To access the training video's in the portal, please register for an account and request access to your contract or medical group. Pricing Adjustment/ Medicare crossover claim cutback applied. Billed Amount On Detail Paid By WWWP. Procedure May Not Be Billed With A Quantity Of Less Than One. Diagnosis Code indicated is not valid as a primary diagnosis. This Member, As Indicated By Narrative History, Does Not Agree To Abstinence from Alcohol Or Other Drugs And Is Ineligible For AODA Treatment. The Treatment Request Is Not Consistent With The Members Diagnosis. Training CompletionDate Exceeds The Current Eligibility Timeline. Denied. Refer to the Onine Handbook. Please Indicate Mileage Traveled. Service Denied. This Procedure Is Limited To Once Per Day. This Is A Manual Increase To Your Accounts Receivable Balance. Rqst For An Acute Episode Is Denied. The Member Is School-age And Services Must Be Provided In The Public Schools. Services Not Provided Under Primary Provider Program. The Members Profile Indicates This Member Is Possibly Alcoholic And/or Chemically Dependent, And Intensive Aoda Treatment Appears Warranted. According to CMS Medicare Claims Processing Manual, Place of Service codes (POS) are used to identify where, i.e., physician office, inpatient hospital, a procedure or service is furnished to a patient. Claim Denied. Claim contains duplicate segments for Present on Admission (POA) indicator. Request was not submitted Within A Year Of The CNAs Hire Date. Denied. Claim Is For A Member With Retro Ma Eligibility. Pricing Adjustment/ Prior Authorization pricing applied. Medical Necessity For Food Supplements Has Not Been Documented. Second Other Surgical Code Date is required. Effective 04/01/09, the BadgerCare Plus Core Plan will limit coverage for Brochodilators-Beta Agonists to Proventil HFA and Serevent. Has Already Issued A Payment To Your NF For This Level L Screen. Dispense as Written indicator is not accepted by . POS codes are required under the provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Refer To Dental HandbookOn Billing Emergency Procedures. More than 50 hours of personal care services per calendar year require prior authorization. Was Unable To Process This Request. The Fourth Occurrence Code Date is invalid. Billing Provider does not have required Certification Addendum on file. Valid group codes for use on Medicare remittance advice are:. Based on these reimbursement guidelines, claims may deny when the following revenue codes are billed without the appropriate HCPCS code: Claim Reduced Due To Member Income Available Toward Cost Of Care (Nursing Home Liability). Payment reduced. Language Comprehension And Language Production Are Equivalent To Cognition, Thus Formal Speech Therapy Is Not Needed. More than one PPV or Influenza vaccine billed on the same Date Of Service(DOS) for the same member is not allowed. A code with no Trip Modifier billed on same day as a code with Modifier U1 are considered the same trip. Will Only Pay For One. Outside Lab,element 20 On CMS 1500 Claim Form Must Be Checked Yes When Handling Charges Are Billed. The diagnosis codes must be coded to the highest level of specificity. One or more Diagnosis Code(s) is not payable by Wisconsin Well Woman Program for the Date(s) of Service. Home Health, Personal Care And Private Duty Nursing Services Are Subject To A Monthly Cap. 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. 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). Please Correct And Resubmit. Claim date(s) of service modified to adhere to Policy. Claim Denied For Invalid Billing Type Frequency Code, Claim Type, Or SubmittedAdjustment Provider Number Does Not Match Original Claims Provider Number. Pricing Adjustment/ Resource Based Relative Value Scale (RBRVS) pricing applied. The quantity billed of the NDC is not equally divisible by the NDC package size. Claims may deny when reported and not meeting the ICD-10-CM Laterality policy for Diagnosis-to-Diagnosis comparison. This service was previously paid under an equivalent Procedure Code. NDC was reimbursed at brand WAC (Wholesale Acquisition Cost) (Wholesale Acquisition Cost) rate. Other Medicare Managed Care Response not received within 120 days for providerbased bill. Drug Dispensed Under Another Prescription Number. Denied. Effective September 1, 2021: Benefit Changes to Total Disc Arthroplasty for Medicaid and CHIP. Details Include Revenue/surgical/HCPCS/CPT Codes. Amount Indicated In Current Processed Line On R&S Report Is The Manual Check You Recently Received. This Member Is Receiving Concurrent AODA/Psychotherapy Services And Is Therefore Only Eligible For Maintenance Hours. The Service/procedure Proposed Is Not Supported By Submitted Documentation. Please Indicate The Dollar Amount Requested For The Service(s) Requested. Please Correct And Resubmit. Invalid Service Facility Address. Medicaid Remittance Advice Remark Code:M86 MMIS EOB Code:100. OA 10 The diagnosis is inconsistent with the patient's gender. Also, to ensure claims process and pay accurately, Staywell may deny a claim and ask for pertinent medical documentation from the provider or supplier who submitted the claim. Providers May Only Bill For Assessments And Care Plans Twice Per Calendar Year. The Procedure(s) Requested Are Not Medical In Nature. No Interim Billing Allowed On Or After 01-01-86. Number Is Missing Or Incorrect. Please Supply The Appropriate Modifier. Prior Authorization is required for manipulations/adjustments exceeding 20 perspell of illness. 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. All services should be coordinated with the Hospice provider. The Total Number Of Sessions Requested Exceeds Quarterly Guidelines. The Procedure Requested Is Not Allowable For The Process Type Indicated On TheRequest. This Unbundled Procedure Code And Billed Charge Were Rebundled To Another Code, Which Was Either Billed By The Provider On This Claim Or Added By Claimcheck. It Corrects A Mispayment FoundDuring Claims Processing Or Resulting From Retroactive File Changes. Denied. codes are provided per day by the same individual physician or other health care professional. Denied due to Procedure Is Not Allowable For Diagnosis Indicated. Member Has Already Been Granted Actute Episode for 3 Months In This Cal Yr. Reimb Is Limited To Average Monthy NH Cost And Services Above That Are Consider Non-covered Services. This Modifier has been discontinued by CMS or AMA for the Date Of Service(DOS)(s). Procedure Code Modifier(s) Invalid For Date Of Service(DOS) Or For Prior Authorization Date Of Receipt. This Surgical Code Has Encounter Indicator restrictions. Denied. Provider Not Authorized To Perform Procedure. Revenue code is not valid for the type of bill submitted. Will Not Authorize New Dentures Under Such Circumstances. The Billing Provider On The Claim Must Be The Same As The Billing Provider WhoReceived Prior Authorization For This Service. . Please Correct and Resubmit. If you are still unable to resolve the login problem, read the troubleshooting steps or report your issue. 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. Speech Therapy Is Not Warranted. The Clinical Profile/Diagnosis Makes This Member Ineligible For AODA Services. Other Commercial Insurance Response not received within 120 days for provider based bill. The Comprehensive Community Support Program reimbursement limitations have been exceeded. 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. Denied due to Take Home Drugs Not Billable On UB92 Claim Form. The To Date Of Service(DOS) for the First Occurrence Span Code is required. Please Correct Claim And Resubmit. The Service Requested Was Performed Less Than 5 Years Ago. Adjustment and original claim do not have the same finanical payer, 6355 replacing 635R diagnosis (For use of Category of Service only), 6360 replacing 635S diagnosis (For use of Category of Service only), 6365 replacing 635T diagnosis (For use of Category of Service only). This claim was processed using a program assigned provider ID number, (e.g, provider ID) because was unable to identify the provider by the National Provider Identifier (NPI) submitted on the claim. The Submission Clarification Code is missing or invalid. This Mutually Exclusive Procedure Code Remains Denied. Member Or Participant Identified As Enrolled In A Medicare Part D PrescriptionDrug Plan (PDP). Reimbursement Rate Applied To Allowed Amount. No policy override available for BadgerCare Plus Benchmark Plan, Core Plan or Basic Plan. No Functional Regression Has Occurred To Warrant A Spell Of Illness; Submit AsA Prior Authorization Request. Separate reimbursement for drugs included in the composite rate is not allowed. Staywell is committed to continually improving its claims review and payment processes. Condition code must be blank or alpha numeric A0-Z9. Quantity indicated for this service exceeds the maximum quantity limit established by the National Correct Coding Initiative. Amount Recouped For Duplicate Payment on a Previous Claim. Pricing Adjustment/ Medicare benefits are exhausted. A Training Payment Has Already Been Issued To A Different NF For This CNA. Bilateral Surgeries Reimbursed At 150% Of The Unilateral Rate. Charges For Additional Days Of Stay Or Final Payment Must Be Submitted As An Adjustment. Reimbursement Based On Members County Of Residence. Rebill Using Correct Claim Form As Instructed In Your Handbook. Claim Number Given Is Not The Most Recent Number. Pharmacuetical care limitation exceeded. Time Spent In AODA Day Treatment By Affected Family Members Is Not Covered. Header To Date Of Service(DOS) is required. Denied due to Some Charges Billed Are Non-covered. Please watch future remittance advice. Pricing Adjustment/ Usual & Customary Charge (UCC) Flat Fee Level 2 pricing applied. Denied due to Medicare Allowed Amount Required. Your latest EOB will be under Claims on the top menu. All three DUR fields must indicate a valid value for prospective DUR. A standard 12-lead electrocardiogram should be obtained first for patients with a diagnosis of syncope and collapse before performing advanced imaging procedures. Claim Denied/Cutback. Please Bill Your Medicare Intermediary Prior To Submitting To . Denied due to Provider Number Missing Or Invalid. A HCPCS code is required when condition code A6 is included on the claim. Speech Therapy Limited To 45 Treatment Days Per Spell Of Illness W/o Prior Authorization. Rendering Provider is not certified for the Date(s) of Service. Please Review Remittance And Status Report. Denied. Denied due to Discharge Diagnosis 1 Missing Or Invalid, Denied due to Diagnosis Pointer To Diagnosis Code 1 Invalid, Denied due to Diagnosis Pointer To Diagnosis Code 2 Invalid, Denied due to Diagnosis Pointer To Diagnosis Code 3 Invalid, Denied due to Diagnosis Pointer To Diagnosis Code 4 Invalid, Denied due to Diagnosis Pointer To Diagnosis Code 5 Invalid, Denied due to Diagnosis Pointer(s) Are Invalid. 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. Prescriber ID Qualifier must equal 01. The Performing Provider Id, Member Id, And Date Of Service(DOS) Must Match The Completion Certificate Received From Ddes. Condition Code is missing/invalid or incorrect for the Revenue Code submitted. For over 40 years, Washington Publishing Company (WPC) has specialized in managing and distributing data integration information through publications, training, and consulting services. The number of treatments/days reflected by the units entered with revenue code0821, 0831, 0841, 0851, 0880, 0881 exceeds the number of days included in the FROM and TO dates entered on this claim. Do Not Bill Intraoral Complete Series Components Separately. EOB. Birth to 3 enhancement is not reimbursable for place of service billed. Denied as duplicate claim. The canister, dressings and related supplies are included as part of the reimbursement for the negative pressure wound therapy pump. This dental service limited to once per five years.Prior Authorization is needed to exceed this limit. Use The New Prior Authorization Number When Submitting Billing Claim. Prescribing Provider UPIN Or Provider Number Missing. . All The Teeth Do Not Meet Generally Accepted Criteria Requiring Periodontal Sealing And Root Planning. Service(s) Approved By DHS Transportation Consultant. Occurrence Code is required when an Occurrence Date is present. Claim Is Pended For 60 Days. If correct, special billing instructions apply. Please Submit Charges Minus Credit/discount. Provider Not Eligible For Outlier Payment. Procedure Code and modifiers billed must match approved PA. The detail From or To Date Of Service(DOS) is missing or incorrect. Strong knowledge of adjustment and denial reason codes from Electronic Remittance Advices (ERA/835 files) and from paper Explanation of benefits (EOB's) / Explanation of payments (EOP's), CPT and ICD10 codes; Excellent interpersonal and communication skills with professional demeanor and positive attitude We have created a list of EOB reason codes for the help of people who are . Dispense Date Of Service(DOS) is after Date of Receipt of claim. Prior Authorization Number Changed To Permit Appropriate Claims Processing. Therefore itIs Not Necessary To Wait The Full 6 Weeks After Extractions Before Taking Denture Impressions. Denied due to Medicare Allowed, Deductible, Coinsurance And Paid Amounts Do Not Balance. Out-of-State non-emergency services require Prior Authorization. Admit Diagnosis Code is invalid for the Date(s) of Service. Claim Number Given On The Adjustment/reconsideration Request Form Does Not Match Services Originally Billed. Unable To Process This Request Because The Competency Test Date And TrainingCompletion Date Fields Are Blank. The Medicare Claims Processing Manual and the UB-04 Data Specifications Manual outlines requirements for billing outpatient claims including that (HCPCS) codes are required on outpatient claims (UB-04) with related revenue codes. The Provider Type/specialty Is Not Recognized For These Date(s) Of Service. HIPAA EOB codes are returned on the 835 Remittance Advice file and are maintained by the Washington Publishing Company. Refer To Notice From DHS. If you are having difficulties registering please . Denied. Third Other Surgical Code Date is required. Documentation Provided Indicates A Less Elaborate Procedure Should Be Considered. Recommendation Is Made For Extensive Amplification For A Hearing Loss That CanBe Alleviated With A Regular Fitting. Continuous home care must be billed in an hourly quantity equal to or greater than eight hours, up to and including 24 hours. Please Resubmit using A Approved CPT Or HCPCS Procedure Code. The Type Of Psychotherapy Service Requested For This Member Is Considered To be Professionally Unacceptable, Unproven And/or Experimental. The Value Code and/or value code amount is missing, invalid or incorrect. For additional information on HIPAA EOB codes, visit the Code List section of the WPC website at www.wpc-edi.com. 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. 0001 01/01/1900 NOT USED - MEMBER'S DMAP I.D. Independent Laboratory Provider Number Required. No Reimbursement Rates on file for the Date(s) of Service. Prescriptions Or Services Must Be Billed As ASeparate Claim. The From Date Of Service(DOS) and To Date Of Service(DOS) must be in the same calendar month and year. This Service Is Included In The Hospital Ancillary Reimbursement. Claim Denied Due To Incorrect Accommodation. Inpatient psychiatric services are not reimbursable for members age 21 65 (age 22 if receiving services prior to 21st birthday). Non-covered Charges Are Missing Or Incorrect. Please submit claim to HIRSP or BadgerRX Gold. The detail From Date Of Service(DOS) is after the detail To Date Of Service(DOS). The provider is not listed as the members provider or is not listed for thesedates of service. Please Indicate Anesthesia Time For Services Rendered. A Separate Notification Letter Is Being Sent. Individual Vaccines And Combination Vaccine Code May Not Be Billed For The Same Dates Of ervice. At Least One Of The Compounded Drugs Must Be A Covered Drug. CPT is registered trademark of American Medical Association. Only one initial visit of each discipline (Nursing) is allowedper day per member. Six Week Healing Time Is Required Between Endentulation And Final Impressions.Payment For Dentures Will Be Denied Or Recouped If Healing Period Is Not Observed. Timely Filing Request Denied. Reimbursement For This Certification, Test, Segment Has Already Been Issued ToYour NF. The Rendering Providers taxonomy code in the header is invalid. The To Date Of Service(DOS) for the First Occurrence Span Code is invalid. Dollar Amount Of Claim Was Adjusted To Correct Mathematical Error. Pricing Adjustment/ Repackaging dispensing fee applied. The Primary Occurrence Code Date is invalid. Denied. EOB EOB DESCRIPTION. The Travel component for this service must be billed on the same claim as the associated service. Program guidelines or coverage were exceeded. This procedure is age restricted. To better assist you, please first select your state. This is a duplicate claim. Tooth surface is invalid or not indicated. This Claim Has Been Excluded From Home Care Cap To Allow For Acute Episode. Requests For Training Reimbursement Denied Due To Late Billing. The HCPCS procedure code listed for revenue code 0624 is either invalid or non-reimburseable. Claim or Adjustment received beyond 730-day filing deadline. The Lens Formula Does Not Justify Replacement. Denied. Procedure Code Changed To Permit Appropriate Claims Processing. The Procedure Code billed not payable according to DEFRA. Service (Procedure Code/Modifier Combination) is not reimbursable for Date Of Service(DOS). In addition, when distinct service modifier 59 or modifier XE is not appended to auditory screening services and tympanometry/impedance testing, these services may be denied. Annual Physical Exam Limited To Once Per Year By The Same Provider. Service billed is bundled with another service and cannot be reimbursed separately. Timely Filing Deadline Exceeded. This Request Can Only Be Backdated To The Date EDS First Receives The Request In The Mailroom. The Date Of The Screening Request Or The Date Of Screening Is Invalid Or Missing. Reason Code 234 | Remark Codes N20. Claim Detail Denied For Invalid CPT, Invalid CPT/modifier Combination, Or Invalid Type Of Quantity Billed. Denied. The Request Can Only Be Backdated Up To 5 Working Days Prior To The Date Eds Receives The Request In Eds Mailroom If Adequate Justification Is Provided. Claim Reduced Due To Member/participant Deductible. Transplant services not payable without a transplant aquisition revenue code. Procedure Code is not covered for members with a Nursing Home Authorization onthe Date(s) of Service.
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