Member is not enrolled for the detail Date(s) of Service. Dispense Date Of Service(DOS) is required. Header Bill Date is before the Header From Date Of Service(DOS). CPT Code 88305 (Level IV - Surgical pathology, gross and microscopic examination) includes different types of biopsies. There is no action required. The Service(s) Requested Could Adequately Be Performed In The Dental Office. Occurance code or occurance date is invalid. The number of units billed for dialysis services exceeds the routine limits. Anesthesia Modifying Services Must Be Billed Separately From The Charge For Anesthesia Base And Time Units. Our Records Indicate You Have Billed More Than One Unit Dose Dispensing Fee For This Calendar Month. 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. The Documentation Submitted Does Not Substantiate Additional Care. Claim Corrected. Intermittent Peritoneal Dialysis hours must be entered for this revenue code. Denied. Procedure Code is restricted by member age. Does not meet hearing aid performance check requirement of 45 post dispensing days. Denied. Dates of Service reflected by the Quantity Billed for dialysis exceeds the Statement Covers Period. Amount Recouped For Duplicate Payment on a Previous Claim. Procedure Code 59420 Must Be Used For 5 Or More Prenatal Visits With One Charge. Denied due to Detail Billed Amount Missing Or Zero. PATIENT PAID PORTION USED TOWARDS DEDUCTIBLE. Compound drugs require a minimum of two components with at least one payable FowardHealth covered drug. Denied. Refill Indicator Missing Or Invalid. If some of the services were previously paid, submit an adjustment/reconsideration request for the paid claim. Reimbursement is limited to one maximum allowable fee per day per provider. 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. It Must Be In MM/DD/YY Format AndCan Not Be A Future Date. Fifth Diagnosis Code (dx) is not on file. A discrepancy exists between the Other Coverage Indicator and the Other Paid Amount. The Clinical Profile And Narrative History Indicate Day Treatment Is Neither Appropriate Nor A Medical Necessity For This Member. The Medical Records Submitted With The Current Request Conflict Or Disagree With Our Medical Records On This Member. Superior HealthPlan News. Procedure Code Changed To Permit Appropriate Claims Processing. Claim Is For A Member With Retro Ma Eligibility. Please Contact The Surgeon Prior To Resubmitting this Claim. A Payment Has Already Been Issued To A Different Nf. The Service Requested Is Not A Covered Benefit As Determined By . A Fourth Occurrence Code Date is required. Denied. Denied. Services Denied In Accordance With Hearing Aid Policies. Services not allowed for your Provider Type or for your Provider Type without a TB diagnosis. The Quantity Allowed Was Reduced To A Multiple Of The Products Package Size. Member does not meet the age restriction for this Procedure Code. Rendering Provider may not submit claims for reimbursement as both the Surgeonand Assistant Surgeon For The Same Member On The Same DOS. The Third Occurrence Code Date is invalid. No Complete WWWP Participation Agreement Is On File For This Provider. This Member Has Already Received Intensive Day Treatment In The Past Year and is Only Eligible For Reduced Hours At This Time. Day Treatment Exceeding 5 Hours/day Not Payable Regardless Of Prior Authorization. The first position of the attending UPIN must be alphabetic. Please Correct And Resubmit. These Urinalysis Procedures Reimbursed Collectively At The Maximum For Routine Urinalysis With Microscopy. Pricing Adjustment/ Ambulatory Payment Classification (APC) pricing applied. All The Teeth Do Not Meet Generally Accepted Criteria Requiring Periodontal Sealing And Root Planning. Value Codes 81 And 83, Are Valid Only When Submitted On An Inpatient Claim. This Claim HasBeen Manually Priced Using The Medicare Coinsurance, Deductible, And Psyche RedUction Amounts As Basis For Reimbursement. A Total Charge Was Added To Your Claim. Repackaging allowance is not allowed for unit dose NDCs. Claim Number Given Is Not The Most Recent Number. Unable To Process Your Adjustment Request due to Original Claim ICN Not Found. Members do not have to wait for the post office to deliver their EOB in a paper format. The To Date Of Service(DOS) for the Second Occurrence Span Code is invalid. Claim Denied. Dental service limited to twice in a six month period. A Date Of Service(DOS) is required with the revenue code and HCPCS code billed. 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. Discharge Diagnosis 5 Is Not Applicable To Members Sex. Correction Made Per Medical Consultant Review. Suspend Claims With DOS On Or After 7/9/97. Assessment limit per calendar year has been exceeded. Resubmit charges for covered service(s) denied by Medicare on a claim. Service Denied. Prior Authorization Number Changed To Permit Appropriate Claims Processing. Critical care performed in air ambulance requires medical necessity documentation with the claim. Prior Authorization Required For Day Treatment Services If Members FunctionalAssessment Negative. Continue ToUse Appropriate Codes On Billing Claim(s). This drug/service is included in the Nursing Facility daily rate. Training Reimbursement DeniedDue To late Billing. First modifier code is invalid for Date Of Service(DOS). Rebill Using Correct Procedure Code. The Clinical Profile/Diagnosis Makes This Member Ineligible For AODA Services. All ESRD clinical diagnostic laboratory tests must be billed individually to ensure that automated multi-chanel chemistry tests are paid in accordance with the Medicare Provider Reimbursement Manual (PRM) 2711. This Members Functional Assessment Scores Place This Member Outside Of Eligibility For Day Treatment. The Primary Diagnosis Code is inappropriate for the Procedure Code. Pricing Adjustment/ Provider Level of Care (LOC) pricing applied. Each month you fill a prescription, your Medicare Prescription Drug Plan mails you an "Explanation of Benefits" (EOB). Authorization For Surgery Requiring Second Opinion Valid For 6Months After Date Approved. The Second Occurrence Code Date is invalid. Has Already Issued A Payment To Your NF For A Level I Screen With The Same Admission Date. LTC hospital bedhold quantity must be equal to or less than occurrence code 75span date range(s). Request Denied Due To Late Billing. The Information Provided Is Not Consistent With The Intensity Of Services Requested. A Separate Notification Letter Is Being Sent. Claim Detail Denied As Duplicate. Denied due to Provider Signature Is Missing. You Must Adjust The Nursing Home Coinsurance Claim. Because a claim can have edits and audits at both the header and detail levels, EOB codes are listed . Claim Denied Due To Absent Or Incorrect Discharge (to) Date. Members Are Limited To 45 Dates Of Service Per Therapy/spell Of Illness without Prior Authorization. Claim Denied Due To Incorrect Accommodation. The billing provider number is not on file. Member In TB Benefit Plan. Claims may deny when a procedure defined as requiring an anatomical modifier is billed without an associated anatomical modifier. Next step verify the application to see any authorization number available or not for the services rendered. This National Drug Code is not covered under the Core Plan or Basic Plan for the diagnosis submitted. The Service Requested Is Inappropriate For The Members Diagnosis. Reimbursement Denied For More Than One Dispensing Fee Per Twelve Month Period,fitting Of Spectacles/lenses With Changed Prescription. Please Refer To The Original R&S. Condition Code 73 for self care cannot exceed a quantity of 15. DME rental beyond the initial 30 day period is not payable without prior authorization. Reimbursement For Training Is One Time Only. DME rental is limited to 90 days without Prior Authorization. Referral Codes Must Be Indicated For W7001, W7002, W7003, W7006, W7008 And W7013. This Member Is Involved In Intensive Day Treatment, Which Is To Include Psychotherapy Services. Prescriber ID is invalid.e. Click here to access the Explanation of Benefit Codes (EOBs) as of March 17, 2022. For RHCs, place of service is 72, however, you can bill lab services with a place of service 11. Personal Care In Excess Of 250 Hrs Per Calendar Year Requires Prior Authorization. Pharmaceutical care reimbursement for tablet splitting is limited to three permonth, per member. Procedure Code and modifiers billed must match approved PA. Claim Is Pended For 60 Days. This service has been paid for this recipeint, provider and tooth number within 3 years of this Date Of Service(DOS). TPA Certification Required For Reimbursement For This Procedure. Basic knowledge of CPT and ICD-codes. Claim Explanation Codes. One or more Diagnosis Code(s) is invalid for the Date(s) of Service. Denied. Please Reference Payment Report Mailed Separately. Please Review The Cover Letter Attached To Your Claim, Any Informational Messages, And Provide The Requested Information BeforeResubmitting the Claim. Please Clarify. 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. 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. Home Health, Personal Care And Private Duty Nursing Services Are Subject To A Monthly Cap. Outpatient Services To Be Billed As Inpatient Ancillaries When Same Day Stay Occurs Please File An Adjustment/reconsideration Request To Correct Inpatiet Billing. Printable . Restorative Nursing Involvement Should Be Increased. Requests For Training Reimbursement Denied Due To Late Billing. Procedure Not Payable As Submitted. Pricing Adjustment/ Claim has pricing cutback amount applied. By continuing to use our site, you agree to our Privacy Policy and Terms of Use. Secondary Diagnosis Code (dx) is not on file. Claim Previously/partially Paid. The National Drug Code (NDC) was reimbursed at a generic rate. Denied. Effective July 15, 2021 through December 31, 2021: Temporary Relaxation of Prior Authorization . Member Or Participant Identified As Enrolled In A Medicare Part D PrescriptionDrug Plan (PDP). Service Denied. Homecare Services W/o PA Are Not Payable When Prior Authorized Homecare Services have Been Provided To The Same Member. 12/06/2022 . Rural Health Clinics May Only Bill Revenue Codes On Medicare Crossover Claims. Routine foot care is limited to no more than once every 61days per member. 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 .