Unable To Process This Request Due To Either Missing, Invalid OrMismatched National Provider Identifier # (NPI)/Provider Name/POP ID. We have created a list of EOB reason codes for the help of people who are working on denials, AR-follow-up, medical coding, etc. No Rendering Provider Status Found for the From and To Date Of Service(DOS). Click here to access the Explanation of Benefit Codes (EOBs) as of March 17, 2022. Submitted rendering provider NPI in the detail is invalid. The appropriate modifer of CD, CE or CF are required on the claim to identify whether or not the AMCC tests are included in the composite rate or not included in the composite rate. More Than 5 Consecutive Calendar Days Of Continuous Care Are Not Payable. Multiple Requests Received For This Ssn With The Same Screen Date. Vision Diagnostic Services Limited To 1 Of These: Vision Exam, Diagnostic Review, Supplemental Test Or Contact Lens Therapy. Calls are recorded to improve customer satisfaction. Claim Reduced Due To Member/participant Deductible. Use The New Prior Authorization Number When Submitting Billing Claim. Medical explanation of benefits. Procedure code 00942 is allowed only when provided on the same date ofservice as procedure code 57520. Six hour limitation on evaluation/assessment services in a 2 year period has been exceeded. Member is enrolled in Medicare Part A on the Date(s) of Service. Providers should submit adequate medical record documentation that supports the claim (services) billed. One or more Occurrence Code(s) is invalid in positions nine through 24. From Date Of Service(DOS) is before Admission Date. Your 1099 Liability Has Been Credited. Claims and Billing | NC Medicaid - NCDHHS More than 50 hours of personal care services per calendar year require prior authorization. Service(s) Denied/cutback. The Members Gait Is Not Functional And Cannot Be Carried Over To Nursing. 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 . Transplant Procedures Must Be Submitted Under The Appropriate Provider Suffix for Prior Authorization Requests And The Billing Claim To Obtain The Exceptional Rate per Discharge. Pricing Adjustment/ Medicare benefits are exhausted. HCPCS Procedure Code is required if Condition Code A6 is present. Please Resubmit. Pharmaceutical care reimbursement for tablet splitting is limited to three permonth, per member. X . Not A WCDP Benefit. Did You check More Than One Box?If So, Correct And Resubmit. Please Correct And Resubmit. Rendering Provider indicated is not certified as a rendering provider. This Adjustment/reconsideration Request Was Initiated By . Formal Speech Therapy Is Not Needed. 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 code next to this was 264, which was described on the back of Frank's EOB as "Over What Medicare Allows" Total Patient Cost: $15.00 - Frank's office visit copayment; Amount Paid to the Provider: $50.00 - the amount of money that Frank's Medicare Advantage Plan sent to Dr. David T. 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. Documentation Indicates That Client Is Able To Direct Cares And Can Safely Direct A PCW. Copayment Should Not Be Deducted From Amount Billed. The Member Has Shown No Significant Functional Progress Toward Meeting Or Maintaining Established & Measurable Treatment Goals Over A 6 Month Period. OA 13 The date of death precedes the date of service. One or more To Date(s) of Service is missing for Occurrence Span Codes in positions three through 24. Denied. Refer to the DME area of the Online Handbook for claims submission requirements for compression garments. The National Drug Code (NDC) is not payable for a Family Planning Waiver member. Charges For Anesthetics Are Included In Charge For All Surgical Procedures. Claim Denied Due To Absent Or Incorrect Discharge (to) Date. 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. Personal Care In Excess Of 250 Hrs Per Calendar Year Requires Prior Authorization. When Billing For Basic Screening Package, Charge Must Be Indicated Under Procedure W7000. . Denied/Cutback. Adjustment Denied For Insufficient Information. Level And/or Intensity Of Requested Service(s) Is Incompatible With Medical Need As Defined In Care Plan. Denied. Member enrolled in Medicare Part D for the Dispense Date Of Service(DOS). Req For Acute Episode Is Denied. Please note that the submission of medical records is not a guarantee of payment. The Materials/services Requested Are Principally Cosmetic In Nature. The header total billed amount is invalid. Denied due to Claim Contains Future Dates Of Service. This Procedure Code Is Denied As Incidental/Integral To Another Procedure CodeBilled On This Claim. HealthDrive Corporation Senior Reimbursement Specialist - Medical These Urinalysis Procedures Reimbursed Collectively At The Maximum For Routine Urinalysis With Microscopy. Surgical Procedure Code billed is not appropriate for members gender. Please Select A Procedure Code In The 58980-58988 Range That Best Describes The Procedure Being Performed. Denied due to Statement Covered Period Is Missing Or Invalid. This Procedure Code Is Not Valid In The Pharmacy Pos System. Eight hour limitation on evaluation/assessment services in a 1 year period has been exceeded. The Medicare copayment amount is invalid. Do Not Indicate NS On The Claim When The NDC Billed Is For A Generic Drug. Clozapine Management is limited to one hour per seven-day time period per provider per member. List of Explanation of Benefit Codes Appearing on the Remittance Advice Level, Intensity Or Extent Of Service(s) Requested Has Been Modified Consistent With Medical Need As Defined In The Plan Of Care. We encourage you to take advantage of this easy-to-use feature. An xray or diagnostic urinalysis is reimbursable only when performed on the same Date Of Service(DOS) and billed on the same claim as the initial office visit. Denied. Reason Code 234 | Remark Codes N20. Service(s) Denied. Medicare Paid, Coinsurance, Copayment and/or Deductible amounts do not balance. Medicare accepts any National Uniform Billing Committee (NUBC) approved revenue codes. Department of Health Services (DHS) Authorized Payment Is Being Withheld Due toa Final Rate Settlement. Eighth Diagnosis Code (dx) is not on file. New Prescription Required. At Least One Of The Compounded Drugs Must Be A Covered Drug. First Other Surgical Code Date is invalid. The following are the most common reasons HCFA/CMS-1500 and UB/CMS-1450 paper claims for Veteran care are rejected: Requires the 17 alpha-numeric internal control number (ICN) [format: 10 digits + "V" + 6 digits] or 9-digit social security number (SSN) with no special characters. PDF WellCare Procedure Codes - HealthHelp This claim is being denied because it is an exact duplicate of claim submitted. Service Denied. Claim Detail Denied For Invalid CPT, Invalid CPT/modifier Combination, Or Invalid Type Of Quantity Billed. Charges Paid At Reduced Rate Based Upon Your Usual And Customary Pricing Profile. (part JHandbook). EOB Any EOB code that applies to the entire claim (header level) prints here. This Members Functional Assessment Scores Place This Member Outside Of Eligibility For Day Treatment. New Coding Integrity Reimbursement Guidelines | Wellcare 51.42 Board Directors Or Designees Statement & Signature Required OnThe Claim Form For Payment Of Functional Assessment. Repackaging allowance is not allowed for unit dose NDCs. Insufficient Documentation To Support The Request. Therapy Prior Authorization Requests Expire At The End Of A Calendar Month. Billing and Coding | Provider Resources | Superior HealthPlan No Action Required on your part. Medicaid Claim Adjustment Reason Code:B13 - thePracticeBridge 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. Submitted rendering provider NPI in the header is invalid. This service is not payable with another service on the same Date Of Service(DOS) due to National Correct Coding Initiative. EOB for services that should be paid as primary by the Health Plan EPSDT: claims billed with EP modifier 3/28/2022 03/09/2022 2636 In Process DN018 . If it is medically necessary to exceed the limitation, submit an Adjustment/Reconsideration request with supporting documentation. This drug is a Brand Medically Necessary (BMN) drug. The Second Other Provider ID is missing or invalid. The Screen Date Is Either Missing Or Invalid. We have created a list of EOB reason codes for the help of people who are . Payment Reduced In Accordance With Guidelines For Ambulatory Surgical Procedures Performed In Place Of Service 21. This Is An Adjustment of a Previous Claim. There Is Evidence That The Member Is Not Detoxified From Alcohol And/or Other Drugs and is Therefore Not Currently Eligible For AODA Day Treatment. Subsequent surgical procedures are reimbursed at reduced rate. All Requests Must Have A 9 Digit Social Security Number. Benefit Payment Determined By DHS Medical Consultant Review. Service 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.