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Prescription Drug Plan (PDP) payment/denial information required on the claim to WCDP. 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. Use This Claim Number For Further Transactions. Denied. Service Denied. This HMO Capitation Payment Is Being Recouped It Was Inappropriately Paid During The Inital February HMO Capitation Cycle. The Functional Assessment Indicates This Member Has Less Than A 50% Likelihoodof Benefit, Therefore Day Treatment Is Not Appropriate. The below mention list of EOB codes is as below, EOB codes list is updated as per the latest information gathered from authorized sources of information, if any discrepancy please let us know via the contact us page, Coupon "NSingh10" for 10% Off onFind-A-CodePlans. CPT/HCPCS codes are not reimbursable on this type of bill. A Third Occurrence Code Date is required. Please Refer To Your Hearing Services Provider Handbook. Second Rental Of Dme Requires Prior Authorization For Payment. Only one antipsychotic drug is allowed without an Attestation to Prescribe More Than One Antipsychotic Drug for a Member 16 Years of Age or Younger. Occupational Therapy Limited To 45 Treatment Days Per Spell Of Illness w/o Prior Authorization. Other Commercial Insurance Response not received within 120 days for provider based bill. 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. The revenue accomodation billing code on the claim does not match the revenue accomodation billing code on the member file or does not match for these dates of service. Timely Filing Deadline Exceeded. The Member Was Not Eligible For On The Date Received the Request. A Training Payment Has Already Been Issued For This Cna. Therefore itIs Not Necessary To Wait The Full 6 Weeks After Extractions Before Taking Denture Impressions. Valid NCPDP Other Payer Reject Code(s) required. This Program Does Not Appear To Meet The Minimum Requirement For AODA Day Treatment Programming (10hrs) And Does Not Qualify For Aoda Day Treatment. Second Other Surgical Code Date is invalid. Condition codes 71, 72, 73, 74, 75, and 76 cannot be present on the same ESRD claim at the same time. The Quantity Allowed Was Reduced To A Multiple Of The Products Package Size. These Supplies/items Are Included In The Purchase Of The Dme Item Billed On The Same Date Of Service(DOS). Request was not submitted Within A Year Of The CNAs Hire Date. Correct Claim Or Submi Paper Claim Noting That Verification Has Occurred. Other Insurance/TPL Indicator On Claim Was Incorrect. Please Correct And Resubmit. Pricing Adjustment/ Payment amount increased based on hospital access paymentpolicies. Principal Diagnosis 7 Not Applicable To Members Sex. The Medical Necessity For The Hours Requested Is Not Supported By The Information Submitted In The Personal Care Assessment Tool. Rqst For An Exempt Denied. Denied due to Member Is Eligible For Medicare. Denied due to NDC Is Not Allowable Or NDC Is Not On File. In 2015 CMS began to standardize the reason codes and statements for certain services. Prescriber ID Qualifier must equal 01. Claim Must Indicate A New Spell Of Illness And Date Of Onset. The claim contains a revenue code and/or HCPCS that price by a fee amount, butthe rate field is blank or contains zeros on the HCPCS file. Referring Provider is not currently certified. A valid Prior Authorization is required for non-preferred drugs. Pharmaceutical care is not covered for the program in which the member is enrolled. Claim Paid In Accordance With Family Planning Contraceptive Services Guidelines. Denied. The Diagnosis Code Is Not Valid On This Date Of Service(DOS). WellCare 2022 schedule; NOFEE: Code is not a covered service on your fee schedule modifiers, Part 2 for CR, GT and blank modifiers IH033: Exceeds clinical guidelines; IH038: Pricing Adjustment/ Maximum Allowable Fee pricing used. Explanation of benefits. Please Resubmit. Dispensing fee denied. Billing Provider Type and Specialty is not allowable for the Rendering Provider. Additional servcies may be billed with H0046 and will count toward mental health and/or substance abuse treatment policy limits for prior authorization. This Is A Manual Increase To Your Accounts Receivable Balance. Prior Authorization (PA) required for payment of this service. Modification Of The Request Is Necessitated By The Members Minimal Progress. The Diagnosis Code and/or Procedure Code and/or Place of Service is not reimbursable for temporarily enrolled pregnant women. . Third Other Surgical Code Date is required. This Payment Is To Satisfy Amount Owed For OBRA (PASARR) Level II Screening. The taxonomy code for the attending provider is missing or invalid. Procedure Code is not allowed on the claim form/transaction submitted. CPT Code 88305 (Level IV - Surgical pathology, gross and microscopic examination) includes different types of biopsies. Please Resubmit Corr. Pricing Adjustment/ Pharmacy dispensing fee applied. Refer To Your Pharmacy Handbook For Policy Limitations. According to CMS policy and the American College of Radiology, a chest X-ray (CPT codes 71045, 71046) should not be performed for screening purposes in the absence of pertinent signs, symptoms or diseases. Pricing Adjustment/ Traditional dispensing fee applied. Men. Avoiding denial reason code CO 22 FAQ Q: We received a denial with claim adjustment reason code (CARC) CO 22. Duplicate/second Procedure Deemed Medically Necessary And Payable. Home Health visits (Nursing and therapy) in excess of 30 visits per calendar year per member require Prior Authorization. Second And Subsequent Cerebral Evoked Response Tests Paid At A Reduced Rate Per Guidelines. Denied due to Detail Billed Amount Missing Or Zero. This Member Is Receiving Concurrent AODA/Psychotherapy Services And Is Therefore Only Eligible For Maintenance Hours. Pharmaceutical care indicates the prescription was not filled. Prior Authorization is required for service(s) exceeding mental health and/or substance abuse benefit guidelines. Reimbursement For HCPCS Procedure Code 58300 Includes IUD Cost. The Members Profile Indicates This Member Is Possibly Alcoholic And/or Chemically Dependent, And Intensive Aoda Treatment Appears Warranted. Denied. Supervisory visits for Unskilled Cases allowed once per 60-day period. Information inadequate to establish medical necessity of procedure performed.Please resubmit with additional supporting documentation. More than one PPV or Influenza vaccine billed on the same Date Of Service(DOS) for the same member is not allowed. Fifth Diagnosis Code (dx) is not on file. The National Drug Code (NDC) was reimbursed at a generic rate. The Request Has Been Approved To The Maximum Allowable Level. We maintain and annually update a List of Current Procedural Terminology (CPT)/Healthcare Common Procedure Coding System (HCPCS) Codes (the Code List), which identifies all the items and services included within certain designated health services (DHS) categories or that may qualify for certain exceptions. The Medical Necessity For Psychotherapy Services Has Not Been Documented, ThusMaking This Member Ineligible For The Requested Service. OA 12 The diagnosis is inconsistent with the provider type. Please Indicate Separately On Each Detail. WCDP member enrolled in Medicare Part D. Claim is excluded from Drug Rebate Invoicing. Purchase of a blood glucose monitor includes the first 30 days of supplies for the monitor. Medicare Providers | Wellcare If authorization number available . Pricing Adjustment/ Revenue code flat rate pricing applied. Correct Claim Or Resubmit With X-ray. Pharmaceutical Care Code must be billed with a payable drug detail or if a prescription was not filled, the quantity dispensed must be zero. This National Drug Code is not covered under the Core Plan or Basic Plan for the diagnosis submitted. Denied. 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. The Member Has At Least 4 Posterior Teeth, Including Bicuspids On Each Side, which Can Be Used For Chewing. A Qualified Provider Application Is Being Mailed To You. Medical Billing and Coding Information Guide. This drug has been paid under an equivalent code within seven days of this Date Of Service(DOS). Calls are recorded to improve customer satisfaction. Denied due to From Date Of Service(DOS)/date Filled Is Missing/invalid. Ancillary Codes Dates Of Service And/or Quantity Billed Do Not Match Level Of Care authorized Dates. Service Denied. Services Requiring Prior Authorization Cannot Be Submitted For Payment On A Claim In Conjunction With Non Prior Authorized Services. Procedure Code is allowed once per member per lifetime. Real time pharmacy claims require the use of the NCPDP Plan ID. Submitted referring provider NPI in the detail is invalid. Other Payer Date can not be after claim receipt date. Reimbursement Is Limited To The Average Monthly Nursing Home Cost And Services Above That Amount Are Considered Non-covered Services. We Are Recouping The Payment. Occurrence Codes 50 And 51 Are Invalid When Billed Together. Questionable Long-term Prognosis Due To Apparent Root Infection. EDI TRANSACTION SET 837P X12 HEALTH CARE . Does not reimburse both the global service and the individual component parts of the service for the same Date Of Service(DOS). Explanation of Benefit Codes (EOBs) Mar 14, 2022 1 EOB EOB DESCRIPTION. Type of Bill is invalid for the claim type. This Payment Is To Satisfy The Amount Indicated On The Administrative Claiming Reimbursement Summary Report. Voided Claim Has Been Credited To Your 1099 Liability. ACCOM REV CODE QTY BILLED NOT EQUAL TO DTL DOS. Only One Interperiodic Screen Is Allowed Per Day, Per Member, Per Provider. Multiple Prescriptions For Same Drug/ Same Fill Date, Not Allowed. Home Health services for CORE plan members are covered only following an inpatient hospital stay. Incidental modifier is required for secondary Procedure Code. Accommodation Days Missing/invalid. Rqst For An Acute Episode Is Denied. To access the training video's in the portal, please register for an account and request access to your contract or medical group. This service is not covered under the ESRD benefit. The Comprehensive Community Support Program reimbursement limitations have been exceeded. The Member Has Received A 93 Day Supply Within The Past Twelve Months. NDC- National Drug Code is not covered on a pharmacy claim. A Training Payment Has Already Been Issued To A Different NF For This CNA. Denied due to Member Not Eligibile For All/partial Dates. Payment Recovered For Claim Previously Processed Under Wrong Member ID Number. CNAs Eligibility For Nat Reimbursement Has Expired. Whenever claim denied with CO 197 denial code, we need to follow the steps to resolve and reimburse the claim from insurance company: First step is to verify the denial reason and get the denial date. Services Beyond The Six Week Postpartum Period Are Not Covered, Per DHS. Nine Digit DEA Number Is Missing Or Incorrect. Denied/Cutback. Your 1099 Liability Has Been Credited. Please Use This Claim Number For Further Transactions. It Must Be In MM/DD/YY FormatAnd Can Not Be A Future Date. This service is not payable with another service on the same Date Of Service(DOS) due to National Correct Coding Initiative. The National Drug Code (NDC) is not a benefit for the Date Of Service(DOS). Due To Non-covered Services Billed, The Claim Does Not Meet The Outlier Trim Point. 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. Second Other Surgical Code Date is required. Part C Explanation of Benefits (EOB) Materials. Claim paid at program allowed rate. Revenue codes 082X, 083X, 084X, 085X, 0800 or 0881 (X frequency not equal to 5) exist on an ESRD claim for a member who has selected method 1 or no method and the claim does not contain condition codes 71, 72, 73 ,74, 75, or 76. Please Disregard Additional Information Messages For This Claim. CO/96/N216. A WCDP drug rebate agreement for this drug is not on file for the Date Of Service(DOS). A valid Prior Authorization is required. The Existing Appliance Has Not Been Worn For Three Years. Valid Numbers Are Important For DUR Purposes. Medicare paid amount(s) have been incorrectly applied to both the claim headerand details. 2004-79 For Instructions. Billed Amount Is Greater Than Reimbursement Rate. Denied. Due To Miscellaneous Or Unspecified Reason, Adjustment/Resubmission was initiated by Provider, Adjustment/Resubmission was initiated by DHS, Adjustment/Resubmission was initiated by EDS, Adjustment Generated Due To Change In Patient Liability, Payout Processed Due To Disproportionate Share. Denied due to Provider Signature Date Is Missing Or Invalid. EOB Code: EOB Description: 0000: This claim/service is pending for program review. Out Of State Billing Provider Not Enrolled For Entire Detail DOS Span. Services Not Allowed For Your Provider T. The Procedure Code has Place of Service restrictions. Home Health, Personal Care And Private Duty Nursing Services Are Subject To A Monthly Cap. Claim/adjustment/reconsideration Request Received After 730 Days From Date(s) of Service. Denied due to Claim Exceeds Detail Limit. NFs Eligibility For Reimbursement Has Expired. As a result, providers experience more continuity and claim denials are easier to understand. Please Ask Prescriber To Update DEA Number On TheProvider File. 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. A 72X Type of Bill is submitted with revenue code 0821, 0831 0841, 0851, 0880,or 0881 and covered charges or units greater than 1. Resubmit With All Appropriate Diagnoses Or Use Correct HCPCS Code. Complex Care Services Are Limited To One Per Date Of Service(DOS) Per Member. Service Allowed Once Per Lifetime, Per Tooth. Anesthesia and moderate sedation services billed with pain management services for a patient age 18 or older may deny unless a surgical procedure CPT code range 10021-69990 (other than pain management procedures) is also billed on the claim. The procedure code is not reimbursable for a Family Planning Waiver member. Canon R-FRAME-EB 84 Eb This Procedure Code Is Denied As Incidental/Integral To Another Procedure CodeBilled On This Claim. One or more Diagnosis Codes has a gender restriction. Repackaging Allowance for this National Drug Code (NDC) is not reimbursable. NDC is obsolete for Date Of Service(DOS). Laboratory Is Not Certified To Perform The Procedure Billed. Refer To Provider Handbook. For dates of service on or after 7/1/10 for TOB 72X an occurrence code 51 and value code D5 are required when the KT/V reading was performed. A valid header Medicare Paid Date is required. Denied. Questionable Long-term Prognosis Due To Decay History. The Change In The Lens Formula Does Not Warrant Multiple Replacements. The Service Requested Is Not Medically Necessary. Training Completion Date Must Be Within A Year Of The CNAs Certification, Test, Date. Pricing Adjustment/ Usual & Customary Charge (UCC) rate pricing applied. Invalid/obsolete Procedure Code For Determination Of Refraction, Service Denied. All Day Treatment Services For Members With Nursing Home Status Should Be Billed Under Procedure Code W8912(pre 10/1/03)/h2012(post 10/1/03) And Require PriorAuthorization. Denied due to The Member WCDP Id Number Is Incorrect Or Not On Our Current Eligibility File. Claim Denied The Combined Medicare And Private Insurance Payments Equal Or Exceed The Lesser Of The And Medicare Allowable Amounts. Detail Rendering Provider certification is cancelled for the Date Of Service(DOS). Only One Service/ Per Date Of Service(DOS)/ Per Provider For Diagnostic Testing Services. Different Drug Benefit Programs. Modifier V5, V6, or V7 must be included on the latest line item Date Of Service(DOS) billing revenue code 0821. The Procedure Requested Is Not Appropriate To The Members Sex. NDC- National Drug Code is not allowed for the member on the Date Of Service(DOS). The respiratory care services billed on this claim exceed the limit. Claims adjustments. One or more Diagnosis Code(s) is invalid for the Date(s) of Service. Individual Replacements Reimbursed As Dispensing A Complete Appliance. Denied. All The Teeth Do Not Meet Generally Accepted Criteria Requiring Gingivectomy. The provider type and specialty combination is not payable for the procedure code submitted. Resubmit Using Valid Rn/lpn Procedure Codes And A Valid PA Number. You Must Adjust The Nursing Home Coinsurance Claim. Claim Corrected. Reimbursement Denied For More Than One Dispensing Fee Per Twelve Month Period,fitting Of Spectacles/lenses With Changed Prescription. Denied. Procedure Denied Per DHS Medical Consultant Review. this Procedure Code Is Denied As Mutually Exclusive To Another Code Billed On This Claim. A six week healing period is required after last extraction, prior to obtaining impressions for denture. A federal drug rebate agreement for this drug is not on file for the Date Of Service(DOS)(DOS). Note: This PA Request Has Been Backdated A Maximum Of 3 Weeks Prior To Its First Receipt By EDS, Based Upon Difficulty In Obtaining The Physicians Written Prescription. Pharmacuetical care limitation exceeded. No Matching, Complete Reporting Form Is On File For This Client. Professional Service code is invalid. Claims may deny when reported with incompatible ICD-10-CM Laterality policy for Diagnosis-to-Modifier comparison. Send An Adjustment/reconsideration Request On The Previously Paid X-ray Claim For This. The Documentation Submitted Indicates The Tasks Specified Can Be Completed During The Visits Approved. More than 6 hours of evaluation/assessment in a 2 year period must be billed astreatment services and count toward the MH/SA policy limits for prior authorization. Physical Therapy Limited To 35 Treatment Days Per Spell Of Illness W/o Prior Authorization. Effective With Claims Received On And After 10/01/03 , Occurrence Codes 50 And 51 Are Invalid. Secondary Diagnosis Code(s) in positions 2-9 cannot duplicate the Primary Discharge Diagnosis. One or more Date(s) of Service is missing for Occurrence Span Codes in positions 9 through 24. Only One Panoramic Film Or Intraoral Radiograph Series, By The Same Provider, Per Year Allowed. Denied. Charges Paid At Reduced Rate Based Upon Your Usual And Customary Pricing Profile. The National Drug Code (NDC) is not on file for the Dispense Date Of Service(DOS). Denied. Comprehension And Language Production Are Age-appropriate. Denied. PDF Claim Adjustment Reason Codes (CARCs) and Enclosure 1 - California HTTP Status Code Connect Time (ms) Result; 2023-03-01 04:10:52: 200: 255: Page Active: Click here to access the Explanation of Benefit Codes (EOBs) as of March 17, 2022. Please Submit A Separate New Day Claim For Copayment Exempt Days/services. All Home Health Services Exceeding 8 Hours Per Day Or 40 Or More Hours Per Week Require Prior Authorization. The Member Has Shown No Ability Within 6 Months To Carry Over Abilities GainedFrom Treatment In A Facility To The Members Place Of Residence. Denied. These coding rules are published within the Medicare Claims Processing Manual, Current Procedural Terminology (CPT) by the American Medical Association (AMA) and ICD-10-CM guidelines governed by Medicare and Medicaid Services (CMS) and the National Center for Health Statistics (NCHS). Based on reimbursement guidelines it is not appropriate for providers to bill inpatient Evaluation and Management (E/M) services while the patient is in an observation status. Alternatively, CPT XXXXX has been billed in the previous 10 days for a CPT code with a 10-day post-operative period, or in the previous 90 days for a code with a 90-day post-operative period by the same provider. For Newly Certified CNAs, Date Of Inclusion Is T heir Test 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. Member is assigned to an Inpatient Hospital provider. Denied due to Provider Number Missing Or Invalid. This Request Can Only Be Backdated To The Date EDS First Receives The Request In The Mailroom. Denied due to Procedure Or Revenue Code(s) Are Missing On The Claim. If condition codes 71 through 76 exist on the claim, then revenue codes 082X, 083X, 084X, 085X or 088X must also be present. Please Furnish A Breakdown Of Your Procedure Code And Charge In Question GivenOn The Adjustment/reconsideration Request. The procedure code has Family Planning restrictions. The service is not reimbursable for the members benefit plan. PDF Explanation of Benefit Codes (EOBs) - Province of Manitoba Risk Assessment/Care Plan is limited to one per member per pregnancy. Request Denied Because The Screen Date Is After The Admission Date. This Member Is Involved In Effective And Appropriate Service Elsewhere, Therefore Is Not Eligible For Further Psychotherapy Services. Please Request A Corrected EOMB Through The Medicare Carrier And Adjust With The Corrected EOMB. Additional Encounter Service(s) Denied. The Service Requested Is Included In The Nursing Home Rate Structure. ICD-9-CM Diagnosis code in diagnosis code field(s) 1 through 9 is missing or incorrect. Complex care of 17-plus hours and complex care of less than 17 hours are not allowed on the same Date Of Service(DOS). No policy override available for BadgerCare Plus Benchmark Plan, Core Plan or Basic Plan. The Service Requested Was Performed Less Than 3 Years Ago. The Member Is School-age And Services Must Be Provided In The Public Schools. CORE Plan Members are limited to 25 non-emergency outpatient hospital visits per enrollment year. A claim cannot contain only Not Otherwise Specified (NOS) Surgical Procedure Codes. . Crossover Claims/adjustments Must Be Received Within 180 Days Of The Medicare Paid Date. WWWP Does Not Process Interim Bills. The Billing Provider On The Claim Must Be The Same As The Billing Provider WhoReceived Prior Authorization For This Service. Find top links about Wellcare Cvs Caremark Login along with social links, FAQs, and more. Claim Denied In Order To Reprocess WithNew ID. Denied. Prescription Date is after Dispense Date Of Service(DOS). Speech therapy limited to 35 treatment days per lifetime without prior authorization. Dental service limited to twice in a six month period. Reimbursement For This Service Has Been Approved. Wellcare Explanation Of Payment Codes USA Health Denials with solutions in Medical Billing; Denials Management - Causes of denials and solution in medical billing; Medical Coding denials with solutions Request Denied. Determinations as to whether services are reasonable and necessary for an individual patient should be made on the same basis as all other such determinations: with reference to accepted standards of medical practice and the medical circumstances of the individual case. Endurance Activities Do Not Require The Skills Of A Therapist. Resubmit Private Duty Nursing Services For Complex Children With Documentation Supporting The Level Of Care. Please Resubmit using A Approved CPT Or HCPCS Procedure Code. Compound drugs require a minimum of two components with at least one payable FowardHealth covered drug. (part JHandbook). Service(s) exceeds four hour per day prolonged/critical care policy. The Revenue Code is not reimbursable for the Date Of Service(DOS). All services should be coordinated with the primary provider. Diagnosis Indicated Is Not Allowable For Procedures Designated As Mycotic Procedures. What to Expect with WellCare CMS (UPDATED-60 days in) Denied due to Claim Or Adjustment Received After The Late Billing Filing Limit. Please Rebill Only CoveredDates. Unable To Process This Request Due To Either Missing, Invalid OrMismatched National Provider Identifier # (NPI)/Provider Name/POP ID. ESRD claims are not allowed when submitted with value code of A8 (weight) and a weight of more than 500 kilograms and/or the value code of A9 (height) and the height of more than 900 centimeters. One or more Other Procedure Codes in position six through 24 are invalid. The Diagnosis Is Not Covered By WWWP. Medicare Claim Copy And EOMB Have Been Submitte d For Processing Of Coinsurance And Deductible. Billing Provider is not certified for the Date(s) of Service. The Request Has Been Back datedto Date of Receipt. This Claim Cannot Be Processed. Please Contact The Surgeon Prior To Resubmitting this Claim. Back-up dialysis sessions are limited to three per lifetime. Medicaid id number does not match patient name. Unable To Process Your Adjustment Request due to Claim ICN Not Found. Rural Health Clinics May Only Bill Revenue Codes On Medicare Crossover Claims. Requests For Training Reimbursement Denied Due To Late Billing. Continuous home care must be billed in an hourly quantity equal to or greater than eight hours, up to and including 24 hours. Header To Date Of Service(DOS) is required. The Processor Control Number (PCN) for SeniorCare member over 200% FPL is missing, or the PCN is invalid for a WCDP member, member or SeniorCare member at or below 200% FPL. Drug(s) Billed Are Not Refillable. 2. Members age does not fall within the approved age range. Billing Provider is not certified for the detail From Date Of Service(DOS). Diag Restriction On ICD9 Coverage Rule edit. Pricing Adjustment/ Payment amount decreased based on Pay for Performance policies. Payment reduced. Reimbursement for this procedure and a related procedure is limited to once per Date Of Service(DOS). Member is assigned to a Lock-in primary provider. You Received A PaymentThat Should Have gone To Another Provider. Good Faith Claim Denied For Timely Filing. These case coordination services exceed the limit. There is no action required. The Lens Formula Does Not Justify Replacement. PDF How to read EOB codes - Washington Only Medicare crossover claims are reimbursable. Procedure Code 59420 Must Be Used For 5 Or More Prenatal Visits With One Charge. Providers must ensure that the E&M CPT codes selected reflect the services furnished. Revenue Code Required. A Training Payment Has Already Been Issued To Your NF For This CNA. Services Submitted On Improper Claim Form. Out of State Billing Provider not certified on the Dispense Date. Unable To Process Your Adjustment Request due to This Claim Is In Post Pay Billing For Third Party Liability Payment. This Service Is Not Payable Without A Modifier/referral Code. Denied. . BMN prior authorization may be submitted for Mental Health drugs for which a Core Plan transitioned member has been previously grandfathered. Amount Indicated In Current Processed Line On R&S Report Is The Manual Check You Recently Received. The sum of the Medicare paid, deductible(s), coinsurance, copayment and psychiatric reduction amounts does not equal the Medicare allowed amount. Please Contact The Hospital Prior Resubmitting This Claim. Principle Surgical Procedure Code Date is missing. The Total Number Of Hours Per Day Requested For AODA Day Treatment Exceeds Guidelines And The Request Has Been Adjusted Accordingly. Condition code must be blank or alpha numeric A0-Z9.