EOB Codes List|Explanation of Benefit Reason Codes (2023) February 7, 2022 by medicalbillingrcm. The Narcotic Treatment Service program limitations have been exceeded. Second And Subsequent Cerebral Evoked Response Tests Paid At A Reduced Rate Per Guidelines. An amount in the Gross Amount Due field and/or Usual and Customary Charge field is required. Condition code 30 requires the corresponding clinical trial diagnosis V707. Claim Is Pended For 60 Days. Duplicate ingredient billed on same compound claim. The Maximum Allowable Was Previously Approved/authorized. 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. Pricing Adjustment/ Medicare pricing cutbacks applied. Do Not Indicate NS On The Claim When The NDC Billed Is For A Generic Drug. Watch FutureRemittance And Status Reports For Its Finalization Before Resubmitting. One or more Surgical Code Date(s) is invalid in positions seven through 24. Rural Health Clinics May Only Bill Revenue Codes On Medicare Crossover Claims. Therefore, physician provider claim would deny. Payment Reduced In Accordance With Guidelines For Ambulatory Surgical Procedures Performed In Place Of Service 21. By continuing to use our site, you agree to our Privacy Policy and Terms of Use. Documentation Does Not Justify Reconsideration For Payment. No Financial Needs Statement On File. This Check Automatically Increases Your 1099 Earnings. Reimb Is Limited To The Average Montly NH Cost And Services Above that Amount Are Considered non-Covered Services. Please Provide The Type Of Drug Or Method Used To Stop Labor. Service(s) Denied. Claimchecks Editing And Your Supporting Documentation Was Reviewed By The DHS Medical Consultant. Principal Diagnosis 9 Not Applicable To Members Sex. RN Home Health visits and Supervisory visits are not reimbursable on the same Date Of Service(DOS) for same provider. 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. Channel: Medicare covered Codes Explanation Viewing all 30 articles Browse latest View live Explanation of Benefit. No More Than 2 Medication Check Services (30 Minutes) Are Payable Per Date Of Service(DOS). 1. Contact Wisconsin s Billing And Policy Correspondence Unit. Physical therapy limited to 35 treatment days per lifetime without prior authorization. Please Furnish A NDC Code And Corresponding Description. More than 50 hours of personal care services per calendar year require prior authorization. Basic Knowledge of Explanation of Benefits (EOB) interpretation. Procedure not payable for Place of Service. This Dental Service Limited To Once Every Six Months, Unless Prior Authorized. Review Patient Liability/paid Other Insurance, Medicare Paid. Incorrect Liability Start/end Dates Or Dollar Amounts Must Be Corrected Through County Social Services Agency Before Claim/Adjustment/Reconsideration RequestCan be Processed. (Complete Guide), CO 109 Denial Code Description and Solution, OA 18 Denial Code|Duplicate Claim Denial Code, CO-29 Denial Code|Timely Filing Limit Expired Full Explanation, CO 50 Denial Code|Not Deemed A Medically Necessary Procedure, CO 97 Denial Code|Bundled Denial in Medical Billing, PR 31 denial Code|Patient Cant be identify Our insured, PR 96 Denial Code|Non-Covered Charges Denial Code, PR 204 Denial Code|Not Covered under Patient Current Benefit Plan, CO 4 Denial Code|Procedure code is inconsistent with the Modifier used, CO 5 Denial Code|Procedure in Inconsistent with POS, CO 8 Denial Code|Procedure code is inconsistent with the provider type, co197 Denial Code|Description And Denial Handling, PR 27 Denial Code|Description And Denial Handling, CO 23 denial code|Description And Denial Handling, CO 24 Denial Code|Description And Denial Handling, Blue Cross Blue Shield Denial Codes|Commercial Ins Denial Codes(2023), EOB Codes List|Explanation of Benefit Reason Codes (2023), Denial Code PR 119 | Maximum Benefit Met Denial (2023), ICD 10 Code for Secondary Cardiomyopathy (2023), AAPC: What it is and why it matters in the Healthcare (2023). The topic of Requirements for Compression Garments can be found in the Claims Section, Submission Chapter. The Functional Assessment Indicates This Member Has Less Than A 50% Likelihoodof Benefit, Therefore Day Treatment Is Not Appropriate. Please Request Prior Authorization For Additional Days. Reimbursement For Panel Test Only- Individual Tests In Addition To Panel Test Disallowed. CPT/HCPCS codes are not reimbursable on this type of bill. When Billing For Basic Screening Package, Charge Must Be Indicated Under Procedure W7000. This Claim Has Been Denied Due To A POS Reversal Transaction. HTTP Status Code Connect Time (ms) Result; 2023-03-01 04:10:52: 200: 255: Page Active: 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. Please Indicate Computation For Unloaded Mileage. Please Correct and Resubmit. 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. Unable To Process This Request Due To Either Missing, Invalid OrMismatched National Provider Identifier # (NPI)/Provider Name/POP ID. Multiple Referral Charges To Same Provider Not Payble. Header Billing Provider used as Detail Performing Provider, Header Performing Provider used as Detail Performing Provider. Diag Restriction On ICD9 Coverage Rule edit. Prior authorization requests for this drug are not accepted. Rn Visit Every Other Week Is Sufficient For Med Set-up. Service Billed Limited To Three Per Pregnancy Per Guidelines. Please Resubmit using A Approved CPT Or HCPCS Procedure Code. Medicare Disclaimer Code Used Inappropriately. Header From Date Of Service(DOS) is after the header To Date Of Service(DOS). Please Correct And Re-bill. Avoiding denial reason code CO 22 FAQ Q: We received a denial with claim adjustment reason code (CARC) CO 22. The American College of Emergency Physicians (ACEP) also indicates that it is not appropriate to perform screening with advanced imaging for syncope patients, however be guided by the patients history and physical exam findings. Do Not Use Informational Code(s) When Submitting Billing Claim(s). Denied. Training Request Denied Because Either The Training Date On The Request Is After The CNAs Certification Test Date Or Its Not Within A Year Of That Date. Pharmacuetical care limitation exceeded. Revenue code billed with modifier GL must contain non-covered charges. Supervising Nurse Name Or License Number Required. Claim Number Given On The Adjustment/reconsideration Request Form Does Not Match Services Originally Billed. Language Comprehension And Language Production Are Equivalent To Cognition, Thus Formal Speech Therapy Is Not Needed. Members do not have to wait for the post office to deliver their EOB in a paper format. The content shared in this website is for education and training purpose only. This dental service limited to once per five years.Prior Authorization is needed to exceed this limit. External Cause Diagnosis May Not Be The Single Or Primary Diagnosis. These Services Paid In Same Group on a Previous Claim. Only One Panoramic Film Or Intraoral Radiograph Series, By The Same Provider, Per Year Allowed. The number of tooth surfaces indicated is insufficient for the procedure code billed. Early Refill Alert. If this is your first visit, be sure to check out the FAQ & read the forum rules.To view all forums, post or create a new thread, you must be an AAPC Member.If you are a member and have already registered for member area and forum access, you can log in by clicking here.If you've forgotten your username or password use our . 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. wellcare eob explanation codes. Do not resubmit. Refill Indicator Missing Or Invalid. The Performing Provider Id, Member Id, And Date Of Service(DOS) Must Match The Completion Certificate Received From Ddes. Fourth Other Surgical Code Date is required. The Request May Only Be Back-dated Two Weeks Prior To Receipt By EDS. Denied due to Provider Number Missing Or Invalid. This Payment Is To Satisfy The Amount Owed For OBRA Level 1. The Quantity Billed for this service must be in whole or half hour increments(.5) Increments. Claim Must Indicate A New Spell Of Illness And Date Of Onset. This National Drug Code (NDC) has Encounter Indicator restrictions. Denied by Claimcheck based on program policies. Please Furnish A UB92 Revenue Code And Corresponding Description. Denied. Denied. Providers May Only Bill For Assessments And Care Plans Twice Per Calendar Year. 3101. HTTP Status Code Connect Time (ms) Result; 2023-03-01 04:10:52: 200: 255: Page Active: Dosings for Narcotic Treatment Service program are limited to six per Sunday thru Saturday calendar week. Assistant Surgery Must Be Billed Separately By The Assistant Surgeon With Modifier 80. If A Reporting Form Is Not Submitted Within 60 Days, The claim detail will be denied. The Service(s) Requested Could Be Adequately Performed With Local Anesthesia In The Dental Office. Please Resubmit A New Adjustment/reconsideration Request Form And Indicate TheMost Recent Cclaim Number Where Payment Was Made Or Allowed. Multiple Providers Of Treatment Are Not Indicated For This Member. Only Four Dates Of Service Are Allowed Per Line Item (detail) For Each Procedure. Timely Filing Request Denied. Continuous home care and routine home care may not be billed for the same member on the same Date Of Service(DOS). Denied due to Provider Signature Date Is Missing Or Invalid. 2D3D CODES: Radiation treatment delivery, superficial and/or ortho voltage, per day 77401 Radiation treatment delivery, >1 MeV; simple 77402 . Members age does not fall within the approved age range. Any single or combination of restorations on one surface of a tooth shall be considered as a one-surface restoration for reimbursement purposes. Please Submit Charges Minus Credit/discount. Denied. Header Rendering Provider number is not found. Good Faith Claim Correctly Denied. Services Included In The Inpatient Hospital Rate Are Not Separately Reimbursable. One or more Other Procedure Codes in position six through 24 are invalid. First Other Surgical Code Date is invalid. Please submit claim to BadgerRX Gold. You Must Either Be The Designated Provider Or Have A Referral. Denied. The Procedure Requested Is Not Allowable For The Process Type Indicated On TheRequest. Denied. Adjustment Requested Member ID Change. Admit Date and From Date Of Service(DOS) must match. Member is enrolled in Medicare Part B on the Date(s) of Service. If You Have Already Obtained SSOP, Please Disregard This Message. Modifier invalid for Procedure Code billed. Performed After Therapy/dayTreatment Have Begun Must Be Billed As Therapy Or Limit-exceed Psych/aoda/func. Denied. Member is enrolled in Medicare Part D for the Dispense Date Of Service(DOS). NDC- National Drug Code is not allowed for the member on the Date Of Service(DOS). Medicare Part A Or B Charges Are Missing Or Incorrect. The Performing Or Billing Provider On The Claim Does Not Match The Billing Provider On Theprior Authorization File. Reimbursement of this service is included in the reimbursement of the most complex/complete procedure performed. Members I.d. Child Care Coordination services are reimbursable only if both the member and provider are located in Milwaukee County. Claim Denied. Repackaged National Drug Codes (NDCs) are not covered. The Primary Diagnosis Code is inappropriate for the Revenue Code. Previously Denied Claims Are To Be Resubmitted As New-day Claims. One or more Diagnosis Code(s) is invalid for the Date(s) of Service. The Resident Or CNAs Name Is Missing. Amount Paid On Detail By WWWP Is Less Than Billed Or Reimbursement Rate Due ToPrior Payment By Other Insurance. The Primary Diagnosis Code is inappropriate for the Procedure Code. Claims may deny when reported with mutually exclusive code combinations according to the ICD-10-CM Excludes 1 Notes guideline policy. CPT is registered trademark of American Medical Association. Prescribing Provider UPIN Or Provider Number Missing From Claim And Attachment. HIPAA EOB codes are returned on the 835 Remittance Advice file and are maintained by the Washington Publishing Company. Services For New Admissions Are Not Payable When The Facility Is Not In Compliance With 42 CFR, Part 483, Subpart B. Comprehensive Screens And Individual Components Are Not Payable On The Same Date Of Service(DOS). Timely Filing Deadline Exceeded. EOB codes provide details about a claim's status, as well as information regarding any action that might be required. "Laterality" (side of the body affected) is a coding convention added to relevant ICD-10 codes to increase specificity. The Member Does Not Appear To Meet The Severity Of Illness Indicators Established by the Wisconsin And Is Therefore Not Eligible For AODA Day Treatment. Request was not submitted Within A Year Of The CNAs Hire Date. No Action Required on your part. The Comprehensive Community Support Program reimbursement limitations have been exceeded. Home Health, Personal Care And Private Duty Nursing Services Are Subject To A Monthly Cap. Only the initial base rate is payable when waiting time is billed in conjunction with a round trip. Additional Psychotherapy Is Not Considered Appropriate Or Inline With More Effective, Available Services. 0001: Member's . Purchase Only Allowed; Medical Need For Rental Has Not Been Documented. Please watch future remittance advice. Information inadequate to establish medical necessity of procedure performed.Please resubmit with additional supporting documentation. Pricing Adjustment/ Long Term Care pricing applied. Unable To Process Your Adjustment Request due to This Claim Is In Post Pay Billing For Third Party Liability Payment. Condition code 70-76 is required on an ESRD claim when Influenza/PPV/HEP B HCPCS codes are the only codes being billed with condition code A6. WCDP member enrolled in Medicare Part D. Claim is excluded from Drug Rebate Invoicing. Claim Detail Denied Due To Required Information Missing On The Claim. Computed tomography (CT) of the head or brain (CPT 70450, 70460, 70470), Computed tomographic angiography (CTA) of the head (CPT 70496), Magnetic resonance angiography (MRA) of the head (CPT 70544, 70545, 70546), Magnetic resonance imaging (MRI) of the brain (CPT 70551, 70552, 70553), Duplex scan of extracranial arteries (CPT 93880,93882), Computed tomographic angiography (CTA) of the neck(CPT 70498), Magnetic resonance angiography (MRA) of the neck(CPT 70547, 70548, 70549), ICD-10 Diagnosis codes G43.009, G43.109, G43.709, G43.809, G43.829, G43.909. Services Denied In Accordance With Hearing Aid Policies. Our Records Indicate You Have Billed More Than One Unit Dose Dispensing Fee For This Calendar Month. You can even print your chat history to reference later! A valid Referring Provider ID is required. Pricing Adjustment/ Spenddown deductible applied. Pricing Adjustment/ Traditional dispensing fee applied. PLEASE RESUBMIT CLAIM LATER. In general, the more complex the visit, the higher the E&M level of code you may bill within the appropriate category. Drugs Prescribed and Filled on the Same Day, Cannot have a Refill Greater thanZero. Discharge Diagnosis 4 Is Not Applicable To Members Sex. Prescription Drug Plan (PDP) payment/denial information is required on the claim to SeniorCare. The total billed amount is missing or is less than the sum of the detail billed amounts. The detail From Date Of Service(DOS) is required. Medical Billing and Coding Information Guide. 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. The National Drug Code (NDC) submitted with this HCPCS code is CMS terminated or not covered by the program. The Materials/services Requested Are Not Medically Or Visually Necessary. 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. 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). Training CompletionDate Exceeds The Current Eligibility Timeline. The revenue code and HCPCS code are incorrect for the type of bill. Effective With Claims Received On And After 10/01/03 , Occurrence Codes 50 And 51 Are Invalid. Level Of Care/accommodation Code Billed Is Not Applicable To Your Provider Specialty. Services restricted to EPSDT clients valid only with a Full Scope, EPSDT-eligible Aid Code. Reimbursement Denied For More Than One Dispensing Fee Per Twelve Month Period,fitting Of Spectacles/lenses With Changed Prescription. OA 10 The diagnosis is inconsistent with the patient's gender. 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. Questionable Long-term Prognosis Due To Apparent Root Infection. Please Refer To The All Provider Handbook For Instructions. Here are just a few of them: EOB CODE. Consultation or surgical procedures are not reimbursable in conjuctions with Emergency Room services. The Information Provided Indicates Regression Of The Member. X-rays and some lab tests are not billable on a 72X claim. Please Clarify The Number Of Allergy Tests Performed. Please Attach Copy Of Medicare Remittance. Please Resubmit. . Admission Date is on or after date of receipt of claim. Please submit claim to HIRSP or BadgerRX Gold. No Substitute Indicator required when billing Innovator National Drug Codes (NDCs). Revenue code submitted is no longer valid. Service Denied. Missing or invalid level of effort submitted and/or reason for service, professional service, or result of service code billed in error. NDC was reimbursed at generic WAC (Wholesale Acquisition Cost) rate. The Screen Date Must Be In MM/DD/CCYY Format. This Modifier has been discontinued by CMS or AMA for the Date Of Service(DOS)(s). Denied. Psychotherapy Provided In The Members Home Is Not A Covered Benefit Of . Payment(s) For Capital Or Medical Education Are Generated By EDS And May Not Be Billed By The Provider. Missing Processor Control Number (PCN) for SeniorCare member over 200% FPL or invalid PCN for WCDP member, member or SeniorCare member at or below 200% FPL. Billing Provider is not certified for the detail From Date Of Service(DOS). Member is not enrolled in /BadgerCare Plus for the Date(s) of Service. This drug is not covered for Core Plan members. Charges For Anesthetics Are Included In Charge For All Surgical Procedures. Per Information From Insurer, Claims(s) Was (were) Paid. Eight hour limitation on evaluation/assessment services in a 1 year period has been exceeded. Billing Provider Type and Specialty is not allowable for the service billed. Single Bitewing X-rays Limited To Once Per Day And No More Than Two InA Six Month Period. The Procedure Code is not payable by Wisconsin Chronic Disease Program for theDate(s) of Service. The submitted claim contains value code 68 and 48 or 49 but does not contain revenue code 0634 or 0635 and HCPCS Q4055. Out Of State Billing Provider Not Enrolled For Entire Detail DOS Span. Valid Numbers Are Important For DUR Purposes. The Service Requested Is Considered To Be Professionally Unacceptable, Unproven and/or Experimental. Type of Bill indicates services not reimbursable or frequency indicated is notvalid for the claim type. Number Is Missing Or Incorrect. NCTracks AVRS. The first occurrence span from Date Of Service(DOS) is after the to Date Of Service(DOS). Pricing Adjustment/ Third party liability amount applied is greater than the amount paid by the program. This is a same-day claim for bill types 13X, 14X, 71X, or 83X and there are multiple units or combination of chemistry/hemotology tests. The Clinical Profile, Narrative History, And Treatment History Indicate The Recipient Is Only Eligible For Maintenance Hours. New Prescription Required. The three key components when selecting the appropriate level of E&M services provided are history, examination, and medical decision-making. WCDP is the payer of last resort. This service is not payable for the same Date Of Service(DOS) as another service included on the same claim, according to the National Correct Coding Initiative. It is a duplicate of another detail on the same claim. Member must receive this service from the state contractor if this is for incontinence or urological supplies. Claim or Adjustment received beyond 365-day filing deadline. ACTION DESCRIPTION. Personal care subsequent and/or follow up visits limited to seven per Date Of Service(DOS) per member. Routine foot care is limited to no more than once every 61days per member. This Request Can Only Be Backdated To The Date EDS First Receives The Request In The Mailroom. Previously Denied Claims Are To Be Resubmitted As New Day Claims. 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. A six week healing period is required after last extraction, prior to obtaining impressions for denture. CORE Plan Members are limited to 25 non-emergency outpatient hospital visits per enrollment year. Denied. Other Insurance Or Medicare Response Not Received Within 120 Days For ProviderBased Bill. Ancillary Codes Dates Of Service And/or Quantity Billed Do Not Match Level Of Care authorized Dates. The From Date Of Service(DOS) for the First Occurrence Span Code is invalid. The To Date Of Service(DOS) for the Second Occurrence Span Code is required. Denied. The Pharmaceutical Care Code (PCC) does not have a rate on file for the Date Of Service(DOS). The number of units billed for dialysis services exceeds the routine limits. Please Review All Provider Handbook For Allowable Exception. The Service Requested Is Included In The Nursing Home Rate Structure. A claim cannot contain only Not Otherwise Specified (NOS) Surgical Procedure Codes. . Crossover Claims/adjustments Must Be Received Within 180 Days Of The Medicare Paid Date. The Services Requested Are Not Reasonable Or Appropriate For The AODA-affectedmember. Separate reimbursement for drugs included in the composite rate is not allowed. For example, a claim from a physician provider with place of service 11 (Office) would be considered incorrectly coded when a claim from an outpatient facility (e.g. Denied. This Member, As Indicated By Narrative History, Does Not Agree To Abstinence from Alcohol Or Other Drugs And Is Ineligible For AODA Treatment.
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