Other Medicare Part A Response not received within 120 days for provider basedbill. Claim Detail Pended As Suspect Duplicate. Result of Service submitted indicates the prescription was filled witha different quantity. Only Four Dates Of Service Are Allowed Per Line Item (detail) For Each Procedure. NDC is obsolete for Date Of Service(DOS). The first position of the attending UPIN must be alphabetic. Quantity Billed is invalid for the Revenue Code. Submitclaim to the appropriate Medicare Part D plan. Code. Questionable Long-term Prognosis Due To Poor Oral Hygiene. Pricing Adjustment/ Usual & Customary Charge (UCC) flat fee pricing applied. Claim cannot contain both Condition Codes A5 and X0 on the same claim. Default Prescribing Physician Number XX9999991 Was Indicated. Fifth Other Surgical Code Date is required. One or more Diagnosis Code(s) is not payable by Wisconsin Well Woman Program for the Date(s) of Service. The Clinical Profile And Narrative History Indicate Day Treatment Is Neither Appropriate Nor A Medical Necessity For This Member. The Member Has At Least 4 Posterior Teeth, Including Bicuspids On Each Side, which Can Be Used For Chewing. A six week healing period is required after last extraction, prior to obtaining impressions for denture. Procedure Code and modifiers billed must match approved PA. Timely Filing Deadline Exceeded. Reason Code 161: Attachment referenced on the claim was not received in a timely fashion. Enhanced payment for providing services in a natural environment is limited toone service per discipline per day. Detail Denied. This service is not payable for the same Date Of Service(DOS) as another service included on this claim. We encourage you to take advantage of this easy-to-use feature. 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. CNAs Eligibility For Training Reimbursement Has Expired. Claim Denied. This Service Is A Resubmission Of A Service Previously Denied For Prior Authorization. Authorization For Surgery Requiring Second Opinion Valid For 6Months After Date Approved. $150.00 Reimbursement Limit Has Been Reached For Individual And Group Pncc Health Education/nutritional Counseling. Services restricted to EPSDT clients valid only with a Full Scope, EPSDT-eligible Aid Code. Denied. Your Adjustment/reconsideration Request For Additional Payment Has Been Denied, Request Was Received Beyond The 90 Day Requirement For Payment Reconsideration. Basic knowledge of CPT and ICD-codes. The Submission Clarification Code is missing or invalid. Multiple Providers Of Treatment Are Not Indicated For This Member. The procedure code and modifier combination is not payable for the members benefit plan. Service(s) Billed Are Included In The Total Obstetrical Care Fee. External Cause Diagnosis May Not Be The Single Or Primary Diagnosis. Area of the Oral Cavity is required for Procedure Code. Voided Claim Has Been Credited To Your 1099 Liability. Cannot bill for both Assay of Lab and other handling/conveyance of specimen. Submit Claim To For Reimbursement. Here are just a few of them: EOB CODE. Department of Health Services (DHS) Authorized Payment Is Being Withheld Due toan Audit. If A Reporting Form Is Not Submitted Within 60 Days, The claim detail will be denied. Service Must Be Billed On Drug Claim Form Utilizing NDC Codes. This National Drug Code (NDC) requires a whole number for the Quantity Billed. Please Itemize Services Including Date And Charges For Each Procedure Performed. Claims may deny when reported and not meeting the ICD-10-CM Laterality policy for Diagnosis-to-Diagnosis comparison. Denied. Rendering Provider is not certified for the Date(s) of Service. Request Denied Because The Screen Date Is After The Admission Date. The Second Modifier For The Procedure Code Requested Is Invalid. Please Correct And Resubmit. Denied due to The Members First Name Is Missing Or Incorrect. Claim Denied For Invalid Billing Type Frequency Code, Claim Type, Or SubmittedAdjustment Provider Number Does Not Match Original Claims Provider Number. Medicare Paid The Total Allowable For The Service. This National Drug Code (NDC) is only payable as part of a compound drug. The header total billed amount is required and must be greater than zero. Do Not Submit Claims With Zero Or Negative Net Billed. Reason Code: 234. Service(s) Must Be Submitted On Paper Claim Form Along With Preoperative History And Physical Report And Operation Report. Submitted referring provider NPI in the header is invalid. Claims may be denied if the only reported diagnosis is syncope and collapse when any of the listed diagnostic head, brain, carotid artery or neck imaging procedures are billed. This Payment Is To Satisfy The Amount Owed For OBRA Level 1. Procedure Code Used Is Not Applicable To Your Provider Type. Please Correct And Resubmit. At Least One Of The Compounded Drugs Must Be A Covered Drug. Occupational Therapy Limited To 45 Treatment Days Per Spell Of Illness w/o Prior Authorization. Consultation or surgical procedures are not reimbursable in conjuctions with Emergency Room services. The Request Does Not Meet Generally Accepted Conditions Requiring Fluoride Treatments. Denied. Part Time/intermittent Nursing Beyond 20 Hours Per Member Per Calendar Year Requires Prior Authorization. Denied/Cutback. The procedure code has Family Planning restrictions. Please Review All Provider Handbook For Allowable Exception. Professional Components Are Not Payable On A Ub-92 Claim Form. This Member Appears To Continue To Abuse Alcohol And/or Other Drugs And Is Therefore Not Eligible For Day Treatment. Denied due to Some Charges Billed Are Non-covered. Billed Amount Is Greater Than Reimbursement Rate. This Claim Has Been Denied Due To A POS Reversal Transaction. The Procedure Code billed not payable according to DEFRA. Level Of Care/accommodation Code Billed Is Not Applicable To Your Provider Specialty. Providers will find a list of all EOB codes used with the corresponding description on the last page of the Remittance Advice. The From Date Of Service(DOS) for the First Occurrence Span Code is invalid. Denied. Drug(s) Billed Are Not Refillable. NDC- National Drug Code is invalid for the Dispense Date Of Service(DOS). The Service Billed Does Not Match The Prior Authorized Service. NDC was reimbursed at generic WAC (Wholesale Acquisition Cost) rate. Please Resubmit Using Newborns Name And Number. CO/96/N216. HMO Extraordinary Claim Denied. Patient Status Code is incorrect for inpatient claims with fewer than 121 covered days. A valid Level of Effort is also required for pharmacuetical care reimbursement. Revenue code is not valid for the type of bill submitted. Value codes 48 Homoglobin Reading and 49 Hematocrit Reading, must have a zero in the far right position. Day Treatment Exceeding 5 Hours/day Not Payable Regardless Of Prior Authorization. OA 12 The diagnosis is inconsistent with the provider type. MLN Matters Number: MM6229 Related . This Procedure Is Denied Per Medical Consultant Review. Money Will Be Recouped From Your Account. The Diagnosis Code Is Not Valid On This Date Of Service(DOS). Member is enrolled in a State-contracted managed care program for the Date(s) of Service. Claim Denied. Services Must Be Submitted On Proper Claim/adjustment/reconsiderationRequest Form. Up to a $1.10 reduction has been applied to this claim payment. Certifying Agency Verified Member Was Not Eligible for Dates Of Services. Denied due to Claim Or Adjustment Received After The Late Billing Filing Limit. The Requested Transplant Is Not Covered By . Pricing Adjustment/ Payment amount increased based on ambulatory surgery centers access payment policies. Cutback/denied. Please Correct And Resubmit. For over 40 years, Washington Publishing Company (WPC) has specialized in managing and distributing data integration information through publications, training, and consulting services. Pricing Adjustment/ Pharmacy pricing applied. NDC was reimbursed at State Maximum Allowable Cost (SMAC) rate. Reimbursement rate is not on file for members level of care. Traditional dispensing fee may be allowed. Denied. Resubmit With All Appropriate Diagnoses Or Use Correct HCPCS Code. PDN services billed on this claim exceed 12 hours/day per nurse, PDN services billed on this claim exceed 60 hours/week per nurse, PDN services billed on this claim exceed 24 hours/day per member. Psych Evaluation And/or Functional Assessment Ser. RN And LPN Subsequent Care Visits Limited To 6 Hrs Per Day/per Member/per Provider. Detail To Date Of Service(DOS) is required. Payment Subject To Pharmacy Consultant Review. Claims Cannot Exceed 28 Details. Claim Is For A Member With Retro Ma Eligibility. The value code 48 (Hemoglobin reading) or 49 (Hematocrit) is required for the revenue code/HCPCS code combination. This Payment Is To Satisfy The Amount Owed For OBRA Nurse Aid Training. Member Name Missing. Claim Explanation Codes. Phone: 800-723-4337. Please Supply NDC Code, Name, Strength & Metric Quantity. Pricing Adjustment/ Medicare pricing cutbacks applied. Rural Health Clinics May Only Bill Revenue Codes On Medicare Crossover Claims. Secondary Diagnosis Code (dx) is not on file. No action required. HCPCS Procedure Code is required if Condition Code A6 is present. This care may be covered by another payer per coordination of benefits. Please Furnish A Breakdown Of Your Procedure Code And Charge In Question GivenOn The Adjustment/reconsideration Request. Out Of State Billing Provider Not Enrolled For Entire Detail DOS Span. Benefit code These codes are submitted by the provider to identify state programs. Denied. Risk Assessment/Care Plan is limited to one per member per pregnancy. 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 . Benefit Payment Determined By Fiscal Agent Review. The Service Performed Was Not The Same As That Authorized By . Ability to proficiently use Microsoft Excel, Outlook and Word. Panel And Individual Test Not Payable For Same Member/Provider/ Date Of Service(DOS). 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. Lab Procedures Billed In Conjunction With Family Planning Pharmacy Visit Denied as not a Benefit. Contact Wisconsin s Billing And Policy Correspondence Unit. The CNA Is Only Eligible For Testing Reimbursement. Denied. If You Have Already Obtained SSOP, Please Disregard This Message. Denials with solutions in Medical Billing; Denials Management - Causes of denials and solution in medical billing; Medical Coding denials with solutions CPT Or CPT/modifier Combination Is Not Valid On This Date Of Service(DOS). Prescriber ID Qualifier must equal 01. Claim Denied. Billing Provider Received Payment From Both Medicare And For Clai m. An Adjustment/reconsideration Request Has Been Made To The Billing Providers Account. A group code is a code identifying the general category of payment adjustment. Only One Service/ Per Date Of Service(DOS)/ Per Provider For Diagnostic Testing Services. Denied/Cutback. Pricing Adjustment/ Pharmacy dispensing fee applied. If it is medically necessary to exceed the limitation, submit an Adjustment/Reconsideration request with supporting documentation. Wis Adm Code 106.04(3)(b) Requires Providers To Reimburse The Person/party (eg, County) That Previously. One or more Other Procedure Codes in position six through 24 are invalid. Service Denied. Pricing Adjustment/ Medicare benefits are exhausted. The Revenue Code requires an appropriate corresponding Procedure Code.