As A Reminder, This Procedure Requires SSOP. Member first name does not match Member ID. Member is enrolled in a commercial health insurance on the Dispense Date Of Service(DOS). All Home Health Services Exceeding 8 Hours Per Day Or 40 Or More Hours Per Week Require Prior Authorization. Reason Code 160: Attachment referenced on the claim was not received. These Supplies/items Are Included In The Purchase Of The Dme Item Billed On The Same Date Of Service(DOS). A six week healing period is required after last extraction, prior to obtaining impressions for denture. The Request Has Been Back datedto Date of Receipt. The total of amounts billed for the DOS on the claim exceeds the allowed dailylimit for PDN services. Rimless Mountings Are Not Allowable Through . Claim Is Being Reprocessed, No Action On Your Part Required. Pricing Adjustment/ Payment amount increased based on hospital access paymentpolicies. Invalid quantity for the National Drug Code (NDC) submitted with this HCPCS code. The Procedure Requested Is Not Allowable For The Process Type Indicated On TheRequest. One or more To Date(s) of Service is missing for Occurrence Span Codes in positions three through 24. The three key components when selecting the appropriate level of E&M services provided are history, examination, and medical decision-making. Claim Detail Pended As Suspect Duplicate. Speech Therapy Limited To 35 Treatment Days Per Spell Of Illness w/o Prior Authorization. Rqst For An Acute Episode Is Denied. Resubmit Complete And/or Second Page Of Medicares EOMB Showing All Total And Payments. Refer To Provider Handbook. Schedule 3, 4 or 5 drugs are limited to the original dispensing plus 5 refillsor 6 months. Members I.d. Billed Procedure Not Covered By WWWP. One or more Date(s) of Service is missing for Occurrence Span Codes in positions 9 through 24. Service Allowed Once Per Lifetime, Per Tooth. Qty And/or Detail Charge Do Not Divide Out Equally For Dates Of Service and/orQty Given. The Diagnosis Does Not Indicate A Significant Change In the Members Condition. -OR- The claim contains value code 49but does not contain revenue code 0636 and HCPCS Q4054. Reduction To Maintenance Hours. Service Must Be Billed On Drug Claim Form Utilizing NDC Codes. Service billed is bundled with another service and cannot be reimbursed separately. Other Coverage Code is missing or invalid. Service not covered as determined by a medical consultant. Dispense Date Of Service(DOS) is invalid. Denied. Recoding/adjusting claim may result in a different DRG code assignmentand reimbursement. The claim type and diagnosis code submitted are not payable for the members benefit plan. Denied. Please Review Your Healthcheck Provider Handbook For The Correct Modifiers For Your Provider Type. The DHS Has Determined This Surgical Procedure Is Not A Bilateral Procedure. Procedure Code is not payable for SeniorCare participants. When Billing For Basic Screening Package, Charge Must Be Indicated Under Procedure W7000. Member Is Enrolled In A Family Care CMO. Complete Refusal Detail Is Not Payable Without Referral/treatment Details. If the KT/V reading was not performed, then the value code D5 with 9.99 must be present without the occurrence code 51. Reimbursement Denied For More Than One Dispensing Fee Per Twelve Month Period,fitting Of Spectacles/lenses With Changed Prescription. 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. 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. Dollar Amount Of Claim Was Adjusted To Correct Mathematical Error. Unable To Process Your Adjustment Request due to Claim ICN Not Found. Healthcheck Screening Limited To Two Per Year From Birth To Age 3 And One Per Year For Age3 Or Older. Details Include Revenue/surgical/HCPCS/CPT Codes. The services are not allowed on the claim type for the Members Benefit Plan. Claim Reduced Due To Member Income Available Toward Cost Of Care (Nursing Home Liability). 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. Please Refer To The PDL For Preferred Drugs In This Therapeutic Class. An ICD-9-CM Diagnosis Code of greater specificity must be used for the Fifth Diagnosis Code. Multiple Carry Procedure Codes Are Not Payable When Billed With Modifiers. Fourth Other Surgical Code Date is invalid. The Surgical Procedure Code of greatest specificity must be used. Drugs Prescribed and Filled on the Same Day, Cannot have a Refill Greater thanZero. Duplicate Item Of A Claim Being Processed. Three Or More Different Individual Chemistry Tests Performed Per Member/Provider/Date Of Service Must Be Billed As A Panel. Denied. If it is medical necessary for more than 13 or 14 services per calendar month, submit an adjustment request with supporting documentation. A National Provider Identifier (NPI) is required for the Billing Provider. One or more Diagnosis Code(s) is invalid for the Date(s) of Service. Paid In Accordance With Dental Policy Guide Determined By DHS. One or more Condition Code(s) is invalid in positions eight through 24. Reimbursement For HCPCS Procedure Code 58300 Includes IUD Cost. Occurrence Codes 50 And 51 Are Invalid When Billed Together. Denied. Reimbursement Rate Applied To Allowed Amount. Up General Assistance Payments Should Not Be Indicated On Claims. Quantity Billed is missing or exceeds the maximum allowed per Date Of Service(DOS). Service Provided Before Prior Authorization Was Obtained Is Not Allowable. 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. Medicare Paid The Total Allowable For The Service. The Sixth Diagnosis Code (dx) is invalid. Procedure not payable for Place of Service. Day Treatment exceeding 120 hours per month is not payable regardless of PriorAuthorzation. Assistant Surgery Must Be Billed Separately By The Assistant Surgeon With Modifier 80. Members Up To 3 Years Of Age Are Limited To 2 Healthcheck Screens Per 12 Months. Purchase Only Allowed; Medical Need For Rental Has Not Been Documented. Questionable Long-term Prognosis Due To Apparent Root Infection. 51.42 Board Directors Or Designees Statement & Signature Required OnThe Claim Form For Payment Of Functional Assessment. The first position of the attending UPIN must be alphabetic. Other Insurance Disclaimer Code Used Is Inappropriate For This Members Insurance Coverage. Purchase of additional DME/DMS item exceeding life expectancy rRequires Prior Authorization. The detail From Date Of Service(DOS) is required. This Procedure, When Billed With Modifier HK, Is Payable Only If The Member Is Under The Age Of 19. 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 . The Revenue Code is not payable for the Date(s) of Service. The service is not reimbursable for the members benefit plan. Amount Paid On Detail By WWWP Is Less Than Billed Or Reimbursement Rate Due ToPrior Payment By Other Insurance. Mail-to name and address - We mail the TRICARE EOB directly to. Remittance Advice Remark Codes (RARCs) are used to provide additional explanation for an adjustment already described by a CARC or to convey information about remittance processing; Search for a Reason or Remark Code. The Tooth Is Not Essential For Support Of A Partial Denture. Please Indicate The Dollar Amount Requested For The Service(s) Requested. Denied. This Procedure Code Is Not Valid In The Pharmacy Pos System. No Action On Your Part Required. Good Faith Claim Denied. Procedure Code billed is not appropriate for members gender. Resubmit Claim With Corrected Tooth Number/letter Or With X-ray Documenting Tooth Placement. Fifth Diagnosis Code (dx) is not on file. Other Amount Submitted Not Reimburseable. Other Therapies Currently Provide Sufficient Services To Meet The Members Needs. Prescribing Provider UPIN Or Provider Number Missing From Claim And Attachment. Permanent Tooth Restoration/sealant, Limited To Once Every 3 Years Unless Narrative Documents Medical Necessity. The Performing Or Billing Provider On The Claim Does Not Match The Billing Provider On Theprior Authorization File. Independent RHCs Must Bill Codes W6251, W6252, W6253, W6254 Or W6255. Claim Is Being Reprocessed Through The System. Denied. Occupational therapy limited to 35 treatment days per lifetime without prior authorization. This dental service limited to once per five years.Prior Authorization is needed to exceed this limit. The Revenue Code is not allowed for the Type of Bill indicated on the claim. WWWP Does Not Process Interim Bills. Please Do Not File A Duplicate Claim. Formal Speech Therapy Is Not Needed. Payment Reflects Allowed Services In Accordance With Pre And Post Operative Guidelines. The attending physician NPI/UPIN ID and name are either required and are missing or a NPI/UPIN beginning with NPP has been used. Denied. Effective July 15, 2021 through December 31, 2021: Temporary Relaxation of Prior Authorization . Denied/Cutback. Denied/cutback. Service(s) paid at the maximum daily amount per provider per member. EPSDT/healthcheck Indicator Submitted Is Incorrect. A Payment Has Already Been Issued For This SSN. Dental service limited to twice in a six month period. Acute Care General And Specialty Hospitals Are Subject To Pre-admission Requirements Or The Pre-admission Review Number Indicated Is Invalid. We encourage you to take advantage of this easy-to-use feature. Competency Test Date Is Not A Valid Date. Outside Lab Indicator Must Be Y For The Procedure Code Billed. The Service Requested Is Not A Covered Benefit As Determined By . Unable To Process Your Adjustment Request due to The Claim Type Of The Adjustment Does Not Match The Claim Type Of The Original Claim. The Revenue Code is not payable by Wisconsin Well Woman Program for the Date(s) of Service. Home care ongoing assessments are allowed once every sixty days per member.nt, But Arepayable Every Fifty-fourth Day For Flexibility In Scheduling. Claim Denied. FFS CLAIM PROFESSIONAL ASC X12N VERSION . Service(s) Approved By DHS Transportation Consultant. This CNAs Social Security Number, SSN, Is Not On The EDS Nurse Aide Registry File. Denied. WellCare 2016 NA_11_16 NA6PROGDE80121E_1116 . The Surgical Procedure Code has Diagnosis restrictions. Header From Date Of Service(DOS) is after the header To Date Of Service(DOS). A Fourth Occurrence Code Date is required. Payment Authorized By Department of Health Services (DHS) To Be Recouped at a Later Date. Explanation of Benefits (EOB) The four-digit explanation of benefits (EOB) codes and the corresponding narratives indicate that the submitted claim paid as billed or describe the reason the claim suspended, was denied, or did not pay in full. Benefit code These codes are submitted by the provider to identify state programs. Personal Care Services Exceeding 30 Hours Per 12 Month Period Per Member Require Prior Authorization. new construction homes in northwest suburbs illinois,