It Must Be In MM/DD/YY FormatAnd Can Not Be A Future Date. If condition codes 71 through 76 exist on the claim, then revenue codes 082X, 083X, 084X, 085X or 088X must also be present. Please Provide The Type Of Drug Or Method Used To Stop Labor. Continue ToUse Appropriate Codes On Billing Claim(s). Part C Explanation of Benefits (EOB) Materials. Do not resubmit. Please Indicate Computation For Unloaded Mileage. Questionable Long Term Prognosis Due To Gum And Bone Disease. NDC- National Drug Code is invalid for the Dispense Date Of Service(DOS). Policy override must be granted by the Drug Authorizationand Policy Override Center to dispense early. The Reimbursement Code Assigned To This Certification Segment Does Not Authorize a Training Payment. This Payment Is To Satisfy Amount Owed For A Drug Rebate Prior Quarter Correction. Indicator for Present on Admission (POA) is not a valid value. . The CNA Is Only Eligible For Testing Reimbursement. Denied. This service is not covered under the ESRD benefit. Adjustment To Crossover Paid Prior To Aim Implementation Date. Providers May Only Bill For Assessments And Care Plans Twice Per Calendar Year. A National Drug Code (NDC) is required for this HCPCS code. Other Insurance Or Medicare Response Not Received Within 120 Days For ProviderBased Bill. The Other Payer ID qualifier is invalid for . Service Denied. This Is A Duplicate Request. Header To Date Of Service(DOS) is required. Denied/Cutback. Adjustment To Eyeglasses Not Payable As A Repair Service. Outpatient Services To Be Billed As Inpatient Ancillaries When Same Day Stay Occurs Please File An Adjustment/reconsideration Request To Correct Inpatiet Billing. Revenue Code Required. Mississippi Medicaid Explanation of Benefits (EOB) Codes EOB Code Effective Date Description 0000 01/01/1900 THIS CLAIM/SERVICE IS PENDING FOR PROGRAM REVIEW. Please Bill Your Medicare Intermediary Prior To Submitting To . 690 Canon Eb R-FRAME-EB Denied due to The Member WCDP Id Number Is Incorrect Or Not On Our Current Eligibility File. Denied. POS codes are required under the provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Request Denied Due To Late Billing. Please Submit Charges Minus Credit/discount. If You Have Already Obtained SSOP, Please Disregard This Message. Limited to once per quadrant per day. Medicare Paid The Total Allowable For The Service. Member has Medicare Managed Care for the Date(s) of Service. 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. Procedure code 00942 is allowed only when provided on the same date ofservice as procedure code 57520. With Payspan's eEOB member-friendly functionality, members can log into the payer's secure portal and . The Materials/services Requested Are Principally Cosmetic In Nature. Please Correct and Resubmit. Denied due to Provider Signature Is Missing. Invalid/obsolete Procedure Code For Determination Of Refraction, Service Denied. The Rendering Providers taxonomy code in the detail is not valid. Effective 04/01/09, the BadgerCare Plus Core Plan will limit coverage for Hypoglycemics-Insulin to Humalog and Lantus. Here are just a few of them: EOB CODE. Detail From Date Of Service(DOS) is after the ICN Date. The Existing Appliance Has Not Been Worn For Three Years. Benefit code These codes are submitted by the provider to identify state programs. A Second Occurrence Code Date is required. Timely Filing Request Denied. Diagnosis Treatment Indicator is invalid. This Adjustment Was Initiated By . Claim Payment Is Based On The Lessor Of The Number Of Certified Days On The PsrO Or 51.42 Board Stamp Or Admitting Calendar Month Days In Specialty Hospital. Members File Shows Other Insurance. The Narrative History Does Not Indicate the Members Functioning is Impaired due To AODA Usage. Please Supply Modifier Code(s) Corresponding To The Procedure Code Description. Denied. Claims may deny for procedures billed with modifier 79 when the same or different 0-, 10- or 90-day procedure code has not been billed on the same date of service. Please Disregard Additional Informational Messages For This Claim. Billing Provider is not certified for the Date(s) of Service. NDC- National Drug Code is not allowed for the member on the Date Of Service(DOS). PATIENT PAID PORTION USED TOWARDS DEDUCTIBLE. The Processor Control Number (PCN) for SeniorCare member over 200% FPL is missing, or the PCN is invalid for a WCDP member, member or SeniorCare member at or below 200% FPL. Sixth Diagnosis Code (dx) is not on file. Example: Diagnosis code 285.21 is entered as 28521, without a period or space. NUMBER IS MISSING OR INCORRECT 0002 01/01/1900 COULD NOT PROCESS CLAIM. This Procedure Code Is Denied As Incidental/Integral To Another Procedure CodeBilled On This Claim. Resubmit Your Services Using The Appropriate Modifier After YouReceive A Update Providing Additional Billing Information. Please Disregard Additional Information Messages For This Claim. The Rendering Providers taxonomy code is missing in the header. Payment Subject To Pharmacy Consultant Review. The billing provider number is not on file. 0001 01/01/1900 NOT USED - MEMBER'S DMAP I.D. Denied. WWWP Does Not Process Interim Bills. Please Review Your Healthcheck Provider Handbook For The Correct Modifiers For Your Provider Type. The Provider Type/specialty Is Not Recognized For These Date(s) Of Service. Invalid Procedure Code For Dx Indicated. Reimbursement For HCPCS Procedure Code 58300 Includes IUD Cost. Claim Denied. Discharge Diagnosis 2 Is Not Applicable To Members Sex. The Service Requested Is Inappropriate For The Members Diagnosis. Prior Authorization Is Required For Payment Of This Service With This Modifier. Claim reduced to fifteen Hospital Bedhold Days for stays exceeding fifteen days. Amount Paid By Other Insurance Exceeds Amount Allowed By . Header From Date Of Service(DOS) is required. . MassHealth List of EOB Codes Appearing on the Remittance Advice. Surgical Procedure Code billed is not appropriate for members gender. Continuous home care and routine home care may not be billed for the same member on the same Date Of Service(DOS). The Medical Need For This Service Is Not Supported By The Submitted Documentation. Pricing Adjustment/ Paid according to program policy. This Is A Manual Decrease To Your Accounts Receivable Balance. Units Billed Are Inconsistent With The Billed Amount. Contact. Training Completion Date Must Be Prior To And Within A Year Of The CNAs Certification Date. OA 14 The date of birth follows the date of service. The Diagnosis Code is not payable for the member. There are approximately 20 Medicaid Explanation Codes which map to Denial Code 16. These same rules are used by most healthcare claims payers and enforced by the Centers for Medicare and Medicaid Services. Member must receive this service from the state contractor if this is for incontinence or urological supplies. Service not payable with other service rendered on the same date. Please Disregard Additional Messages For This Claim. Modifier invalid for Procedure Code billed. Recd Beyond 90 Days Special Filing Deadline FOr System Generated Adjmts/Medicare X-overs/Other Insurance Reconsideration/Cou rt Order/Fair Hearing. A National Provider Identifier (NPI) is required for the Performing Provider listed in the header. 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. Claims Cannot Exceed 28 Details. An ICD-9-CM Diagnosis Code of greater specificity must be used for the Fourth Diagnosis Code. The Type Of Psychotherapy Service Requested For This Member Is Considered To be Professionally Unacceptable, Unproven And/or Experimental. Two Informational Modifiers Required When Billing This Procedure Code. The Skills Of A Therapist Are Not Required To Maintain The Member. LO DENIED - RCVD MORE THAN 60 DAYS AFTER DATE ON EOB FROM OTHER MA67 2D ADJUSTMENT - DENIAL UPHELD-TIMELINESS NOT JUSTIFIED: 31 N30 34: DENIED - NOT A PLAN MEMBER,PROVIDER MUST BILL E.D.S. 1 PC Dispensing Fee Allowed Per Date Of Service(DOS). Services Submitted On Improper Claim Form. Inpatient Respite Care Is Not Covered For Hospice Members Residing In Nursing Homes. Proposed Orthodontic Service Denied; Examination/study Models Are Approved. Member enrolled in Medicare Part D for the Dispense Date Of Service(DOS). Additional Psychotherapy Is Not Considered Appropriate Or Inline With More Effective, Available Services. Denied. Claim Denied for implementation of new Wisconsin Medicaid Interchange System.Resubmission of the claim is required due to new claim submission guidelines. Subsequent Aide Visits Limited To 7 Hrs Per Day/per Member/per Provider. Billing Provider indicated is not certified as a billing provider. Diag Restriction On ICD9 Coverage Rule edit. Denied/Cutback. No Supporting Documentation. Your latest EOB will be under Claims on the top menu. This CNAs Social Security Number, SSN, Is Not On The EDS Nurse Aide Registry File. Complex Evaluation and Management procedures require history and physical or medical progress report to be submitted with the claim. Medicare RA/EOMB And Claim Dates And/or Charges Do Not Match. Good Faith Claim Denied For Timely Filing. Purchase Only Allowed; Medical Need For Rental Has Not Been Documented. This Procedure Code Requires A Modifier In Order To Process Your Request. Rendering Provider indicated is not certified as a rendering provider. Pricing Adjustment/ Anesthesia pricing applied. Denied. Amount Paid Reduced By Amount Of Other Insurance Payment. Revenue code is not valid for the type of bill submitted. In 2015 CMS began to standardize the reason codes and statements for certain services. Denied. Diagnosis Code indicated is not valid as a primary diagnosis. Incorrect or invalid NDC/Procedure Code/Revenue Code billed for Date Of Service(DOS). The Service Requested Was Performed Less Than 3 Years Ago. The number of tooth surfaces indicated is insufficient for the procedure code billed. Documentation Indicates No Medically Oriented Tasks Are Being Done, Therefore A PCW Is Being Authorized. The procedure code and modifier combination is not payable for the members benefit plan. Second And Subsequent Cerebral Evoked Response Tests Paid At A Reduced Rate Per Guidelines. DRG cannotbe determined. Please Indicate The Dollar Amount Requested For The Service(s) Requested. 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. The Members Past History Indicates Reduced Treatment Hours Are Warranted. Please Resubmit. Please Indicate One Prior Authorization Number Per Claim. Type of Bill is invalid for the claim type. You Must Either Be The Designated Provider Or Have A Refer. 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 Member Is Only Eligible For Maintenance Hours. Pricing Adjustment/ Maximum allowable fee pricing applied. One or more Diagnosis Code(s) in positions 10 through 25 is not on file. Please Indicate The Revenue Code/procedure Code/NDC Code For Which The Credit is To Be Applied. Suspend Claims With DOS On Or After 7/9/97. Services have been determined by DHCAA to be non-emergency. Revenue code requires submission of associated HCPCS code. We have redesigned our website to help you find the information you need more easily. Inpatient psychiatric services are not reimbursable for members age 21 65 (age 22 if receiving services prior to 21st birthday). Refer To The Wisconsin Website @ dhs.state.wi.us. Questionable Long-term Prognosis Due To Poor Oral Hygiene. An ICD-9-CM Diagnosis Code of greater specificity must be used for the Second Diagnosis Code. Non-preferred Drug Is Being Dispensed. Denied. Pricing Adjustment/ Pharmacy pricing applied. NDC- National Drug Code billed is not appropriate for members gender. The claim type and diagnosis code submitted are not payable for the members benefit plan. Description. The Dispense As Written (Daw) Indicator Is Not Allowed For The National Drug Code. Election Form Is Not On File For This Member. Please correct and resubmit. 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. Surgical Procedure Code is not related to Principal Diagnosis Code. Quantity Billed is not equally divisible by the number of Dates of Service on the detail. Department of Health Services (DHS) Authorized Payment Is Being Withheld Due toan Audit. Medication checks by a Psychiatrist and/or Registered Nurse are limited to four services per calendar month. Pricing Adjustment/ Provider Level of Care (LOC) pricing applied. Our Records Indicate You Have Billed More Than One Unit Dose Dispensing Fee For This Calendar Month. Please familiarize yourself with these new explanation codes and update your accounts receivable as indicated. Backdating Allowed Only In Cases Of Retroactive Member/provider Eligibility. General Exercise To Promote Overall Fitness And Flexibility Are Non-covered Services. Pricing Adjustment/ Medicare pricing cutbacks applied. The detail From Date Of Service(DOS) is after the detail To Date Of Service(DOS). A Reimbursement Request For A Level I Screen Must Be Received At Within A Year Of The Screen Date. Hospice Member Services Related To The Terminal Illness Must Be Billed By Hospice Or Attending Physician. Service Denied. Condition code 80 is present without condition code 74. Denied. Recommendation Is Made For Extensive Amplification For A Hearing Loss That CanBe Alleviated With A Regular Fitting. Claims may deny for audiology screening (CPT 92551, 92560, V5008) may be denied when a provider bills for auditory screening services at the same time as a preventive medicine visit (CPT 99381-99397) or wellness visit (CPT G0438-G0439), without appropriate modifier appended to the E&M service to identify a separately identifiable procedure. Detail To Date Of Service(DOS) is invalid. Claims may deny for a CT head or brain, CTA head, MRA head, MRI brain or CT follow-up when the only diagnosis on the claim is a migraine. Prior Authorization (PA) is required for payment of this service. A Procedure Code without a modifier billed on the same day as a Procedure Codewith modifier 11 are viewed as the same trip. The To Date Of Service(DOS) for the Second Occurrence Span Code is invalid. Quantity indicated for this service exceeds the maximum quantity limit established by the National Correct Coding Initiative. That is why we support our provider partners with quality incentive programs, quicker claims payments and dedicated market support. Reimbursement Is At The Unilateral Rate. Reimbursement rate is not on file for members level of care. Assessment Is Not A Covered Service Unless All Four Components Of Skilled Nursing Are Present: Assessment, Planning, Intervention And Evaluation. Procedure Not Payable As Submitted. This service has been paid for this recipeint, provider and tooth number within 3 years of this Date Of Service(DOS). Refer To Your Pharmacy Handbook For Policy Limitations. A Previously Submitted Adjustment Request Is Currently In Process. Denied. Cannot bill for both Assay of Lab and other handling/conveyance of specimen. Restorative Nursing Involvement Should Be Increased. One or more Surgical Code Date(s) is invalid in positions seven through 24. Ninth Diagnosis Code (dx) is not on file. Schedule 3, 4 or 5 drugs are limited to the original dispensing plus 5 refillsor 6 months. Claim Denied For No Client Enrollment Form On File. According To Our Records, The Hospital Has Not Received Prior Authorization For This Surgery. Denied. Denied. Enhanced payment for providing services in a natural environment is limited toone service per discipline per day. Allowance For Coinsurance Is Limited To Allowable Amount Less Medicares Payment. A valid Prior Authorization is required for Brand Medically Necessary Drugs. Claim paid at program allowed rate. Medicare paid amount(s) have been incorrectly applied to both the claim headerand details. A Hospital Stay Has Been Paid For DOS Indicated. First Other Surgical Code Date is invalid. No Action Required. Services billed exceed prior authorized amount. Occupational Therapy Limited To 45 Treatment Days Per Spell Of Illness w/o Prior Authorization. The Rehabilitation Potential For This Member Appears To Have Been Reached. NDC was reimbursed at Employer Medical Assistance Contribution (EMAC) rate. Good Faith Claim Correctly Denied. Please Correct And Resubmit. Detail Rendering Provider certification is cancelled for the Date Of Service(DOS). Healthcheck screenings or outreach limited to three per year for members between the age of one and two years. Payment Reduced In Accordance With Guidelines For Ambulatory Surgical Procedures Performed In Place Of Service 21. Reimbursement determination has been made under DRG 981, 982, or 983. Request Denied Because The Screen Date Is After The Admission Date. Please submit claim to HIRSP or BadgerRX Gold. You Must Either Be The Designated Provider Or Have A Referral. A discrepancy exists between the Other Coverage Indicator and the Other Paid Amount. Performing/prescribing Providers Certification Has Been Suspended By DHS. The Clinical Status Of The Member Does Not Meet Standards Accepted By The Department Of Health And Family Services For Transplant. Revenue code submitted with the total charge not equal to the rate times number of units. Medicare Id Number Missing Or Incorrect. Prescriber ID Qualifier must equal 01. The Functional Assessment Indicates This Member Has Less Than A 50% Likelihoodof Benefit, Therefore Day Treatment Is Not Appropriate. In addition, duplex scan of extracranial arteries, computed tomographic angiography (CTA) of the neck and magnetic resonance angiography (MRA) of the neck are not medically necessary for evaluation of syncope in patients with no suggestion of seizure and no report of other neurologic symptoms or signs. Requires A Unique Modifier. Multiple Screens Performed Within A Fifteen Day Time Frame For This SSN. Only One Ventilator Allowed As Per Stated Condition Of The Member. Therefore itIs Not Necessary To Wait The Full 6 Weeks After Extractions Before Taking Denture Impressions. The Non-contracted Frame Is Not Medically Justified. Denied. NDC was reimbursed at State Maximum Allowable Cost (SMAC) rate. Eyeglasses limited to original plus 1 replacement pair, lens or frame in 12 wit hout Prior Authorization. Independent RHCs Must Bill Codes W6251, W6252, W6253, W6254 Or W6255. Header From Date Of Service(DOS) is after the header To Date Of Service(DOS). Reimbursement limit for all adjunctive emergency services is exceeded. According To Our Records, The Surgeon For This Sterilization Procedure Has NotSubmitted The Members Consent Form. You Received A PaymentThat Should Have gone To Another Provider.