Service(s) exceeds four hour per day prolonged/critical care policy. See Provider Handbook For Good Faith Billing Instructions. The following table outlines the new coding guidelines. Procedure Code 59420 Must Be Used For 5 Or More Prenatal Visits With One Charge. The Reimbursement Code Assigned To This CNA Does Not Authorize A NAT Payment. Supervising Nurse Name Or License Number Required. Effective With Claims Received On And After 10/01/03 , Occurrence Codes 50 And 51 Are Invalid. Services Must Be Submitted On Proper Claim/adjustment/reconsiderationRequest Form. X-rays and some lab tests are not billable on a 72X claim. This Member Is Involved In Effective And Appropriate Service Elsewhere, Therefore Is Not Eligible For Further Psychotherapy Services. If laboratory costs exceed reimbursement, submit a claim adjustment request with lab bills for reconsideration. Healthcheck Screening Limited To Two Per Year From Birth To Age 3 And One Per Year For Age3 Or Older. Billing Provider is not certified for the Date(s) of Service. Service (Procedure Code/Modifier Combination) is not reimbursable for Date Of Service(DOS). Errors in one of the following data elements exceed their field size: Statement covered FROM Date, Admission date, Date Of Service(DOS), Revenue code. The Evaluation Was Received By Fiscal Agent More Than Two Weeks After The Evaluation Date. Other Insurance Disclaimer Code Used Is Inappropriate For This Members Insurance Coverage. Use The New Prior Authorization Number When Submitting Billing Claim. This Procedure Code Is Not Valid In The Pharmacy Pos System. First Other Surgical Code Date is required. Member does not meet the age restriction for this Procedure Code. Pricing Adjustment/ Spenddown deductible applied. Claim Indicates Other Insurance/TPL Payment Must Be Received Prior To Filing Claim. The likelihood of a central nervous system (CNS) cause of the event is extremely low, and patient outcomes are not improved with brain imaging studies. Reimbursement Is Limited To The Average Monthly Nursing Home Cost And Services Above That Amount Are Considered Non-covered Services. Unable To Process Your Adjustment Request due to Provider ID Number On The Claim And On The Adjustment Request Do Not Match. The Primary Diagnosis Code is inappropriate for the Procedure Code. Rebill On Pharmacy Claim Form. Denied due to Medicare Allowed, Deductible, Coinsurance And Paid Amounts Do Not Balance. Split Decision Was Rendered On Expansion Of Units. If you are still unable to resolve the login problem, read the troubleshooting steps or report your issue. These codes provide additional explanation for an adjustment already described by a Claim Adjustment Reason Code (CARC) or convey information about remittance processing. NUMBER IS MISSING OR INCORRECT 0002 01/01/1900 COULD NOT PROCESS CLAIM. Recasing Or Replacement Of Hearing Aid Case Is Limited To Once Per 2 Year Period Per Member Per Provider. Providers May Only Bill For Assessments And Care Plans Twice Per Calendar Year. Code. The Service Requested Was Performed Less Than 3 Years Ago. Effective 1/1: Electronic Prescribing of Controlled Substances Required. This claim has been adjusted due to a change in the members enrollment. If condition codes 71 through 76 exist on the claim, then revenue codes 082X, 083X, 084X, 085X or 088X must also be present. Annual Nursing Home Member Oral Exam Is Allowed Once Per 355 Days Per Recip Per Prov. Denied due to The Members Last Name Is Missing. This Is A Duplicate Request. According to the American Association of Neuromuscular & Electro-Diagnostic Medicine and CMS Policy, nerve conduction studies and a needle electromyography (EMG) must both be performed in order to diagnose radiculopathy (pinched nerve in back or neck). Services In Excess Of This Cap Are Not Reimbursable for this Member. Denied. Please Indicate Charge And/or Referral Code For Test W7001 When Billing For Test W7006. This notice gives you a summary of your prescription drug claims and costs. Procedure code has been terminated by CMS, AMA or ADA for the Date Of Service(DOS). This Service Is Covered Only In Emergency Situations. Timely Filing Deadline Exceeded. The Diagnosis Code is not payable for the member. For Newly Certified CNAs, Date Of Inclusion Is T heir Test Date. The initial rental of a negative pressure wound therapy pump is limited to 90 days; member lifetime. Revenue code submitted with the total charge not equal to the rate times number of units. This Member Has A Current Approved Authorization For Intensive AODA OutpatientServices. Claim Denied For Invalid Diagnosis Code Or Diagnosis Code/CPT Combination. Header From Date Of Service(DOS) is invalid. Dates Of Service For Purchased Items Cannot Be Ranged. Ulcerations Of The Skin Do Not Warrant A New Spell Of Illness. Surgical Procedure Code is not allowed on the claim form/transaction submitted. Per Information From Insurer, Requested Information Was Not Supplied By The Provider. These Supplies/items Are Included In The Purchase Of The Dme Item Billed On The Same Date Of Service(DOS). Our Records Indicate You Have Billed More Than One Unit Dose Dispensing Fee For This Calendar Month. Limited to once per quadrant per day. Insufficient Documentation To Support The Request. The diagnosis code is not reimbursable for the claim type submitted. Value code 48 exceeds 13.0 or value code 49 exceeds 39.0 and HCPCS codes Q4081or J0882 are present but either modifer ED or EE are not present. Denied due to Provider Number Missing Or Invalid. Private Duty Nursing Beyond 30 Hrs /Member Calendar Year Requires Prior Authorization. These services are not allowed for members enrolled in Tuberculosis-Related Services Only Benefit Plan. SeniorCare member enrolled in Medicare Part D. Claim is excluded from Drug Rebate Invoicing. 3101. This ProviderMay Only Bill For Coinsurance And Deductible On A Medicare Crossover Claim. Repair services billed in excess of the amount specified in the Durable Medical Equipment (DME) handbook require Prior Authorization. Non-Reimbursable Service. Reimbursement limits for Community Care Services for the calendar year are close to being exceeded. Claim Number Given Is Not The Most Recent Number. Records Indicate This Tooth Has Previously Been Extracted. Pricing Adjustment/ Reimbursement reduced by the members copayment amount. Service Denied. Prescription limit of five Opioid analgesics per month. The Surgical Procedure Code has Diagnosis restrictions. Pricing Adjustment/ Repackaging dispensing fee applied. Rural Health Clinics May Only Bill Revenue Codes On Medicare Crossover Claims. The Number In The National Provider Identifier (NPI) Section On This Request IsNot A Number Assigned To A Certified Nursing Facility For This Date Of Service(DOS). Good Faith Claim Has Previously Been Denied By Certifying Agency. The To Date Of Service(DOS) for the First Occurrence Span Code is required. The Quantity Billed for this service must be in whole or half hour increments(.5) Increments. Please familiarize yourself with these new explanation codes and update your accounts receivable as indicated. The Submission Clarification Code is missing or invalid. Reimbursement Is At The Unilateral Rate. Member is enrolled in Medicare Part B on the Date(s) of Service. Prescriptions Or Services Must Be Billed As ASeparate Claim. Out Of State Billing Provider Not Enrolled For Entire Detail DOS Span. Resubmit Claim Once Election Form Requirements Are Met Per The Hospice Provider Handbook. 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. Claim Denied. Denied. Please Contact The Hospital Prior Resubmitting This Claim. 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. These Urinalysis Procedures Reimbursed Collectively At The Maximum For Routine Urinalysis With Microscopy. Cannot Be Reprocessed Unless There Is Change In Eligibility Status. 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. CPT Or CPT/modifier Combination Is Not Valid On This Date Of Service(DOS). Pricing Adjustment. The Value Code and/or value code amount is missing, invalid or incorrect. Claims may deny for the initial inpatient admission E&M if a provider from the same provider group and same specialty bills any other inpatient E&M visit, i.e. The Insurance EOB Does Not Correspond To The Dates Of Service/servicesBeing Billed. A Reimbursement Request For A Level I Screen Must Be Received At Within A Year Of The Screen Date. Gastrointestinal Surgery For The Purpose Of Weight Control Is Covered Only As An Emergency Procedure. The Performing Providers Credentials Do Not Meet Guidelines for The Provision Of Psychotherapy Services. Denied due to The Members First Name Is Missing Or Incorrect. For RHCs, place of service is 72, however, you can bill lab services with a place of service 11. Oral exams or prophylaxis is limited to once per year unless prior authorized. The Member Is School-age And Services Must Be Provided In The Public Schools. Ongoing assessment is not reimbursable when skilled nursing visits have been performed within the past sixty days. Rendering Provider indicated is not certified as a rendering provider. If A Reporting Form Is Not Submitted Within 60 Days, The claim detail will be denied. . All three DUR fields must indicate a valid value for prospective DUR. Claim Denied. Physical Therapy Treatment Limited To One Modality, One Procedure, One Evaluation Or One Combination Per Day. This National Drug Code Has Diagnosis Restrictions. Prescription Drug Plan (PDP) payment/denial information required on the claim to WCDP. These case coordination services exceed the limit. TPA Certification Required For Reimbursement For This Procedure. Resubmit Private Duty Nursing Services For Complex Children With Documentation Supporting The Level Of Care. Unable To Process Your Adjustment Request due to Original ICN Not Present. Denied. The Information Provided Indicates Regression Of The Member. Reason Code 161: Attachment referenced on the claim was not received in a timely fashion. Thank You For The Payment On Your Account. Service Must Be Billed On Drug Claim Form Utilizing NDC Codes. Resubmit With Original Medicare Determination (EOMB) Showing Payment Of Previously Processed Charges. Additional Psychotherapy Is Not Considered Appropriate Or Inline With More Effective, Available Services. The Member Is Also Involved In A Structured Living And/or Working Arrangement.A Reduction In Day Treatment Hours Is Indicated. According To Our Records, The Hospital Has Not Received Prior Authorization For This Surgery.