Compound drugs require a minimum of two components with at least one payable FowardHealth covered drug. Member must receive this service from the state contractor if this is for incontinence or urological supplies. Prior Authorization (PA) required for payment of this service. Approved. Claim Denied. Diagnosis Indicated Is Not Allowable For Procedures Designated As Mycotic Procedures. Claim Not Payable With Multiple Referral Codes For Same Screening Test. Pricing Adjustment/ Pharmacy pricing applied. Procedimientos. Out Of State Billing Provider Not Enrolled For Entire Detail DOS Span. Adjustment/reconsideration Request Denied Due To Incorrect/insufficient Information. Was Unable To Process This Request. Occurance code or occurance date is invalid. For additional information on HIPAA EOB codes, visit the Code List section of the WPC website at www.wpc-edi.com. This claim must contain at least one specified Surgical Procedure Code. Providers should submit adequate medical record documentation that supports the claim (services) billed. Claim Detail Denied As Duplicate. Medical Need For Equipment/supply Requested Is Not Supported By Documentation Submitted. Procedure Code is not payable for SeniorCare participants. 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 . Claim Submitted To Good Faith Without Proper Documentation. Good Faith Claim Denied. If Required Information Is Not Received Within 60 Days,the claim will be denied. There are many different remittance adjustment reason codes (RARCs) established for Medicare and we understand their explanations may be "generic" and confusing, so we have provided a listing in the table below of the most commonly used denial messages and RARCs utilized by Medical Review Part B during medical record review. Denied. Req For Acute Episode Is Denied. SeniorCare member enrolled in Medicare Part D. Claim is excluded from Drug Rebate Invoicing. The Rendering Providers taxonomy code in the detail is not valid. A Third Occurrence Code Date is required. You can view these EOBs online by following these steps: Log in to your bcbsm.com account to view your prescriptions coverage. Good Faith Claim Correctly Denied. Please Disregard Additional Messages For This Claim. The Members Demonstrated Response To Current Therapy Does Not Warrant The Intense Freqency Requested. A Payment For The CNAs Competency Test Has Already Been Issued. An ICD-9-CM Diagnosis Code of greater specificity must be used for the SeventhDiagnosis Code. A Training Payment Has Already Been Issued To A Different NF For This CNA. Denied. Revenue code 082X is present on an ESRD claim which also contains revenue code088X (X frequency non equal to 9). As A Reminder, This Procedure Requires SSOP. 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. Claim Denied. To bill any code, the services furnished must meet the definition of the code. Multiple Prescriptions For Same Drug/ Same Fill Date, Not Allowed. Denied/Cutback. Denied. Admission Denied In Accordance With Pre-admission Review Criteria. (National Drug Code). Remittance Advice Remark Codes (RARCs) are used to provide additional explanation for an adjustment already described by a Claim Adjustment Reason Code (CARC) or to convey information about remittance processing. 2434. Member is enrolled in a State-contracted managed care program for the Date(s) of Service. Total billed amount is less than the sum of the detail billed amounts. Pap Smears, Hematocrit, Urinalysis Are Not Reimbursable Separately In Conjunction With Family Planning Medical Visits. Claim Denied. Denied. A: This denial is received when Medicare records indicate that Medicare is the beneficiary's secondary payer. Denied due to Provider Signature Is Missing. The Service Performed Was Not The Same As That Authorized By . A valid header Medicare Paid Date is required. Members Aged 3 Through 21 Years Old Are Limited To One Healthcheck Screening per 12 months. 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). Service Denied. Definitions and text of all the Claim Adjustment Reason Codes and the Remittance Advice Remark Codes used on the claim will be printed on the last page of the RA. This notice gives you a summary of your prescription drug claims and costs. 10 Important Billing Tips for FQHC and RHC Providers. You Must Either Be The Designated Provider Or Have A Referral. The Timeframe Between Certification, Test, Date And Hire Date Exceeds A Year. Prescribing Provider UPIN Or Provider Number Missing From Claim And Attachment. Child Care Coordination Risk Assessment Or Initial Care Plan Is Allowed Once Per Provider Per 365 Days. One or more To Date(s) of Service is invalid for Occurrence Span Codes in positions three through 24. Each month you fill a prescription, your Medicare Prescription Drug Plan mails you an "Explanation of Benefits" (EOB). Repackaged National Drug Codes (NDCs) are not covered. Principal Diagnosis 6 Not Applicable To Members Sex. Home Health Services In Excess Of 60 Visits Per Calendar Month Per Member Required Prior Authorization. For Revenue Code 0820, 0821, 0825 or 0829, HCPCS Code 90999 or Modifier G1-G6 must be present. Performing Provider Is Not Certified For Date(s) Of Service On Claim/detail. Once 50 Initial Visits/year Has Been Reached Within Any One Discipline All Home Health Services Require Pa. Live-agent chat is the easiest and fastest way to get real-time support for an array of topics, including: Member Eligibility. Claim Denied. Reimbursement of this service is included in the reimbursement of the most complex/complete procedure performed. Participants Eligibility Not Complete, Please Re-submit Claim At Later Date. The initial rental of a negative pressure wound therapy pump is limited to 90 days; member lifetime. Attachment was not received within 35 days of a claim receipt. Refer To Dental HandbookOn Billing Emergency Procedures. No matching Reporting Form on file for the detail Date Of Service(DOS). Header From Date Of Service(DOS) is after the header To Date Of Service(DOS). A WCDP drug rebate agreement for this drug is not on file for the Date Of Service(DOS). Other Therapies Currently Provide Sufficient Services To Meet The Members Needs. FL 44 HCPCS/Rates/HIPPS Rate Codes Required. 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). Crosswalk - Adjustment Reason Codes and Remittance Advice (RA) Remark Codes to PHC Explanation (EX) Codes Revised 11/16/2020 Page 1 Key: If RA has . Reimbursement Rate Applied To Allowed Amount. The Secondary Diagnosis Code is inappropriate for the Procedure Code. 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. 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). The billing provider number is not on file. Service Denied. The Sixth Diagnosis Code (dx) is invalid. Denied by Claimcheck based on program policies. Money Will Be Recouped From Your Account. Pricing Adjustment/ Repackaging dispensing fee applied. No Supporting Documentation. In general, the more complex the visit, the higher the E&M level of code you may bill within the appropriate category. Quick Tip: In Microsoft Excel, use the " Ctrl + F " search function to look up specific denial codes. This limitation may only exceeded for x-rays when an emergency is indicated. A number is required in the Covered Days field. One or more Diagnosis Codes has a gender restriction. Recouped. Election Form Is Not On File For This Member. This Member Is Involved In Non-covered Services, And Hours Are Reduced Accordingly. Detail To Date Of Service(DOS) is invalid. Benefit Payment Determined By Fiscal Agent Review. Claim Denied For Invalid Diagnosis Code Or Diagnosis Code/CPT Combination. Claim Is Being Special Handled, No Action On Your Part Required. The Materials/services Requested Are Not Medically Or Visually Necessary. Active Treatment Dose Is Only Approved Once In Six Month Period. Restorative Nursing Involvement Should Be Increased. No Matching, Complete Reporting Form Is On File For This Client. Please Bill Appropriate PDP. Amount Indicated In Current Processed Line On R&S Report Is The Manual Check You Recently Received. Assessment Is Not A Covered Service Unless All Four Components Of Skilled Nursing Are Present: Assessment, Planning, Intervention And Evaluation. This claim has been adjusted because a service on this claim is not payable inconjunction with a separate paid service on the same Date Of Service(DOS) due to National Correct Coding Initiative. For over 40 years, Washington Publishing Company (WPC) has specialized in managing and distributing data integration information through publications, training, and consulting services. Second Surgical Opinion Guidelines Not Met. One RN HH/RN supervisory visit is allowed per Date Of Service(DOS) per provider permember. Explanation of Benefit Codes (EOBs) Mar 14, 2022 4. The Revenue Code is not payable by Wisconsin Well Woman Program for the Date(s) of Service. Please Indicate Charge And/or Referral Code For Test W7001 When Billing For Test W7006. Admit Date and From Date Of Service(DOS) must match. It has now been removed from the provider manuals . Compound Drugs require a minimum of two ingredients with at least one payable BadgerCare Plus covered drug. Please Re-submit This Claim With The Insurance EOB Showing A Denial OrPartial Payment. The Revenue Code is not payable by Wisconsin Chronic Disease Program for the Date(s) of Service. Our Records Indicate This Provider Is Not Certified For AODA Day Treatment. Dispense as Written indicator is not accepted by . Reimbursement For Training Is One Time Only. Please Resubmit. Value codes 48 Homoglobin Reading and 49 Hematocrit Reading, must have a zero in the far right position. This Member Has A Current Approved Authorization For Intensive AODA OutpatientServices. A National Provider Identifier (NPI) is required for the Rendering Provider listed in the header. General Assistance Payments Should Not Be Indicated On Claims. PleaseResubmit Charges For Each Condition Code On A Separate Claim. Claim Is Being Reprocessed, No Action On Your Part Required. Resubmit Private Duty Nursing Services For Complex Children With Documentation Supporting The Level Of Care. Reimbursement For This Service Has Been Approved. Claim Is For A Member With Retro Ma Eligibility. HTTP Status Code Connect Time (ms) Result; 2023-03-01 04:10:52: 200: 255: Page Active: Modifier Invalid: Modifiers Are No Longer Allowed For Procedure Code Billed. This detail is denied. The detail From Date Of Service(DOS) is required. Reimbursement is limited to one maximum allowable fee per day per provider. 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. Member is assigned to a Hospice provider. Services For Members With Medical Status Code TR, SH, SJ, TS Or ST NotAllowed For Your Provider Type, Or For Your Provider Type without a TB Diagnosis. Routine Foot Care Procedures Must Be Billed With Valid Routine Foot Care Diagnosis. Designated codes for conditions such as fractures, burns, ulcers and certain neoplasms require documentation of the side/region of the body where the condition occurs. One or more Diagnosis Code(s) is not payable by Wisconsin Chronic Disease Program for the Date Of Service(DOS). The Medical Necessity For Psychotherapy Services Has Not Been Documented, ThusMaking This Member Ineligible For The Requested Service. Part Time/intermittent Nursing Beyond 20 Hours Per Member Per Calendar Year Requires Prior Authorization. If you are still unable to resolve the login problem, read the troubleshooting steps or report your issue. 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. Occurrence Code is required when an Occurrence Date is present. Submit Claim To Other Insurance Carrier. The Reimbursement Code Assigned To This Certification Segment Does Not Authorize a NAT Payment. Services Are Covered For Medically Needy Members Only When Healthcheck Referral is Indicated On Claim. Medical Billing and Coding Information Guide. The Modifier For The Proc Code Is Invalid. Authorizations. The Revenue/HCPCS Code combination is invalid. Billing Provider Type and Specialty is not allowable for the Place of Service. 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. Crossover Claims/adjustments Must Be Received Within 180 Days Of The Medicare Paid Date. Reimbursement Based On Members County Of Residence. It Corrects Claim Information Found During Research Of An OBRA Drug Rebate Dispute. The Service Requested Was Performed Less Than 5 Years Ago. Please Indicate The Dollar Amount Requested For The Service(s) Requested. Time Spent In AODA Day Treatment By Affected Family Members Is Not Covered. This Member Is Receiving Concurrent AODA/Psychotherapy Services And Is Therefore Only Eligible For Maintenance Hours. The Service Requested Is Covered By The HMO. Has Recouped Payment For Service(s) Per Providers Request. Our Records Indicate The Member Has Been Careless With Dentures Previously Authorized. Complex care of 17-plus hours and complex care of less than 17 hours are not allowed on the same Date Of Service(DOS). Denied. This claim is eligible for electronic submission. Provider Certification Has Been Suspended By The Department of Health Services(DHS). Maximum Reimbursement Amount Has Been Determined By Professional Consultant. The header total billed amount is invalid. This Procedure Code Is Not Valid In The Pharmacy Pos System. Service Fails To Meet Program Requirements. Rinoplastia; Blefaroplastia These codes provide additional explanation for an adjustment already described by a Claim Adjustment Reason Code (CARC) or convey information about remittance processing.