Indiana Medicaid: Providers: Explanation of Benefits (EOB) A WCDP drug rebate agreement for this drug is not on file for the Date Of Service(DOS). Other Medicare Part A Response not received within 120 days for provider basedbill. There are approximately 20 Medicaid Explanation Codes which map to Denial Code 16. Hearing aid repairs are limited to once per six months, per provider, per hearing aid. Rn Visit Every Other Week Is Sufficient For Med Set-up. Claim Denied/Cutback. All services should be coordinated with the Hospice provider. The Request Has Been Back datedto Date of Receipt. This service is payable at a frequency of once per 12-month period, per provider, per hearing aid. Please Resubmit With The Costs For Sterilization Related Charges Identified As Non-covered Charges On The Claim. Third modifier code is invalid for Date Of Service(DOS). Denied. 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). Amount Recouped For Duplicate Payment on a Previous Claim. Denial Code Resolution - JE Part B - Noridian Per Information From Insurer, Claims(s) Was (were) Paid. Split Decision Was Rendered On Expansion Of Units. Claim Is For A Member With Retro Ma Eligibility. Please verify billing. Prescriber ID is invalid.e. Procedure Code and modifiers billed must match approved PA. Channel: Medicare covered Codes Explanation Viewing all 30 articles Browse latest View live Explanation of Benefit. Two Informational Modifiers Required When Billing This Procedure Code. Please submit future claims with the appropriate NPI, taxonomy and/or Zip +4 Code. Day Treatment exceeding 120 hours per month is not payable regardless of PriorAuthorzation. Amount Indicated In Current Processed Line On R&S Report Is The Manual Check You Recently Received. Please Resubmit Corr. Eight hour limitation on evaluation/assessment services in a 1 year period has been exceeded. This Is A Duplicate Request. Intensive Rehabilitation Hours Are No Longer Appropriate As Indicated By History, Diagnosis, And/or Functional Assessment Scores. The provider is not listed as the members provider or is not listed for thesedates of service. Please Correct And Resubmit. As a provider, you have access to a portal that streamlines your work, keeps you up-to-date more than ever before and provides critical information. Denied due to Medicare Allowed, Deductible, Coinsurance And Paid Amounts Do Not Balance. Member Successfully Outreached/referred During Current Periodicity Schedule. PATIENT PAID PORTION USED TOWARDS DEDUCTIBLE. Pharmaceutical care indicates the prescription was not filled. Denied/cutback. Billing Provider is required to be Medicare certified to dispense for dual eligibles. The Rendering Providers taxonomy code in the header is invalid. Good Faith Claim Denied For Timely Filing. Please adjust quantities on the previously submitted and paid claim. $150.00 Reimbursement Limit Has Been Reached For Individual And Group Pncc Health Education/nutritional Counseling. Submitted referring provider NPI in the detail is invalid. Reimbursement rate is not on file for members level of care. The From Date Of Service(DOS) for the Second Occurrence Span Code is required. This Procedure, When Billed With Modifier HK, Is Payable Only If The Member Is Under The Age Of 19. The Header and Detail Date(s) of Service conflict. Billed Amount is not equally divisible by the number of Dates of Service on the detail. Alternatively, the provider has billed a prior inpatient E&M visit, without an inpatient discharge service (CPT 99238-99239) in the interim. A1 This claim was refused as the billing service provider submitted is: . If you haven't created an account yet, register now. Revenue code submitted with the total charge not equal to the rate times number of units. THE WELLCARE GROUP OF COMPANIES . Submit copy of the dated and signed evaluation and indicate if this is an initial Evaluation. DX Of Aphakia Is Required For Payment Of This Service. These Services Paid In Same Group on a Previous Claim. This Check Automatically Increases Your 1099 Earnings. Only One Date For EachService Must Be Used. Medicaid Remittance Advice Remark Code:M86 MMIS EOB Code:100. Birth to 3 enhancement is not reimbursable for place of service billed. Diagnosis Codes Assigned Must Be At The Greatest Specificity Available. Bilateral Surgeries Reimbursed At 150% Of The Unilateral Rate. Denied. Please Refer To Update No. Denied due to Provider Signature Date Is Missing Or Invalid. We have redesigned our website to help you find the information you need more easily. Invalid Admission Date. Start: 01/01/2000 | Last Modified: 03/06/2012 Notes: (Modified 2/28/03, 3/6/2012) N5: Prior authorization is required for Advair or Symbicort if no other Glucocorticoid Inhaled product has been reimbursed within 90 days. What to Expect with WellCare CMS (UPDATED-60 days in) For Review, Forward Additional Information With R&S To WCDP. Medicare Providers | Wellcare Unable To Process Your Adjustment Request due to Member Not Found. Incidental modifier was added to the secondary procedure code. The Treatment Request Is Not Consistent With The Members Diagnosis. Modification Of The Request Is Necessitated By The Members Minimal Progress. This National Drug Code (NDC) has been terminated by CMS for the Date Of Service(DOS). Do Not Bill Intraoral Complete Series Components Separately. Revenue codes 082X, 083X, 084X, 085X, 0800 or 0881 (X frequency not equal to 5) exist on an ESRD claim for a member who has selected method 1 or no method and the claim does not contain condition codes 71, 72, 73 ,74, 75, or 76. The detail From Date Of Service(DOS) is required. Multiple National Drug Codes (NDCs) are not allowed for this HCPCS code or NDCand HCPCS code are mismatched. Other Payer Coverage Type is missing or invalid. 2434. Reimbursement Is At The Unilateral Rate. Member eligibility file indicates that BadgerCare Plus Benchmark, CorePlan or Basic Plan member. Denied. Pricing Adjustment/ Repackaging dispensing fee applied. PDF Remittance and Status (R&S) Reports - Tmhp The Request Does Not Meet Generally Accepted Conditions Requiring Fluoride Treatments. All Home Health Services Exceeding 8 Hours Per Day Or 40 Or More Hours Per Week Require Prior Authorization. Denied. Admission Denied In Accordance With Pre-admission Review Criteria. A more specific Diagnosis Code(s) is required. Once you register and have access to the provider portal, you will find a variety of video training available in the Resources section of the portal. Denied. If you are still unable to resolve the login problem, read the troubleshooting steps or report your issue. Handwritten Changes/corrections On The Medicare EOMB Are Not Acceptable. Unable To Process Your Adjustment Request due to. If required information is not received within 60 days, the claim will be. Please Furnish A UB92 Revenue Code And Corresponding Description. The revenue accomodation billing code on the claim does not match the revenue accomodation billing code on the member file or does not match for these dates of service. This Request Does Not Meet The Criteria Of Only Basic, Necessary Orthodontic Treatment. Denied. Claim Detail Pended As Suspect Duplicate. Traditional dispensing fee may be allowed. A Valid Level Of Effort Is Required For Billing Compound Drugs Or Pharmaceutical Care. These codes provide additional explanation for an adjustment already described by a Claim Adjustment Reason Code (CARC) or convey information about remittance processing. You can view these EOBs online by following these steps: Log in to your bcbsm.com account to view your prescriptions coverage. 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). If you are having difficulties registering please . Please Ask Prescriber To Update DEA Number On TheProvider File. Only two dispensing fees per month, per member are allowed. The From Date Of Service(DOS) and To Date Of Service(DOS) must be in the same calendar month and year. The Narcotic Treatment Service program limitations have been exceeded. This claim did not include the Plan ID, therefore we assigned TXIX as the Plan ID for this claim. Claim contains an unclassified drug HCPCS procedure code or a drug HCPCS procedure code included in the composite rate. A Trading Partner Agreement/profile Form(s) Authorizing Electronic Claims Submission Is Required. Compound Drug Service Denied. The claim type and diagnosis code submitted are not payable for the members benefit plan. A National Drug Code (NDC) is required for this HCPCS code. Emergency Services Indicator must be "Y" or Pregnancy Indicator must be "Y" for this aid code. Dollar Amount Of Claim Was Adjusted To Correct Mathematical Error. Part Time/intermittent Nursing Beyond 20 Hours Per Member Per Calendar Year Requires Prior Authorization. Members Age 3 And Older Must Have An Oral Assessment And Blood Pressure Check.With Appropriate Referral Codes, For Payment Of A Screening. If Required Information Is not received within 60 days, the claim detail will be denied. You can choose to receive only your EOBs online, eliminating the paper . Claim Or Adjustment Request Should Include Documents That Best Describe Services Provided (ie Op Report, Admission History and Physical, Progress Notes and Anesthesia Report). Services Denied In Accordance With Hearing Aid Policies. Based on these reimbursement guidelines, claims may deny when the following revenue codes are billed without the appropriate HCPCS code: Detail To Date Of Service(DOS) is required. Denied. A HCPCS code is required when condition code A6 is included on the claim.