EOB Codes or Explanation of Benefit Codes are present on the last page of remittance advice, these EOB codes are in form of numbers and every number has a specific meaning. We have created a list of EOB reason codes for the help of people who are working on denials, AR-follow-up, medical coding, etc.

The below mention list of explanation of benefit Codes is as below

EOB Remark Codes

EOB Codes	Description
0	This claim/service is pending for program review.
1	Member’s I.d. Number Is Missing Or Incorrect
2	Number On Claim Does Not Match Number On Prior Authorization Request.
3	A minimum of one detail is required.
4	DME rental beyond the initial 30 day period is not payable without prior authorization.
5	Charges Paid At Reduced Rate Based Upon Your Usual And Customary Pricing Profile.
6	Amount Paid Reduced By Amount Of Other Insurance Payment.
7	Information inadequate to establish medical necessity of procedure performed.Please resubmit with additional supporting documentation.
8	The Number Of Weeks Has Been Reduced Consistent With Goals And Progress Documented.
9	Member Name Missing. Please Correct And Resubmit.
10	Member is enrolled in Medicare Part A and/or Part B on the on the Dispense Dateof Service.
11	Medicare Part A Services Must Be Resubmitted. Please Attach Copy Of Medicare Remittance.
12	Service Paid At The Maximum Amount Allowed By ReimbursementPolicies.
13	Dollar Amount Of Claim Was Adjusted To Correct Mathematical Error.
14	A discrepancy exists between the Other Coverage Indicator and the Other Paid Amount.
15	Pediatric Community Care is limited to 12 hours per DOS.
16	Drug Dispensed Under Another Prescription Number. Multiple Prescriptions For Same Drug/ Same Fill Date, Not Allowed.
17	The Evaluation Was Received By Fiscal Agent More Than Two Weeks After The Evaluation Date.
18	Allowance For Coinsurance Is Limited To Allowable Amount Less Medicare’s Payment. Medicare Deductible Is Paid In Full.
19	Medicare Paid The Total Allowable For The Service.
20	Claim Reduced Due To Member/participant Spenddown.
21	Procedure Code is allowed once per member per lifetime.
22	Service(s) Must Be Submitted On Paper Claim Form Along With Preoperative History And Physical Report And Operation Report.
23	Performing Provider Is Not Certified For Date(s) Of Service On Claim/detail.
24	Provider Certification Has Been Suspended By The Department of Health Services(DHS).
25	Billing or Rendering Provider certification is cancelled for the From Date Of Service(DOS).
26	ICD-9-CM Diagnosis Code 2 Is Invalid.
27	ICD-9-CM Diagnosis Code 3 Is Invalid
28	ICD-9-CM Diagnosis Code 4 Is Invalid.
29	Member last name does not match Member ID.
30	Referring Provider is not currently certified.
31	Reimbursement Rate Applied To Allowed Amount.
32	ICD-9-CM Diagnosis Code 5 Is Invalid
33	The Member Was Not Eligible For On The Date Received the Request. Contact Wisconsin ‘s Billing And Policy Correspondence Unit.
34	Service Billed Limited To Three Per Pregnancy Per Guidelines.
35	Claim Denied Due To Invalid Pre-admission Review Number.
36	Payment For Immunotherapy Service Included In Reimbursement For Allergy Extract Injection.
37	Claim Denied. Consent Form Is Missing, Incomplete, Or Contains Invalid Information.
38	The Member Is Enrolled In An HMO. The Service Requested Is Covered By The HMO.
39	The Service Requested Is Not A Covered Benefit Of The Program.
40	Rendering Provider ID is not on file.
41	The Procedure Requested Is Not On ‘s Files.
42	The Procedure Requested Is Not Allowable For The Process Type Indicated On TheRequest. Contact Wisconsin ‘s Billing And Policy Correspondence Unit.
43	The Service Requested Is Inappropriate For The Member’s Diagnosis.
44	The provider is not authorized to perform or provide the service requested.
45	The Service Requested Does Not Correspond With Age Criteria.
46	The Procedure Requested Is Not Appropriate To The Member’s Sex.
47	These case coordination services exceed the limit.
48	The Modifier For The Proc Code Is Invalid. Please Supply The Appropriate Modifier. If The Proc Code Does Not Require A Modifier, Please Remove The Modifier.
49	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.
50	Payment Reduced By Member Copayment.
51	The sum of the Accommodation Days is not equal to the sum of Covered plus Non-Covered Days, or the From and To Dates of Service cannot be the same.
52	The Admit Date is required.
53	Service(s) Billed Are Included In The Total Obstetrical Care Fee.
54	Claim Denied Due To Absent Or Incorrect Discharge (to) Date.
55	Please Indicate The Dollar Amount Requested For The Service(s) Requested.
56	Detail From Date Of Service(DOS) is after the ICN Date.
57	Members Up To 3 Years Of Age Are Limited To 2 Healthcheck Screens Per 12 Months.
58	Targeted Rate Service
59	Normal delivery payment includes the induction of labor.
60	Admit Diagnosis is required.
61	Indicated Diagnosis Is Not Applicable To Member’s Sex.
62	This Member Has Completed Primary Intensive Services And Is Now Only Eligible For after Care/follow-up Hours.
63	Reimbursement For This Service Is Included In The Transportation Base Rate.
64	Claim reduced to fifteen Hospital Bedhold Days for stays exceeding fifteen days.
65	The respiratory care services billed on this claim exceed the limit.
66	Claim Reduced Due To Member/participant Deductible.
68	Procedure Code is not payable for SeniorCare participants.
69	Please Furnish A CPT/HCPCS Code.
70	Please Furnish A NDC Code And Corresponding Description. (National Drug Code).
71	Claim Denied. Only One Outpatient Claim Per Date Of Service(DOS) Allowed.
72	This Claim Paid At Rate Per Visit.
73	Please Furnish A UB92 Revenue Code And Corresponding Description.
74	Billing Provider is restricted from submitting electronic claims.
75	Please Furnish An ICD-9 Surgical Code And Corresponding Description.
76	Please Supply Modifier Code(s) Corresponding To The Procedure Code Description.
77	Member Successfully Outreached/referred During Current Periodicity Schedule.
78	Claim Indicates Other Insurance/TPL Payment Must Be Received Prior To Filing Claim.
79	Has Manually Split The Dates Of Service To Reflect 2 Fiscal Years/Reimbursement Rates.
80	Diagnosis Code submitted does not indicate medical necessity or is not appropriate for service billed.
81	Amount Paid By Other Insurance Exceeds Amount Allowed By .
82	Prior Authorization Number Changed To Permit Appropriate Claims Processing.
83	Review Of Adjustment/reconsideration Request Shows Original Claim Payment Was Max Allowed For Medical Service/Item/NDC.
84	Provider signature and/or date is required
85	Different Drug Benefit Programs. Prescriptions Or Services Must Be Billed As ASeparate Claim.
86	Claim cannot contain both Condition Codes A5 and X0 on the same claim. PleaseResubmit Charges For Each Condition Code On A Separate Claim.
87	Supply The Place Of Service Code On The Request Form (the Place Of Service Where The Service/procedure Would Be Performed).
88	Claim Number Given On The Adjustment/reconsideration Request Form Does Not Match Services Originally Billed. Please Clarify.
89	Denied. Missing Or Invalid Level Of Effort And/or Reason For Service Code, Professional Service Code, Result Of Service Code Billed In Error.
90	Invalid Provider Type To Claim Type/Electronic Transaction.
91	A valid Referring Provider ID is required.
92	Facility Provider Number Required.
93	First modifier code is invalid for Date Of Service(DOS).
94	Refill Indicator Missing Or Invalid. Please Correct And Resubmit.
95	Dispense as Written indicator is not accepted by .
96	Other Insurance/TPL Indicator On Claim Was Incorrect. Please Correct And Resubmit.
97	Denied. Services Beyond The Six Week Postpartum Period Are Not Covered, Per DHS.
98	Capitation Payment.
99	Please Indicate Computation For Unloaded Mileage.
100	Denied as duplicate claim. Services on this claim were previously partially paid or paid in full.
101	This detail is denied. It is a duplicate of another detail on the same claim.
102	Duplicate Item Of A Claim Being Processed. Please Do Not File A Duplicate Claim.
103	Denied as duplicate claim. Services on this claim were previously partially paid or paid in full.
104	Non-Reimbursable Service. Service Fails To Meet Program Requirements.
105	Claim Denied. Acknowledgement Of Receipt Of Hysterectomy Info Form Is Missing, Incomplete, Or Contains Invalid Information.
106	Invalid Medicare disclaimer submitted.
107	Benefit program funds are exhausted.
108	Denied. The Provider Type/specialty Is Not Recognized For These Date(s) Of Service.
109	Unable To Reach Provider To Correct Claim. Please Correct Claim And Resubmit.
110	Benefit Payment Determined By Fiscal Agent Review.
111	The Clinical Profile/Diagnosis Makes This Member Ineligible For AODA Services.
112	Service code is invalid.
114	Schedule 3, 4 or 5 drugs are limited to the original dispensing plus 5 refillsor 6 months.
115	Unable To Process Your Adjustment Request due to
116	Procedure Code or Drug Code not a benefit on Date Of Service(DOS).
117	A Version Of Software (PES) Was In Error. You Received A PaymentThat Should Have gone To Another Provider. We Are Recouping The Payment. No Action Required on your part.
118	This Claim Is Being Reprocessed As An Adjustment On This R&s Report. Please Check The Adjustment Icn For The Reprocessed Claim.
119	Services Billed On This Claim/adjustment Have Been Split to Facilitate Processing.
120	Consistent With Documented Medical Need, The Number Of Services Requested HaveBeen Reduced.
121	The Service/procedure Proposed Is Not Supported By Submitted Documentation.
122	This Claim Is A Reissue of a Previous Claim.
123	This Is An Adjustment of a Previous Claim.
124	Thank You For The Payment On Your Account. Your 1099 Liability Has Been Credited.
125	A Photocopy Of The PA Request Form Has Been Mailed Separately Identifying the Reimbursement Rate For The Procedure Codes Authorized.
126	The Service Requested Is Not A Covered Benefit As Determined By .
127	These Services Paid In Same Group on a Previous Claim.
128	Service Provided Before Prior Authorization Was Obtained Is Not Allowable.
129	Participant’s Eligibility Not Complete, Please Re-submit Claim At Later Date.
130	Member has Medicare Supplemental coverage for the Date(s) of Service.
131	Partial Payment Withheld Due To Previous Overpayment.
132	Payment Is To Satisfy Amount Owed By .
133	The Admit Type code is invalid.
134	Voided Claim Has Been Credited To Your 1099 Liability.
135	No Substitute Indicator required when billing Innovator National Drug Codes (NDCs).
136	A New Prior Authorization Number Has Been Assigned To This Request In Order ToProcess. Use The New Prior Authorization Number When Submitting Billing Claim.
137	This Claim Paid At Per Diem Rate.
138	Service(s) Do Not Meet Guidelines.
139	Speech Therapy Evaluations Are Limited To 4 Hours Per 6 Months.
140	Claim Denied. Please Refer To Update No. 2004-79 For Instructions.
141	Claim Denied Due To Invalid Occurrence Code(s).
142	Denied. Resubmit the Claim with the Appropriate Modifier for Provider Type andSpecialty.
143	Patient Status Code is incorrect for inpatient claims with fewer than 121 covered days.
144	No Interim Billing Allowed On Or After 01-01-86.
145	NCPDP Format Error Found On Medicare Drug Claim. Please Resubmit.
146	Non-scheduled drugs are limited to the original dispensing plus 11 refills or 12 months.
147	Denied/cutback. Claim Must Indicate A New Spell Of Illness And Date Of Onset.
148	Dispensing replacement parts and complete appliance on same Date Of Service(DOS) not Allowed.
149	Amount Recouped For Duplicate Payment on a Previous Claim.
150	Amount Recouped For Mother Baby Payment (newborn).
151	Medicare Id Number Missing Or Incorrect. Please Correct And Resubmit.
152	Medicare paid amount(s) have been incorrectly applied to both the claim headerand details.
153	The header total billed amount is invalid.
154	Medicare Deductible Amount Was Incorrect Or Not Provided On Crossover Claim. Please Resubmit.
155	This Procedure Code Not Approved For Billing. Please Resubmit using A Approved CPT Or HCPCS Procedure Code.
156	The Medicare Paid Amount is missing or incorrect.
157	Occupational Therapy Limited To 45 Treatment Days Per Spell Of Illness w/o Prior Authorization.
158	Quantity Billed is missing or exceeds the maximum allowed per Date Of Service(DOS).
159	A valid header Medicare Paid Date is required.
160	Medicare Allowed Amount Was Incorrect Or Not Provided On Crossover Claim. Please Resubmit.
161	Assistant Surgery Must Be Billed Separately By The Assistant Surgeon With Modifier 80.
162	Multiple Unloaded Trips for same day, same member, require unique Trip Modifiers. A code with no Trip Modifier billed on same day as a code with Modifier U1 are considered the same trip.
163	Service Denied/cutback. Day Treatment Exceeding 5 Hours/day Not Payable Regardless Of Prior Authorization.
164	Frequency or number of injections exceed program policy guidelines.
165	Two Informational Modifiers Required When Billing This Procedure Code.
166	The Procedure Code billed not payable according to DEFRA.
167	Requested Documentation Has Not Been Submitted.
168	Member Is Eligible For Champus. Please File With Champus Carrier.
169	Admission Denied In Accordance With Pre-admission Review Criteria.
170	Please Resubmit A New Adjustment/reconsideration Request Form And Indicate TheMost Recent Cclaim Number Where Payment Was Made Or Allowed.
171	Claim or Adjustment received beyond 365-day filing deadline.
172	Member is not enrolled for the detail Date(s) of Service.
173	Member Expired Prior To Date Of Service(DOS) On Claim.
174	Dialysis/EPO treatment is limited to 13 or 14 services per calendar month. If it is medical necessary for more than 13 or 14 services per calendar month, submit an adjustment request with supporting documentation.
175	Rendering Provider indicated is not certified as a rendering provider.
176	This Service Is Included In The Hospital Ancillary Reimbursement.
177	A Place of Service code is required.
178	The Service Requested Is Not Medically Necessary.
179	The Medical Need For This Service Is Not Supported By The Submitted Documentation.
180	Denied. Procedure Not Payable As Submitted.
181	The Narrative History Does Not Indicate the Member’s Functioning is Impaired due To AODA Usage.
182	Billing Provider Type and/or Specialty is not allowable for the service billed.
183	Provider Not Authorized To Perform Procedure.
184	Procedure Code is restricted by member age.
185	Procedure Code billed is not appropriate for member’s gender.
186	Vision Exam limited to one per year.
187	Only Four Dates Of Service Are Allowed Per Line Item (detail) For Each Procedure.
188	Ancillary Billing Not Authorized By State.
189	Acute Care General And Specialty Hospitals Are Subject To Pre-admission Requirements Or The Pre-admission Review Number Indicated Is Invalid.
190	This Member Has Received Primary AODA Treatment In The Last Year And Is Therefore Not Eligible For Primary Intensive AODA Treatment At This Time.
191	The Services Requested Are Not Reasonable Or Appropriate For The AODA-affectedmember.
192	Prior Authorization (PA) is required for this service. An approved PA was not found matching the provider, member, and service information on the claim.
193	Charges For Anesthetics Are Included In Charge For All Surgical Procedures.
194	Laboratory Is Not Certified To Perform The Procedure Billed.
195	This Member, As Indicated By Narrative History, Does Not Agree To Abstinence from Alcohol Or Other Drugs And Is Ineligible For AODA Treatment.
196	Individual Audiology Procedures Included In Basic Comprehensive Audiometry.
197	Drug(s) Billed Are Not Refillable. New Prescription Required.
198	Capitation Payment Recouped Due To Member Disenrollment.
199	Procedure Dates Do Not Fall Within Statement Covers Period.
200	Duplicate/second Procedure Deemed Medically Necessary And Payable.
201	Rendering Provider is not certified for the Date(s) of Service.
202	Pharmaceutical care reimbursement for tablet splitting is limited to three permonth, per member.
203	Days supply is invalid.
204	Performing/prescribing Provider’s Certification Has Been Suspended By DHS.
205	Detail Rendering Provider certification is cancelled for the Date Of Service(DOS).
206	HMO Payment Equals Or Exceeds Hospital Rate Per Discharge.
207	Good Faith Claim Denied. Certifying Agency Verified Member Was Not Eligible for Dates Of Services.
208	The Nursing Home Condition Code Is A5.
209	Claim Denied Due To Incorrect Accommodation.
210	Independent Laboratory Provider Number Required.
211	Drugs Prescribed and Filled on the Same Day, Cannot have a Refill Greater thanZero.
212	Procedue Code is allowed once per member per calendar year.
213	The Service(s) Billed Are Considered Paid In The Payment For The Surgical Procedure.
214	PATIENT PAID PORTION USED TOWARDS DEDUCTIBLE.
215	Medicare Copayment Out Of Balance. Please Resubmit.
216	This Is A Manual Increase To Your Accounts Receivable Balance.
217	This Is A Manual Decrease To Your Accounts Receivable Balance.
218	Prior Authorization is required for service(s) exceeding mental health and/or substance abuse benefit guidelines.
219	Reimbursement For Panel Test Only- Individual Tests In Addition To Panel Test Disallowed.
220	Tooth surface is invalid or not indicated.
221	The detail billed amount is required.
222	Claim Currently Being Processed. No Action On Your Part Required.
223	Claim Currently Being Processed. No Action On Your Part Required.
224	Quantity dispensed is invalid.
225	This Member’s Clinical Profile Is Not Within The Diagnostic Limitation For Medical Day Treatment.
226	Well-baby visits are limited to 12 visits in the first year of life.
227	Members Are Limited To 45 Dates Of Service Per Therapy/spell Of Illness without Prior Authorization.
228	Medicare Part B Deducted Charges.
229	The Type of Bill is invalid.
230	Physical Therapy, Occupational Therapy Or Speech Therapy Limited To 90 Min PerDay.
231	Procedure Denied Per DHS Medical Consultant Review.
232	Source of Admit is missing or invalid.
233	The Documentation Submitted Does Not Substantiate Additional Care.
234	Second Rental Of Dme Requires Prior Authorization For Payment.
235	Denied/Cutback. Purchase of additional DME/DMS item exceeding life expectancy rRequires Prior Authorization.
236	Normal delivery reimbursement includes anesthesia services.
237	Annual Physical Exam Limited To Once Per Year By The Same Provider
238	The Clinical Profile And Narrative History Indicate Day Treatment Is Neither Appropriate Nor A Medical Necessity For This Member.
239	Private Duty Nursing Beyond 30 Hrs /Member Calendar Year Requires Prior Authorization.
240	Prescription Number is required.
241	Benefit Payment Determined By DHS Medical Consultant Review.
242	Prescription Date is invalid.
243	The Functional Assessment Indicates This Member Has Less Than A 50% Likelihoodof Benefit, Therefore Day Treatment Is Not Appropriate.
244	Submit copy of the dated and signed evaluation and indicate if this is an initial Evaluation.
245	A SeniorCare drug rebate agreement is not on file for this drug for the Date Of Service(DOS).
246	Please Indicate The Revenue Code/procedure Code/NDC Code For Which The Credit is To Be Applied.
247	Procedure code has been terminated by CMS, AMA or ADA for the Date Of Service(DOS).
248	Complete Refusal Detail Is Not Payable Without Referral/treatment Details.
249	A Second Surgical Opinion Is Required For This Service.
250	Maximum Number Of Outreach Refusals Has Been Reached For This Period.
251	This Is Not A Good Faith Claim. Resubmit Claim Through Regular Claims Processing.
252	Good Faith Claim Denied Because Of Provider Billing Error.
253	Multiple Referral Charges To Same Provider Not Payble.
254	Accommodation Days Missing/invalid. Please Correct And Resubmit.
255	Referral/treatment Procedures Are Not Payable When Billed With A Complete Refusal Detail.
256	The Nursing Home Condition Code Is X0.
257	This Member’s Functional Assessment Scores Place This Member Outside Of Eligibility For Day Treatment.
258	Claim paid according to Medicare’s reimbursement methodology.
259	Denied. This Service Is A Resubmission Of A Service Previously Denied For Prior Authorization.
260	Denied. Services Must Be Submitted On Proper Claim/adjustment/reconsiderationRequest Form.
261	Claim Denied. Only One Panoramic Film Or Intraoral Radiograph Series, By The Same Provider, Per Year Allowed.
262	The Related Surgical Procedure is not a covered service under Wisconsin Medicaid or BadgerCare Plus.
263	Prior Authorization is required for manipulations/adjustments exceeding 20 perspell of illness.
264	Subsequent surgical procedures are reimbursed at reduced rate.
265	Newborn Care Must Be Billed Under Newborn Name And Number; Occurrence Codes 50& 51 Cannotbe Present if Billing Under Newborn Name.
266	Part Time/intermittent Nursing Beyond 20 Hours Per Member Per Calendar Year Requires Prior Authorization.
267	This Member Appears To Continue To Abuse Alcohol And/or Other Drugs And Is Therefore Not Eligible For Day Treatment.
268	Member is enrolled in Medicare Part D for the Dispense Date Of Service(DOS). Prescription Drug Plan (PDP) payment/denial information is required on the claim to SeniorCare.
269	Services Cutback/denied, Charges Greater Than Patient Liability, Not Responsible For Noncovered Services In Excess Of Patient Liability.
270	Any single or combination of restorations on one surface of a tooth shall be considered as a one-surface restoration for reimbursement purposes.
271	Your Adjustment/reconsideration Request For Additional Payment Has Been Denied, Request Was Received Beyond The 90 Day Requirement For Payment Reconsideration.
272	This Member Does Not Appear To Be Suffering From A Chronic Or Acute Mental Illness And Is Therefore Not Eligible For Day Treatment.
273	Resubmit charges for covered service(s) denied by Medicare on a claim.
274	Complex care of 17-plus hours and complex care of less than 17 hours are not allowed on the same Date Of Service(DOS).
275	Adjustment/reconsideration Request Denied Due To Incorrect/insufficient Information. Review Billing Instructions. Use This Claim Number If You Resubmit.
276	The sum of all Value Code amounts must be numeric and less than or equal to 999.999.999.
277	This drug/service is included in the Nursing Facility daily rate.
278	Member is covered by a commercial health insurance on the Date(s) of Service.
279	The Member Information Provided By Medicare Does Not Match The Information On Files.
280	Incorrect Liability Start/end Dates Or Dollar Amounts Must Be Corrected Through County Social Services Agency Before Claim/Adjustment/Reconsideration RequestCan be Processed.
281	Member ID is Required.
282	Inpatient psychiatric services are not reimbursable for members age 21 — 65 (age 22 if receiving services prior to 21st birthday).
283	Adjustment Denied For Insufficient Information. Please Supply NDC Code, Name, Strength & Metric Quantity. Use This Claim Number For Further Transactions.
284	When Billing For Basic Screening Package, Charge Must Be Indicated Under Procedure W7000.
285	Six hour limitation on evaluation/assessment services in a 2 year period has been exceeded. Additional servcies may be billed with H0046 and will count toward mental health and/or substance abuse treatment policy limits for prior authorization.
286	The Service Requested Is Considered To Be Professionally Unacceptable, Unproven and/or Experimental.
287	Member is enrolled in a State-contracted managed care program for the Date(s) of Service.
288	The Revenue/HCPCS Code combination is invalid.
289	Out-of-State non-emergency services require Prior Authorization.
290	Payment Recovered For Claim Previously Processed Under Wrong Member ID Number.
291	All ESRD laboratory tests for a Date Of Service(DOS) must be billed on the same claim.
292	Intensive Rehabilitation Hours Are No Longer Appropriate As Indicated By History, Diagnosis, And/or Functional Assessment Scores.
293	Good Faith Claim Denied. Certifying Agency Did Not Verify Member Eligibility within 70 Day Period.
294	A one year service guarantee for any necessary repair is included in the hearing aid depensing fee.
295	Does not meet hearing aid performance check requirement of 45 post dispensing days.
296	All Outpatient Services/or Accommodations And Ancillaries Are Denied, Therefore The Total Charge Is Denied.
297	Vision Diagnostic Services Limited To 1 Of These: Vision Exam, Diagnostic Review, Supplemental Test Or Contact Lens Therapy.
298	Individual Replacements Reimbursed As Dispensing A Complete Appliance.
299	The Clinical Profile, Narrative History, And Treatment History Indicate The Recipient Is Only Eligible For Maintenance Hours.
300	All Home Health Services Exceeding 8 Hours Per Day Or 40 Or More Hours Per Week Require Prior Authorization.
301	Additional Encounter Service(s) Denied. The Diagnosis Does Not Indicate A Significant Change In the Member’s Condition.
302	The Rehabilitation Potential For This Member Appears To Have Been Reached. The Member Is Only Eligible For Maintenance Hours.
303	The Date Of The Screening Request Or The Date Of Screening Is Invalid Or Missing. Please Correct And Resubmit.
304	This Claim Cannot Be Processed. Please Submit A Separate New Day Claim For Copayment Exempt Days/services.
305	The Member Is Also Involved In A Structured Living And/or Working Arrangement.A Reduction In Day Treatment Hours Is Indicated.
306	Serviced Denied. Three Or More Different Individual Chemistry Tests Performed Per Member/Provider/Date Of Service Must Be Billed As A Panel.
307	Service Denied. An Individual CBC Or Chemistry Test With A CBC Or Chemistry Panel, Performed Per Member/Provider/Date Of Service Must Be Billed w/ Appropriate Panel Code.
308	Claim Submitted To Good Faith Without Proper Documentation. See Provider Handbook For Good Faith Billing Instructions.
309	Consultation or surgical procedures are not reimbursable in conjuctions with Emergency Room services.
310	The Unit Dose Indicator is invalid.
311	Independent RHC’s Must Bill Codes W6251, W6252, W6253, W6254 Or W6255.
312	Claim Paid In Accordance With Family Planning Contraceptive Services Guidelines.
313	Claim Denied. Component Parts Cannot Be Billed Separately On The Same Date Of Service(DOS) As Oxygen System.
314	This Member Has Already Received Intensive Day Treatment In The Past Year and is Only Eligible For Reduced Hours At This Time.
315	A Trading Partner Agreement/profile Form(s) Authorizing Electronic Claims Submission Is Required. Refer To The Wisconsin Website @ dhs.state.wi.us
316	Back-up dialysis sessions are limited to three per lifetime.
317	The Value Code(s) submitted require a revenue and HCPCS Code.
318	Urinalysis And X-rays Are Reimbursed Only When Performed In Conjunction With An Initial Office Visit On Same Date Of Service(DOS).
319	Four X-rays are allowed per spell of illness per provider. Reconsideration With Documentation Warranting More X-rays.
320	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.
321	Oral exams or prophylaxis is limited to once per year unless prior authorized.
322	Service(s) Denied/cutback. The Maximum Prior Authorized Service Limitation Or Frequency Allowance Has Been Exceeded.
323	Psych Evaluation And/or Functional Assessment Ser. Performed After Therapy/dayTreatment Have Begun Must Be Billed As Therapy Or Limit-exceed Psych/aoda/func
324	Has Recouped Payment For Service(s) Per Provider’s Request.
325	Services have been determined by DHCAA to be non-emergency.
326	Services Billed Denied As Being Covered In The Payment For Day Rx Per Medical Day Treatment Guidelines.
327	This Member Is Receiving Concurrent AODA/Psychotherapy Services And Is Therefore Only Eligible For Maintenance Hours.
328	This Member Is Involved In Non-covered Services, And Hours Are Reduced Accordingly.
329	Reduction To Maintenance Hours. The Functional Assessment And/or Progress Status Report Does Not Indicate Any Change, and/or Positive Rehabilitation Potential.
330	Day Treatment Services For Member’s With Inpatient Status Limited To 20 Hours.
331	Prior Authorization Required For Day Treatment Services If Member’s FunctionalAssessment Negative.
332	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.
333	Procedure Code Used Is Not Applicable To Your Provider Type.
334	Inpatient mental health services performed by master’s level psychotherapists or substance abuse counselors are not covered.
335	The Comprehensive Community Support Program reimbursement limitations have been exceeded.
336	Reimbursement limits for Community Care Services for the calendar year are close to being exceeded.
337	Denied. Provider Is Not A Qualified Provider For presumptively Eligible Recipients. A Qualified Provider Application Is Being Mailed To You.
338	Denied. 51.42 Board Director’s Or Designee’s Statement & Signature Required OnThe Claim Form For Payment Of Functional Assessment.
339	The Member’s Past History Indicates Reduced Treatment Hours Are Warranted.
340	HMO Extraordinary Claim Denied. Documentation Does Not Justify Fee For ServiceProcessing .
341	Denied. No Extractions Performed. Edentulous Alveoloplasty Requires Prior Authotization.
342	The Request Does Not Meet Generally Accepted Conditions Requiring Fluoride Treatments.
343	Correction Made Per Medical Consultant Review.
344	Medication checks by a Psychiatrist and/or Registered Nurse are limited to four services per calendar month.
345	Master Level Providers Must Bill Under A Mental Health Clinic Number; Not Under a Private Practice Or Supervisor Number.
346	The Service Requested Was Performed Less Than 3 Years Ago.
347	Description & Use Of Day RX Procedure Codes Based On Member’s Status-not the place Of Service Where Day Rx Service Performed.
348	Dates of Service reflected by the Quantity Billed for dialysis exceeds the Statement Covers Period.
349	The Service Requested Was Performed Less Than 5 Years Ago.
350	Reimbursement is limited to one maximum allowable fee per day per provider.
351	Second And Subsequent Cerebral Evoked Response Tests Paid At A Reduced Rate Per Guidelines.
352	The billing provider number is not on file.
353	The Existing Appliance Has Not Been Worn For Three Years.
354	Non-preferred Drug Is Being Dispensed. Please Refer To The PDL For Preferred Drugs In This Therapeutic Class.
355	Member History Indicates Member Was In Another Facility During This Period.
356	Adjustments To Correct Copayment Deductions On ‘date Ranged’ Claims Are Not Payable.
357	Home Health Services In Excess Of 60 Visits Per Calendar Month Per Member Required Prior Authorization.
358	Summarize Claim To A One Page Billing And Resubmit.
359	Procedure Code Changed To Permit Appropriate Claims Processing.
360	Home Health Services In Excess Of 160 Home Health Visits Per Calendar Year PerMember Require Prior Authorization.
361	Dispensing fee denied. Only two dispensing fees per month, per member are allowed.
362	Services Denied In Accordance With Hearing Aid Policies. Please Refer To Your Hearing Services Provider Handbook.
363	This obstetrical service was previously paid for this Date Of Service(DOS) for thismember.
364	No payment allowed for Incidental Surgical Procedure(s).
365	Claim Denied/Cutback. Purchase Of A DME/DMS Item Exceeding One Per Month Requires Prior Authorization.
366	A valid Prior Authorization is required for non-preferred drugs.
367	The Member Has Been Totally Without Teeth And An Appliance For 5 Years.
368	Comprehensive Screens And Individual Components Are Not Payable On The Same Date Of Service(DOS)
369	This drug is limited to a quantity for 34 days or less.
370	Outpatient Services To Be Billed As Inpatient Ancillaries When Same Day Stay Occurs Please File An Adjustment/reconsideration Request To Correct Inpatiet Billing.
371	HCPCS Procedure Code is required if Condition Code A6 is present.
372	Lab Procedures Billed In Conjunction With Family Planning Pharmacy Visit Denied as not a Benefit.
373	Value Code 48 And 49 Must Have A Zero In The Far Right Position. Please Correct and Resubmit.
374	Participant Is Enrolled In Medicare Part D. Beginning 09/01/06, Providers AreRequired To Bill Part D And Other Payers Prior To Seniorcare Or Seniorcare WillDeny The Claim.
375	Physical Therapy Treatment Limited To One Modality, One Procedure, One Evaluation Or One Combination Per Day.
376	This drug is limited to a quantity for 100 days or less.
377	The Tooth Is Not Essential To Maintain An Adequate Occlusion.
378	Tooth number or letter is not valid with the procedure code for the Date Of Service(DOS).
379	Second Surgical Opinion Guidelines Not Met. See Physician’s Handbook For Details.
380	Denied. The Service Performed Was Not The Same As That Authorized By .
381	Records Indicate This Tooth Has Previously Been Extracted. Correct Claim Or Resubmit With X-ray.
382	Denied. Crossover Claims/adjustments Must Be Received Within 180 Days Of The Medicare Paid Date.
383	Service Denied. Authorization For Surgery Requiring Second Opinion Valid For 6Months After Date Approved.
384	Transplant Procedures Must Be Submitted Under The Appropriate Provider Suffix for Prior Authorization Requests And The Billing Claim To Obtain The Exceptional Rate per Discharge.
385	Denied. Prosthodontic Services Appear To Have Started After Member EligibilityLapsed.
386	Eyeglasses limited to original plus 1 replacement pair, lens or frame in 12 wit hout Prior Authorization.
387	Outside Lab,element 20 On CMS 1500 Claim Form Must Be Checked Yes When Handling Charges Are Billed.
388	A valid procedure code is required.
389	Header From Date Of Service(DOS) is required.
390	Compound Drug Service Denied. At Least One Of The Compounded Drugs Must Be A Covered Drug.
391	Denied. Adjustment To Eyeglasses Not Payable As A Repair Service.
392	The Member Has At Least 4 Posterior Teeth, Including Bicuspids On Each Side, which Can Be Used For Chewing.
393	Member File Indicates Part B Coverage Please Resubmit Indicating Value Code 81and The Part B Payable Charges.
394	Resubmit Professional Component On The Proper Claim Form With The EOMB Attached. Professional Components Are Not Payable On A Ub-92 Claim Form.
395	Denied. Services Not Provided Under Primary Provider Program.
396	Denied. Multiple Tooth Extract On Same Date Of Service(DOS) Must Be Billed As Single And Additional Tooth Extract In Same Quadrant.
397	The Billing Provider On The Claim Must Be The Same As The Billing Provider WhoReceived Prior Authorization For This Service.
398	A valid Prior Authorization is required.
399	Date Of Service Must Fall Between The Prior Authorization Grant Date And Expiration Date.
400	The Performing Or Billing Provider On The Claim Does Not Match The Billing Provider On Theprior Authorization File.
401	Claims For Sterilization Procedures Must Reflect ICD-9 Diagnosis Code V25.2. Please Correct And Resubmit.
402	Claim or adjustment/reconsideration request must have both a Revenue Code and either a HCPCS Code or CPT Code.
403	The Performing Provider Id, Member Id, And Date Of Service(DOS) Must Match The Completion Certificate Received From Ddes.
404	The member has no Level of Care (LOC) authorization on file or the LOC on filedoes not match the LOC on the claim.
405	The Service(s) Requested Could Adequately Be Performed In The Dental Office.
406	Pap Smears, Hematocrit, Urinalysis Are Not Reimbursable Separately In Conjunction With Family Planning Medical Visits.
407	Personal Care Services Exceeding 30 Hours Per 12 Month Period Per Member Require Prior Authorization.
408	The Diagnosis Code is not payable for the member.
409	No Reimbursement Rates on file for the Date(s) of Service.
410	Timely Filing Request Denied. Received Beyond Special Filing Deadline For ThisType Of Claim Or Adjustment/reconsideration.
411	Timely Filing Deadline Exceeded. No Supporting Documentation. Please Refer To The All Provider Handbook For Instructions.
412	Timely Filing Deadline Exceeded. Documentation Does Not Justify Reconsideration For Payment. Please Review All Provider Handbook For Allowable Exception
413	Initial Visit/Exam limited to once per lifetime per provider.
414	Reimbursement of this service is included in the reimbursement of the most complex/complete procedure performed.
415	Payment reduced. All rental payments have been deducted from the purchase costsince the DME item was rented and subsequently purchased for the member.
416	Service Denied, refer to Medicare’s Billing and/or Policy Guidelines.
417	The Service(s) Requested Could Be Adequately Performed With Local Anesthesia In The Dental Office.
418	Good Faith Claim Has Previously Been Denied By Certifying Agency. Resubmit Claim With Copyof A Temporary ID Card, EVS Printed Response Or Indicate The AVR Transaction Log Number.
419	These Urinalysis Procedures Reimbursed Collectively At The Maximum For Routine Urinalysis With Microscopy.
420	Prescription limit of five Opioid analgesics per month. Prescriber must contact the Drug Authorization and Policy Override Center for policy override.
421	Prescription limit of five Opioid analgesics per month. No policy override available for BadgerCare Plus Benchmark Plan, Core Plan or Basic Plan.
422	An antipsychotic drug has recently been dispensed for this member. 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
424	Billing Provider ID is Not on File.
425	Prescriber ID is invalid.e. Please Indicate Separately On Each Detail.
426	Claim Denied. Payment Is Limited To One Unit Dose Service Per Calendar Month, Per Legend Drug, Per Member.
427	Claim Payment Is Based On The Lessor Of The Number Of Certified Days On The PsrO Or 51.42 Board Stamp Or Admitting Calendar Month Days In Specialty Hospital.
428	Do Not Use Informational Code(s) When Submitting Billing Claim(s). Continue ToUse Appropriate Codes On Billing Claim(s).
429	The Procedure Code Indicated Is For Informational Purposes Only.
430	Has Processed This Claim With A Medicare Part D Attestation Form.
431	Speech Therapy Limited To 35 Treatment Days Per Spell Of Illness w/o Prior Authorization.
432	Denied. Service Billed Exceeds Restoration Policy Limitation.
433	Physical Therapy Limited To 35 Treatment Days Per Spell Of Illness W/o Prior Authorization.
434	These Individual Vaccines Must Be Billed Under The Appropriate Combination Injection Code.
435	Occupational Therapy Limited To 35 Treatment Days Per Spell Of Illness W/o Prior Authorization.
436	Annual Nursing Home Member Oral Exam Is Allowed Once Per 355 Days Per Recip Per Prov.
437	Questionable Long-term Prognosis Due To Poor Oral Hygiene.
438	Service Denied. Referring Physician With Credential Other Than Md Is Not Applicable To Type Of Service Provided.
439	Service(s) paid at the maximum daily amount per provider per member.
440	Hearing aid repairs are limited to once per six months, per provider, per hearing aid.
441	Claim Or Adjustment Request Should Include Documents That Best Describe Services Provided (ie Op Report, Admission History and Physical, Progress Notes and Anesthesia Report).
442	Claim Denied Due To Absence Of Prescribing Physician’s Name And/or An Indication Of Wheelchair/Rx on File. Please Correct And Resubmit.
443	Repair services billed in excess of the amount specified in the Durable Medical Equipment (DME) handbook require Prior Authorization.
444	Good Faith Claim Denied For Timely Filing.
445	Good Faith Claim Correctly Denied. Cannot Be Reprocessed Unless There Is Change In Eligibility Status.
446	This service is payable at a frequency of once per 12-month period, per provider, per hearing aid.
447	Hearing Aid Batteries Are Limited To 12 Monaural/24 Binaural Batteries Per 30-day Period, Per Provider, Per Hearing Aid.
448	Questionable Long-term Prognosis Due To Decay History.
449	Questionable Long Term Prognosis Due To Gum And Bone Disease.
450	No Separate Payment For IUD. Reimbursement For HCPCS Procedure Code 58300 Includes IUD Cost.
451	A Previously Submitted Adjustment Request Is Currently In Process. Watch FutureRemittance And Status Reports For Its Finalization Before Resubmitting.
452	Claim Number Given Is Not The Most Recent Number. Please Review Remittance AndStatus Reports For More Recent Adjustment Claim Number, Correct And Resubmit.
453	Claim Denied For No Consent And/or PA. Please Resubmit With The Costs For Sterilization Related Charges Identified As Non-covered Charges On The Claim.
454	Denied. Recasing Or Replacement Of Hearing Aid Case Is Limited To Once Per 2 Year Period Per Member Per Provider.
455	Date(s) Of Service on detail must be within a Sunday thru Saturday calendar week.
456	Questionable Long-term Prognosis Due To Apparent Root Infection.
457	Our Records Indicate The Member Has Been Careless With Dentures Previously Authorized. Will Not Authorize New Dentures Under Such Circumstances.
458	Documentation Provided Indicates A Less Elaborate Procedure Should Be Considered.
459	The Tooth Is Not Essential For Support Of A Partial Denture.
460	Supplemental Payment Authorized By Department of Health Services (DHS) Due to aAudit.
461	Supplement Payment Authorized By Department of Health Services (DHS) Due to a Final Rate Settlement.
462	Supplemental Payment Authorized By Department of Health Services (DHS) Due to an Interim Rate Settlement.
463	Supplemental Payment Authorized By Department of Health Services (DHS) Due to a Department Of Justice Settlement.
464	Department of Health Services (DHS) Authorized Payment Is Being Withheld Due toan Audit.
465	Department of Health Services (DHS) Authorized Payment Is Being Withheld Due toa Final Rate Settlement.
466	Department of Health Services (DHS) Authorized Payment Is Being Withheld Due toan Interim Rate Settlement.
467	Department of Health Services (DHS) Authorized Payment Is Being Withheld Due toa Department Of Justice Settlement.
468	Payment Authorized By Department of Health Services (DHS) To Be Recouped at a Later Date.
469	Claim Is Being Special Handled, No Action On Your Part Required. Please Disregard Additional Informational Messages For This Claim.
470	Claim Is Being Reprocessed, No Action On Your Part Required. Please Do Not Resubmit Your Claim. Please Disregard Additional Messages For This Claim.
471	Claim Is Being Reprocessed Through The System. No Action On Your Part Required. Please Do Not Resubmit Your Claim, And Disregard Additional Informational Messages for this claim.
472	Claim Is Being Reprocessed On Your Behalf, No Action On Your Part Required. Please Disregard Additional Information Messages For This Claim.
473	Claims Cannot Exceed 28 Details. Details Include Revenue/surgical/HCPCS/CPT Codes. Combine Like Details And Resubmit.
474	Services Denied. Once 50 Initial Visits/year Has Been Reached Within Any One Discipline All Home Health Services Require Pa.
475	Speech Therapy Limited To 45 Treatment Days Per Spell Of Illness W/o Prior Authorization.
476	Physical Therapy Limited To 45 Treatment Days Per Spell Of Illness W/o Prior Authorization.
477	Billing Provider indicated is not certified as a billing provider.
478	Claim Reduced Due To Member Income Available Toward Cost Of Care (Nursing Home Liability).
479	Previously Denied Claims Are To Be Resubmitted As New-day Claims. Use The ICN which Is In An Allowed Or Paid Status When Filing An Adjustment/ReconsiderationRequest.
480	Date Of Service/procedure/charges Billed On The Adjustment/reconsideration Request Do Not Match The Original Claim. Please Clarify.
481	Please Furnish A Breakdown Of Your Procedure Code And Charge In Question GivenOn The Adjustment/reconsideration Request. Please Use This Claim Number For Further Transactions.
482	Services Requiring Prior Authorization Cannot Be Submitted For Payment On A Claim In Conjunction With Non Prior Authorized Services. Please Resubmit Corr
483	Review Has Determined No Adjustment Payment Allowed. Original Payment/denial Processed Correctly.
484	Denied/recouped. Covered By An HMO As A Private Insurance Plan. You Must Either Be The Designated Provider Or Have A Referral.
485	Quantity limits exceeded.
486	Please Clarify Services Rendered/provide A Complete Description Of Service.
487	Please Provide A Legible Claim Form.
488	Please Provide One Way Mileage.
489	General Assistance Payments Should Not Be Indicated On Claims. Please Correct And Submit.
490	Medicare RA/EOMB And Claim Dates And/or Charges Do Not Match.
491	To allow for Medicare Pricing correct detail denials and resubmit.
492	Changes/corrections Were Made To Your Claim Per Dental Processing Guidelines.
493	Claim Denied Due To Incorrect Billed Amount. Review Patient Liability/paid Other Insurance, Medicare Paid. Do Not Submit Claims With Zero Or Negative Net Billed,
494	Resubmit Complete And/or Second Page Of Medicares EOMB Showing All Total And Payments.
495	Resubmit With Original Medicare Determination (EOMB) Showing Payment Of Previously Processed Charges.
496	Resubmit The Original Medicare Determination (EOMB) Along With Medicares Reconsideration.
497	Please Submit Charges Minus Credit/discount.
498	Pharmaceutical care code must be billed with a valid Level of Effort.
499	Copayment Should Not Be Deducted From Amount Billed. Correct And Resubmit.
500	Extended Care Is Limited To 20 Hrs Per Day.
501	This Claim Is Being Returned. Please Review The Cover Letter Attached To Your Claim, Any Informational Messages, And Provide The Requested Information BeforeResubmitting the Claim.
502	Rental Only Allowed; Medical Need For Purchase Has Not Been Documented.
503	Purchase Only Allowed; Medical Need For Rental Has Not Been Documented.
504	Medical Necessity For Food Supplements Has Not Been Documented.
505	The Service Requested Is Included In The Nursing Home Rate Structure.
506	The Member Does Not Meet The Criteria For Binaural Amplification; One Hearing Aid Is Authorized.
507	The Hearing Aid Recommended Is Not Necessary; The Member Could Be Adequately Fitted With A Conventional Aid.
508	Member Or Participant Identified As Enrolled In A Medicare Part D PrescriptionDrug Plan (PDP). Please Bill Appropriate PDP.
509	The relationship between the Billed and Allowed Amounts exceeds a variance threshold. Verify billed amount and quantity billed. If correct, special billing instructions apply.
510	A valid Prior Authorization is required.
511	This National Drug Code (NDC) is only payable as part of a compound drug.
512	Please Furnish Length Of Time For Services Rendered.
513	Please Indicate Anesthesia Time For Services Rendered.
514	Recommendation Is Made For Extensive Amplification For A Hearing Loss That CanBe Alleviated With A Regular Fitting.
515	The Salzman Index Score Is Under 30.
516	This Request Does Not Meet The Criteria Of Only Basic, Necessary Orthodontic Treatment.
517	Proposed Orthodontic Service Denied; Examination/study Models Are Approved.
518	Quantity Would Always Be 00010 If Number Of Pounds Not Indicated.
519	Claim Denied for implementation of new Wisconsin Medicaid Interchange System.Resubmission of the claim is required due to new claim submission guidelines.
520	Please Indicate Mileage Traveled. Name And Complete Address Of Destination.
521	The Requested Procedure Is Cosmetic In Nature, Therefore Not Covered By .
522	Gastrointestinal Surgery For The Purpose Of Weight Control Is Covered Only As An Emergency Procedure.
523	The Treatment Request Is Not Consistent With The Member’s Diagnosis.
524	Psychotherapy Provided In The Member’s Home Is Not A Covered Benefit Of .
525	The Information Provided Is Not Consistent With The Intensity Of Services Requested.
526	Intensive Multiple Modality Treatment Is Not Consistent With The Information Provided.
527	Multiple Providers Of Treatment Are Not Indicated For This Member.
528	The Duration Of Treatment Sessions Exceed Current Guidelines.
529	The Total Number Of Sessions Requested Exceeds Quarterly Guidelines.
530	No Functional Regression Has Occurred To Warrant A Spell Of Illness; Submit AsA Prior Authorization Request.
531	Documentation Does Not Demonstrate The Member Has The Potential To Reachieve his/her Previous Skill Level.
532	Ulcerations Of The Skin Do Not Warrant A New Spell Of Illness.
533	Please Clarify The Number Of Allergy Tests Performed.
534	The Member’s Poor Motivation, The Long-standing Nature Of The Disability and aLack Of Progress Substantiate Denial.
535	Other Therapies Currently Provide Sufficient Services To Meet The Member’s Needs.
536	The Skills Of A Therapist Are Not Required To Maintain The Member.
537	Use Of Therapy Equipment Alone Is Not Sufficient To Justify Maintenance Therapy.
538	Endurance Activities Do Not Require The Skills Of A Therapist.
539	The Member Appears To Be At A Maximum Level For Age, Diagnosis, And Living Arrangement.
540	Goals Are Not Realistic To The Member’s Way Of Life Or Home Situation, And Serve No Functional Or Maintenance Service.
541	The Procedure(s) Requested Are Not Medical In Nature.
542	The Member Is Involved In group Physical Therapy Treatment.
543	Please Indicate Quantity Dispensed.
544	The Member Is School-age And Services Must Be Provided In The Public Schools.
545	Member is enrolled in Medicare Part D for the Dispense Date Of Service(DOS). Submitclaim to the appropriate Medicare Part D plan.
546	The Long-standing Nature Of Disability And The Minimal Progress Of The Member SSubstantiate Denial.
547	Restorative Nursing Can Provide Follow-through, Based On Diagnosis Of Long-standing Nature, And The Amount Of Therapy.
548	General Exercise To Promote Overall Fitness And Flexibility Are Non-covered Services.
549	Activities To Promote Diversion Or General Motivation Are Non-covered Services.
550	Modification Of The Request Is Necessitated By The Member’s Minimal Progress.
551	Restorative Nursing Involvement Should Be Increased.
552	The Member’s Demonstrated Response To Current Therapy Does Not Warrant The Intense Freqency Requested.
553	Maintenance Is 2 Times Per Week Or Less.
554	The Information Provided Indicates Regression Of The Member.
555	The Member’s Gait Is Not Functional And Cannot Be Carried Over To Nursing.
556	The Materials/services Requested Are Not Medically Or Visually Necessary.
557	Rimless Mountings Are Not Allowable Through .
558	The service requested is not allowable for the Diagnosis indicated.
559	The Maximum Allowable Was Previously Approved/authorized.
560	The Materials/services Requested Are Principally Cosmetic In Nature.
561	The Lens Formula Does Not Justify Replacement.
562	The Change In The Lens Formula Does Not Warrant Multiple Replacements.
563	Quantity Would Be 00010 If Specific Number Of Batteries Dispensed Is Not Indicated.
564	Lenses Only Are Approved; Please Dispense A Contracted Frame. The Non-contracted Frame Is Not Medically Justified.
565	The Request Has Been Approved To The Maximum Allowable Level.
566	The Clinical Status Of The Member Does Not Meet Standards Accepted By The Department Of Health And Family Services For Transplant.
567	The Requested Transplant Is Not Covered By .
568	Level And/or Intensity Of Requested Service(s) Is Incompatible With Medical Need As Defined In Care Plan.
569	Level, Intensity Or Extent Of Service(s) Requested Has Been Modified Consistent With Medical Need As Defined In The Plan Of Care.
570	The Member’s Profile Indicates This Member Is Possibly Alcoholic And/or Chemically Dependent, And Intensive Aoda Treatment Appears Warranted.
571	This Member Is Involved In Intensive Day Treatment, Which Is To Include Psychotherapy Services.
572	Additional Psychotherapy Is Not Considered Appropriate Or Inline With More Effective, Available Services.
573	Insufficient Documentation To Support The Request.
574	Only One Ventilator Allowed As Per Stated Condition Of The Member.
575	Medical Need For Equipment/supply Requested Is Not Supported By Documentation Submitted.
576	The Medical Need For Some Requested Services Is Not Supported By Documentation.
577	The Member’s Clinical Profile/diagnosis Is Not Within Diagnostic Limitations for Psychotherapy Services.
578	The Type Of Psychotherapy Service Requested For This Member Is Considered To be Professionally Unacceptable, Unproven And/or Experimental.
579	This Member Is Involved In Effective And Appropriate Service Elsewhere, Therefore Is Not Eligible For Further Psychotherapy Services.
580	The Medical Necessity For Psychotherapy Services Has Not Been Documented, ThusMaking This Member Ineligible For The Requested Service.
581	The Performing Provider’s Credentials Do Not Meet Guidelines for The Provision Of Psychotherapy Services.
582	Less Expensive Alternative Services Are Available For This Member.
583	Therapy Prior Authorization Requests Expire At The End Of A Calendar Month.
584	Only One Service/ Per Date Of Service(DOS)/ Per Provider For Diagnostic Testing Services.
585	Family Planning Indicator is invalid.
586	EPSDT/healthcheck Indicator Submitted Is Incorrect.
587	Supplemental tests billed on the same Date Of Service(DOS) as vision examination are not payable.
588	Supervising Nurse Name Or License Number Required. Please Correct And Resubmit.
589	Qty And/or Detail Charge Do Not Divide Out Equally For Dates Of Service and/orQty Given.
590	Personal Care In Excess Of 250 Hrs Per Calendar Year Requires Prior Authorization.
591	Procedure May Not Be Billed With A Quantity Of Less Than One.
592	Assessment limit per calendar year has been exceeded. Additional services mustbe billed as treatment services and count towards the Mental Health and/or substance abuse treatment policy for prior authorization.
593	Service Must Be Billed On Drug Claim Form Utilizing NDC Codes.
594	Billing Provider is not certified for Substance Abuse Day Treatment for the Date(s) of Service.
595	The service was previously paid for this Date Of Service(DOS).
596	Other Insurance Disclaimer Code Submitted Is Inappropriate For Private HMO Or HMP Coverage. You Must Either Be The Designated Provider Or Have A Refer
597	No Private HMO Or HMP On File. Other Insurance Disclaimer Code Used Is Inappropriate For This Member’s Insurance Coverage. Submit Claim To Insurance Carrier.
598	Multiple Unloaded Trips For Same Day/same Recip. Requires A Unique Modifier. ACode With No Modifier Billed On The Same Day As A Code With Modifier 11 Are Viewed as the same trip.
599	Provider Not Eligible For Outlier Payment. Please Resubmit As A Regular Claim If Payment Desired.
600	Contact Member’s Hospice for payment of services related to terminal illness.
601	A Hospital Stay Has Been Paid For DOS Indicated. Hospital And Nursing Home Stays Are Not Payable For The Same DOS Unless The Nursing Home Claim Indicated Hospital Bedhold Days.
602	Reimbursement For IUD Insertion Includes The Office Visit.
603	Language Comprehension And Language Production Are Equivalent To Cognition, Thus Formal Speech Therapy Is Not Needed.
604	Progress, Prognosis And/or Behavior Are Complicating Factors At This Time. Speech Therapy Is Not Warranted.
605	Comprehension And Language Production Are Age-appropriate. Formal Speech Therapy Is Not Needed.
606	Services Are Covered For Medically Needy Members Only When Healthcheck Referral is Indicated On Claim.
607	Medically Needy Claim Denied. Documentation Does Not Justify Medically Needy Override.
608	RN Supervisory Visits Are Reimbursable Three Times Per Calendar Month.
609	Denied. Ancillary Codes Dates Of Service And/or Quantity Billed Do Not Match Level Of Care authorized Dates.
610	No More Than 2 Medication Check Services (30 Minutes) Are Payable Per Date Of Service(DOS).
611	Denied. Only One Federally Required Annual Therapy Evaluation Per Calendar Year, Per Member, Per Provider.
612	Room And Board Is Only Reimbursable If Member Has A BQC Nursing Home Authorization. Contact The Nursing Home.
613	Services Submitted On Improper Claim Form. Rebill Using Correct Claim Form As Instructed In Your Handbook.
614	Member first name does not match Member ID.
615	Modifier Invalid: Modifiers Are No Longer Allowed For Procedure Code Billed.
616	Individual Vaccines And Combination Vaccine Code May Not Be Billed For The Same Dates Of ervice
617	Claim Denied. Please Verify The Units And Dollars Billed. Correct Claim Or Submi Paper Claim Noting That Verification Has Occurred.
618	Repackaging Allowance for this National Drug Code (NDC) is not reimbursable.
619	Claim Denied. Do Not Indicate NS On The Claim When The NDC Billed Is For A Generic Drug.
620	Continuous home care must be billed in an hourly quantity equal to or greater than eight hours, up to and including 24 hours.
621	Hospice Member Services Related To The Terminal Illness Must Be Billed By Hospice Or Attending Physician.
622	Continuous home care and routine home care may not be billed for the same member on the same Date Of Service(DOS).
623	Inpatient Respite Care Is Not Covered For Hospice Members Residing In Nursing Homes.
624	Please Resubmit Your Non-healthcheck Services Using The Appropriate Claim SortIndicator Or Electronic Format.
625	According To Our Records, The Surgeon For This Sterilization Procedure Has NotSubmitted The Member’s Consent Form. Please Contact The Surgeon Prior To Resubmitting this Claim.
626	Denied. Surgical Procedures May Only Be Billed With A Whole Number Quantity.
628	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.
629	Multiple services performed on the same day must be submitted on the same claim. If some of the services were previously paid, submit an adjustment/reconsideration request for the paid claim.
630	A Valid Level Of Effort Is Required For Billing Compound Drugs Or Pharmaceutical Care.
631	The member is locked-in to a pharmacy provider or enrolled in hospice. Contactmember’s hospice for payment of services or resubmit with documentation of unrelated Nature of Care.
632	Independent Nurses, Please Note — Payable Services May Not Exceed 12 Hours/dayOr 60 Hours/week.
633	Clozapine Management is limited to one hour per seven-day time period per provider per member.
634	The Member Has Shown No Significant Functional Progress Toward Meeting Or Maintaining Established & Measurable Treatment Goals Over A 6 Month Period.
635	The Member Has Shown No Ability Within 6 Months To Carry Over Abilities GainedFrom Treatment In A Facility To The Member’s Place Of Residence.
636	Program limits were exceeded.
637	Invalid/obsolete Procedure Code For Determination Of Refraction, Service Denied. Rebill Using Correct Procedure Code.
638	Denied/Cutback. Service(s) exceeds four hour per day prolonged/critical care policy. If it is medically necessary to exceed the limitation, submit an Adjustment/Reconsideration request with supporting documentation.
639	Please Provide Copy Of Medicare Explanation Of Benefits/medicare Remittance Advice Attached To Claim.
640	The maximum number of details is exceeded.
641	Healthcheck Screening Limited To Two Per Year From Birth To Age 3 And One Per Year For Age3 Or Older.
642	Referral Codes Must Be Indicated For W7001, W7002, W7003, W7006, W7008 And W7013.
643	Billing Provider is not certified for the detail From Date Of Service(DOS).
644	Consultant Review Indicates There Is A Specific Procedure Code Assigned For The Service You Are Billing. Please Correct And Resubmit.
645	Research Has Determined That The Member Does Not Qualify For Retroactive Eligibility According To Hfs 106.03(3)(b) Of The Wisconsin Administrative Code.
646	Amount Indicated In Current Processed Line On R&S Report Is The Manual Check You Recently Received. This Check Automatically Increases Your 1099 Earnings.
647	Immunization Questions A And B Are Required For Federal Reporting. Please Complete Information.
648	Claim Not Payable With Multiple Referral Codes For Same Screening Test.
649	Please Indicate Charge And/or Referral Code For Test W7001 When Billing For Test W7006.
650	Please Provide The Type Of Drug Or Method Used To Stop Labor. This Information Is Required For Payment Of Inhibition Of Labor.
651	One RN HH/RN supervisory visit is allowed per Date Of Service(DOS) per provider permember.
652	Supervisory visits for Unskilled Cases allowed once per 60-day period.
653	Insufficient Info On Unlisted Med Proc; Submit Claim Or Attachment With A Complete Description Of The Procedure As Described In History and Physical Exam Report, Med Progress, anesthesia or Op Report.
654	Prior Authorization Is Required For Payment Of This Service With This Modifier. Please Indicate One Prior Authorization Number Per Claim.
655	Cutback/denied. $150.00 Reimbursement Limit Has Been Reached For Individual And Group Pncc Health Education/nutritional Counseling.
656	An ICD-9-CM Diagnosis Code of greater specificity must be used for the First Diagnosis Code.
657	An ICD-9-CM Diagnosis Code of greater specificity must be used for the Second Diagnosis Code.
658	The Quantity Billed for this service must be in whole or half hour increments(.5) Increments.
659	Dental service is limited to once every six months without prior authorization(PA).
660	This Payment Is To Satisfy The Amount Owed For OBRA Nurse Aid Training. PleaseReference Payment Report Mailed Separately.
661	For Correct Liability Reimbursement, Do Not Adjust The Level Of Care Days Claim. You Must Adjust The Nursing Home Coinsurance Claim.
662	Revenue Code Required. Do Not Indicate A Hcpcs Or Cpt Procedure Code On An Inpatient Claim.
663	Another PNCC Has Billed For This Member In The Last Six Months. Concurrent Services Are Not Appropriate.
664	An ICD-9-CM Diagnosis Code of greater specificity must be used for the Third Diagnosis Code.
665	Modifiers are required for reimbursement of these services.
666	A Description Of The Service Or A Photocopy Of The Physician’s Signed And Dated Prescription Is Required In Order To Process.
667	This HMO Capitation Payment Is Being Recouped It Was Inappropriately Paid During The Inital February HMO Capitation Cycle.
668	An ICD-9-CM Diagnosis Code of greater specificity must be used for the Fourth Diagnosis Code.
669	An ICD-9-CM Diagnosis Code of greater specificity must be used for the Fifth Diagnosis Code.
670	Prior Authorization Is Required For Payment Of Hospital Exceptional Claims.
671	Denied/Cuback. Risk Assessment/Care Plan is limited to one per member per pregnancy.
672	External Cause Diagnosis May Not Be The Single Or Primary Diagnosis.
673	This Service Is Not Payable Without A Modifier/referral Code.
674	Adjustment/reconsideration Denied, Provider Signature/date Was Not Provided OnThe Adjustment/reconsideration Request.
675	Summarize Claim To A One Page Billing And Resubmit.
676	Service Denied. Please Itemize Services Including Date And Charges For Each Procedure Performed.
677	Subsequent Aide Visits Limited To 7 Hrs Per Day/per Member/per Provider.
678	Billing Provider Type and Specialty is not allowable for the Rendering Provider.
679	The Surgical Procedure Code of greatest specificity must be used.
680	Billing/performing Provider Indicated On Claim Is Not Allowable. This ProviderMay Only Bill For Coinsurance And Deductible On A Medicare Crossover Claim.
681	RN And LPN Subsequent Care Visits Limited To 6 Hrs Per Day/per Member/per Provider.
682	Please Resubmit Medicare’s Nursing Home Coinsurance Days As A New Claim RatherThan An Adjustment/reconsideration Request.
683	Member enrolled in QMB-Only Benefit plan. Only Medicare Crossover claims are reimbursed for coinsurance, copayment, and deductible.
684	Files Indicate You Are A Medicare Provider And Medicare Benefits May Be Available On This Claim. Please Bill Your Medicare Intermediary Prior To Submitting To .
685	Claim Paid Under DRG Reimbursement, Except For Transplants Billed Using Suffixes 05 Through 09.
686	This Payment Is To Satisfy The Amount Owed For OBRA Level 1. Please Reference Payment Report Mailed Separately.
687	Maximum Reimbursement Amount Has Been Determined By Professional Consultant. Submit Claim To For Reimbursement.
688	HPSA-enhanced reimbursement included.
689	Denied. This Dental Service Limited To Once Every Six Months, Unless Prior Authorized.
690	Bill The Single Appropriate Code That Describes The Total Quantity Of Tests Performed.
691	Denied. Service Allowed Once Per Lifetime, Per Tooth.
692	Our Records Indicate This Tooth Previously Extracted. Resubmit Claim With Corrected Tooth Number/letter Or With X-ray Documenting Tooth Placement.
693	This dental service limited to once per five years.Prior Authorization is needed to exceed this limit.
694	Denied. Primary Tooth Restorations Limited To Once Per Year Unless Claim Narrative Documents Medical Necessity.
695	Denied. This Dental Service Limited To Once A Year.
696	Denied. Outside Lab Indicator Must Be Y For The Procedure Code Billed.
697	The number of tooth surfaces indicated is insufficient for the procedure code billed.
698	Member is not enrolled in /BadgerCare Plus for the Date(s) of Service.
699	According To Our Records, The Hospital Has Not Received Prior Authorization For This Surgery. Please Contact The Hospital Prior Resubmitting This Claim.
700	Diagnosis Treatment Indicator is invalid.
701	Service Denied. Diagnosis V25.2 May Only Be Used When Billing For Sterilization Procedures. Please Correct And Resubmit.
702	Member has commercial dental insurance for the Date(s) of Service.
703	Date Of Service/procedure/charges On Medicare EOMB Do Not Match The Original Claim. Please Clarify.
704	Claim Denied The Combined Medicare And Private Insurance Payments Equal Or Exceed The Lesser Of The And Medicare Allowable Amounts.
705	Healthcheck screenings or outreach is limited to six per year for members up to one year of age.
706	Healthcheck screenings or outreach limited to three per year for members between the age of one and two years.
707	Healthcheck screenings or outreach limited to two per year for members betweenthe ages of two and three years.
708	HealthCheck screenings/outreach limited to one per year for members age 3 or older.
709	One Visit Allowed Per Day, Service Denied As Duplicate.
710	Members Age 3 And Older Must Have An Oral Assessment And Blood Pressure Check.With Appropriate Referral Codes, For Payment Of A Screening.
711	All The Teeth Do Not Meet Generally Accepted Criteria Requiring Periodontal Sealing And Root Planning.
712	All The Teeth Do Not Meet Generally Accepted Criteria Requiring Gingivectomy.
713	Dental X-rays Indicate A Dental Cleaning, Followed By Good Dental Care At Home, Would Be Sufficient To Maintain Healthy Gums.
714	Backdating Allowed Only In Cases Of Retroactive Member/provider Eligibility.
715	The Request May Only Be Back-dated Two Weeks Prior To Receipt By EDS.
716	The Value Code and/or value code amount is missing, invalid or incorrect.
717	Billing Provider Name Does Not Match The Billing Provider Number.
718	Referring Provider ID is invalid. Referring Provider ID is not required for this service.
719	Admission Date does not match the Header From Date Of Service(DOS).
720	Billing Provider is not certified for the Date(s) of Service.
721	More Than 5 Consecutive Calendar Days Of Continuous Care Are Not Payable.
722	Members Aged 3 Through 21 Years Old Are Limited To One Healthcheck Screening per 12 months.
723	A Procedure Code without a modifier billed on the same day as a Procedure Codewith modifier 11 are viewed as the same trip.
724	Disposable medical supplies are payable only once per trip, per member, per provider.
725	Medicare Part A Or B Charges Are Missing Or Incorrect.
726	Non-covered Charges Are Missing Or Incorrect.
727	Payment Subject To Pharmacy Consultant Review.
728	Bilateral Surgeries Reimbursed At 150% Of The Unilateral Rate.
729	Dental service is limited to once every six months. This limitation may only exceeded for x-rays when an emergency is indicated.
730	Only the initial base rate is payable when waiting time is billed in conjunction with a round trip.
731	Payment Reduced In Accordance With Guidelines For Ambulatory Surgical Procedures Performed In Place Of Service 21.
732	51.42 Board Stamp Required On All Outpatient Specialty Hospital Claims For Dates Of Service On Or After January 1, 1986.
733	Day Treatment exceeding 120 hours per month is not payable regardless of PriorAuthorzation
734	Services Not Payable When Rendered To An Individual Aged 21-64 Who Is A Resident Of A Nursing Home Imd.
735	The DHS Has Determined This Surgical Procedure Is Not A Bilateral Procedure. Reimbursement Is At The Unilateral Rate.
736	Payment Reduced Due To Patient Liability. Incorrect Liability Start/end DatesOr Dollar Amounts Must Be Corrected Through County Social Services Agency.
737	Paid In Accordance With Dental Policy Guide Determined By DHS.
738	Service Denied A Physician Statement (including Physical Condition/diagnosis) Must Be Affixed To Claims For Abortion Services Refer To Physician Handbook.
739	Nursing Home Visits Limited To One Per Calendar Month Per Provider.
740	Anesthesia Modifying Services Must Be Billed Separately From The Charge For Anesthesia Base And Time Units.
741	Procedure Code 59420 Must Be Used For 5 Or More Prenatal Visits With One Charge. Dates Of Service Must Be Itemized.
742	TPA Certification Required For Reimbursement For This Procedure
743	This Adjustment Was Initiated By . It Corrects A Mispayment FoundDuring Claims Processing Or Resulting From Retroactive File Changes.
744	Multiple Carry Procedure Codes Are Not Payable When Billed With Modifiers.
745	Reimbursement for mycotic procedures is limited to six Dates of Service per calendar year.
746	Routine foot care is limited to no more than once every 61days per member.
747	Routine Foot Care Procedures Must Be Billed With Valid Routine Foot Care Diagnosis.
748	Diagnosis Indicated Is Not Allowable For Procedures Designated As Mycotic Procedures.
749	Routine foot care Diagnoses must be billed with valid routine foot care Procedure Codes.
750	Nine Digit DEA Number Is Missing Or Incorrect.
751	Denied. No Substitution Indicator Invalid For Non-innovator Drugs Not On The Current Wisconsin MAC List.
752	The Total Number Of Hours Per Day Requested For AODA Day Treatment Exceeds Guidelines And The Request Has Been Adjusted Accordingly.
753	This Request Can Only Be Backdated To The Date EDS First Receives The Request In The Mailroom.
754	An Approved AODA Day Treatment Program Cannot Exceed A 6 Week Period.
755	Adequate Justification For Starting Member In AODA Day Treatment Prior To Authorization being Obtained Has Not Been Provided. The Request Has Been Back datedto Date of Receipt.
756	The Request Can Only Be Backdated Up To 5 Working Days Prior To The Date Eds Receives The Request In Eds’ Mailroom If Adequate Justification Is Provided.
757	This Member Has A Current Approved Authorization For Intensive AODA OutpatientServices.
758	The Members Reported Diagnosis Is Not Considered Appropriate For AODA Day Treatment.
759	Our Records Indicate This Provider Is Not Certified For AODA Day Treatment.
760	There Is Evidence That The Member Is Not Detoxified From Alcohol And/or Other Drugs and is Therefore Not Currently Eligible For AODA Day Treatment.
761	The Member Does Not Appear To Be Able Or Willing To Abstain From Alcohol/drug Usage While in Treatment And Is Therefore Not Eligible For AODA Day Treatment.
762	The Information Provided Indicates This Member Is Not Willing Or Able To Participate Inaftercare/continuing Care Services And Is Therefore Not Eligible For AODA Day Treatment.
763	The Member Does Not Appear To Meet The Severity Of Illness Indicators Established by the Wisconsin And Is Therefore Not Eligible For AODA Day Treatment.
764	This Member Has Completed Intensive AODA Treatment Within The Past 12 Months and Documentation Provided Is Not Adequate To Justify Intensive Treatment at this time.
765	This Program Does Not Appear To Meet The Minimum Requirement For AODA Day Treatment Programming (10hrs) And Does Not Qualify For Aoda Day Treatment.
766	AODA Day Treatment Is Not A Covered Service For Members Who Are Residents Of Nursing Homes or Who Are Hospital Inpatients.
767	Time Spent In AODA Day Treatment By Affected Family Members Is Not Covered.
768	HMO Capitation Claim Greater Than 120 Days.
769	Only One Interperiodic Screen Is Allowed Per Day, Per Member, Per Provider.
770	The Revenue Code is not allowed for the Type of Bill indicated on the claim.
771	Member has Medicare Managed Care for the Date(s) of Service.
772	Occurrence Codes 50 And 51 Are Invalid When Billed Together.
773	Occurrence Date is missing or invalid
774	Services Included In The Inpatient Hospital Rate Are Not Separately Reimbursable.
775	Service Denied. Modifier Submitted Is Invalid For The Member Age.
776	The provider is not listed as the member’s provider or is not listed for thesedates of service.
777	This Payment Is A Refund For An Overpayment Of A Provider Assessment
778	Thank You For Your Assessment Payment By Check
779	In Accordance With Your Request, EDS Has Deducted Your Assessment From This Payment
780	This Represents Your Incentive Payment
781	Thank You For Your Assessment Interest Payment.
782	This Payment Is To Satisfy Amount Owed For A Drug Rebate Prior Quarter Correction.
783	Service Denied. Only One Panel Code Within Same Category (CBC Or Chemistry) Maybe Performed Per Member/Provider/Date Of Service.
784	Denied/Cutback. Only one initial visit of each discipline (Nursing) is allowedper day per member.
785	A Less Than 6 Week Healing Period Has Been Specified For This PA. Therefore itIs Not Necessary To Wait The Full 6 Weeks After Extractions Before Taking Denture Impressions.
786	Denied. Permanent Tooth Restoration/sealant, Limited To Once Every 3 Years Unless Narrative Documents Medical Necessity.
787	Denied. Intraoral Complete Series/comprehensive Oral Exam Limited To Once Every Three Years, Unless Prior Authorized.
788	Denied. Single Bitewing X-rays Limited To Once Per Day And No More Than Two InA Six Month Period.
789	Dental service limited to twice in a six month period.
790	Service Denied. This Procedure, When Billed With Modifier HK, Is Payable Only If The Member Is Under The Age Of 19.
791	Denied. This Procedure Is Denied Per Medical Consultant Review.
792	Denied. Procedure Code Modifier(s) Invalid For Date Of Service(DOS) Or For Prior Authorization Date Of Receipt.
793	Denied. Provider Must Have A CLIA Number To Bill Laboratory Procedures.
794	Procedure not allowed for the CLIA Certification Type.
795	Complex Evaluation and Management procedures require history and physical or medical progress report to be submitted with the claim.
796	Handwritten Changes/corrections On The Medicare EOMB Are Not Acceptable. Please Request A Corrected EOMB Through The Medicare Carrier And Adjust With The Corrected EOMB.
797	This Procedure Code Requires A Modifier In Order To Process Your Request.
798	The Second Modifier For The Procedure Code Requested Is Invalid.
799	Reimbursement Denied For More Than One Dispensing Fee Per Twelve Month Period,fitting Of Spectacles/lenses With Changed Prescription.
800	Payment(s) For Capital Or Medical Education Are Generated By EDS And May Not Be Billed By The Provider.
801	One or more Diagnosis Codes are not applicable to the member’s gender.
802	Discharge Diagnosis 2 Is Not Applicable To Member’s Sex.
803	Discharge Diagnosis 3 Is Not Applicable To Member’s Sex.
804	Discharge Diagnosis 4 Is Not Applicable To Member’s Sex.
805	Discharge Diagnosis 5 Is Not Applicable To Member’s Sex.
806	Etiology Diagnosis Code(s) (E-Codes) are invalid as the Admitting/Principal Diagnosis 1.
807	Diagnosis Code indicated is not valid as a primary diagnosis. Correct And Resubmit.
808	Secondary Diagnosis Code(s) in positions 2-9 cannot duplicate the Primary Discharge Diagnosis.
809	This claim must contain at least one specified Surgical Procedure Code. A claim cannot contain only Not Otherwise Specified (NOS) Surgical Procedure Codes.
810	A covered DRG cannot be assigned to the claim. The information on the claim isinvalid or not specific enough to assign a DRG.
811	Relative Weight Not On File.
812	Denied/Cutback. Reimbursement limit for all adjunctive emergency services is exceeded.
813	Claim reimbursement has been cutback to reimbursement limits for denture repairs performed within 6 months. If laboratory costs exceed reimbursement, submit a claim adjustment request with lab bills for reconsideration.
814	Service not covered as determined by a medical consultant
815	Denied/Cutback. Home Health visits (Nursing and therapy) in excess of 30 visits per calendar year per member require Prior Authorization.
816	Denied/Cutback. Therapy visits in excess of one per day per discipline per member are not reimbursable.
817	Charges For Additional Days Of Stay Or Final Payment Must Be Submitted As An Adjustment.
818	Six Week Healing Time Is Required Between Endentulation And Final Impressions.Payment For Dentures Will Be Denied Or Recouped If Healing Period Is Not Observed.
819	Denied/Cutback. Limited to once per quadrant per day.
820	CRNA’s, AA’s, And Anesthesiologists Supervising CRNA’s/AA’s Must Bill AnesthesiA Services Using The Appropriate Modifier. Refer To Provider Handbook.
821	Assessment Is Not A Covered Service Unless All Four Components Of Skilled Nursing Are Present: Assessment, Planning, Intervention And Evaluation.
822	Documentation Indicates That Client Is Able To Direct Cares And Can Safely Direct A PCW.
823	Documentation Indicates No Medically Oriented Tasks Are Being Done, Therefore A PCW Is Being Authorized.
824	Procedure Code is not covered for members with a Nursing Home Authorization onthe Date(s) of Service.
825	Case Plan and/or assessment reimbursment is limited to one per calendar year.Calendar Year.
826	Service is reimbursable only once per calendar month.
827	As A Reminder, This Procedure Requires SSOP. If You Have Already Obtained SSOP, Please Disregard This Message.
828	Claim Denied. Level Of Care/accommodation Code Billed Is Not Applicable To Your Provider Specialty. Please Contact Your District Nurse To Have This Corrected.
829	Timely Filing Deadline Exceeded. Please Submit With Completed timely Filing Form In The All Provider Handbook And Supporting Documentation.
830	Timely Filing Deadline Exceeded. Claim/adjustment Received Beyond The 455 Day Resubmission Deadline.
831	Timely Filing Deadline Exceeded. Rec’d Beyond 90 Days Special Filing Deadline FOr System Generated Adjmts/Medicare X-overs/Other Insurance Reconsideration/Cou rt Order/Fair Hearing
832	Orthosis additions is limited to two per Orthosis within the two year life expectancy of the item without Prior Authorization.
833	Rn Visit Every Other Week Is Sufficient For Med Set-up.
834	Critical care performed in air ambulance requires medical necessity documentation with the claim. Critical care in non-air ambulance is not covered.
835	This Member Has Prior Authorization For Therapy Services. Once Therapy Is Prior Authorized, All Therapy Must Be Billed With A Valid Prior Authorization Number.
836	For Revenue Code 0820, 0821, 0825 or 0829, HCPCS Code 90999 or Modifier G1-G6 must be present.
837	Individual Test Paid. Panel And Individual Test Not Payable For Same Member/Provider/ Date Of Service(DOS). Previously Paid Individual Test May Be Adjusted Under a Panel Code.
838	Ongoing assessment is not reimbursable when skilled nursing visits have been performed within the past sixty days.
839	Home care ongoing assessments are allowed once every sixty days per member.nt, But Arepayable Every Fifty-fourth Day For Flexibility In Scheduling.
840	Denied. Bilateral Procedures Must Be Billed On One Detail With Modifier 50, Quantity Of 1.detail With Modifier 50 May Be Adjusted If Necessary.
841	The timely filing deadline was exceeded.
842	Denied. Member Is Enrolled In A Family Care CMO.
843	All three DUR fields must indicate a valid value for prospective DUR. A valid Level of Effort is also required for pharmacuetical care reimbursement.
844	Personal care subsequent and/or follow up visits limited to seven per Date Of Service(DOS) per member.
845	Service(s) Denied. SMV Or Prescribing Provider Description Code(s) Missing OrInvalid.
846	Denied. This Procedure Code Is Not Valid In The Pharmacy Pos System. Please Submit On The Cms 1500 Using The Correct Hcpcs Code.
847	Pharmacy Clm Submitted Exceeds The Number Of Clms Allowed Per Cal. Wk. (part JHandbook).
848	Medicare Coinsurance Amount Was Not Provided On Crossover Claim. Please Add The Coinsurance Amount And Resubmit.
849	We Have Determined There Were (are) Several Home Health Agencies Willing To Provide Medically Necessary Skilled Nursing Services To This Member.
850	Claim Detail ‘from’ Date Of Service(DOS) And ‘to’ Date Of Service(DOS) Are Required And Must Be Within The Same Calendar Month.
851	Principal Diagnosis 6 Not Applicable To Member’s Sex.
852	This National Drug Code (NDC) requires a whole number for the Quantity Billed.
853	Dispense Date Of Service(DOS) is required.
854	Principal Diagnosis 7 Not Applicable To Member’s Sex.
855	Principal Diagnosis 8 Not Applicable To Member’s Sex.
856	Principal Diagnosis 9 Not Applicable To Member’s Sex.
857	Denied. Resubmit Private Duty Nursing Services For Complex Children With Documentation Supporting The Level Of Care.
858	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.
859	Modifiers submitted are invalid for the Date Of Service(DOS) or are missing..
860	An ICD-9-CM Diagnosis Code of greater specificity must be used for the Sixth Diagnosis Code.
861	An ICD-9-CM Diagnosis Code of greater specificity must be used for the SeventhDiagnosis Code.
862	An ICD-9-CM Diagnosis Code of greater specificity must be used for the Eighth Diagnosis Code.
863	An ICD-9-CM Diagnosis Code of greater specificity must be used for the Ninth Diagnosis Code.
864	Documentation You Have Submitted Does Not Meet The Requirements Of HSS 107.09(4)(k).
865	This Service Is Covered Only In Emergency Situations. Refer To Dental HandbookOn Billing Emergency Procedures.
866	Value Codes 81 And 83, Are Valid Only When Submitted On An Inpatient Claim.
867	Denied. This Procedure Is Limited To Once Per Day. Please Review The Covered Services Appendices Of The Dental Handbook.
868	Denied. Election Form Is Not On File For This Member. Resubmit Claim Once Election Form Requirements Are Met Per The Hospice Provider Handbook.
869	Denied. Homecare Services W/o PA Are Not Payable When Prior Authorized Homecare Services have Been Provided To The Same Member.
870	Denied/cutback. Complex Care Services Are Limited To One Per Date Of Service(DOS) Per Member.
871	Denied. PNCC Risk Assessment Not Payable Without Assessment Score.
872	This Payment Is To Satisfy Amount Owed For OBRA (PASARR) Level II Screening.
873	The Medical Necessity For The Hours Requested Is Not Supported By The Information Submitted In The Personal Care Assessment Tool.
874	The Documentation Submitted Indicates The Tasks Specified Can Be Completed During The Visits Approved.
875	Recouped. Homecare Services W/o PA Are Not Payable When Prior Authorized HomecAre Services Have Been Provided To The Same Member.
876	Child Care Coordination services are reimbursable only if both the member and provider are located in Milwaukee County.
877	The Quantity Allowed Was Reduced To A Multiple Of The Product’s Package Size
878	The Documentation Submitted Does Not Indicate Medically Oriented Tasks Are Medically Necessary, Therefore Personal Care Services Have Been Approved.
879	DX Of Aphakia Is Required For Payment Of This Service
880	Dates Of Service For Purchased Items Cannot Be Ranged. Only One Date For EachService Must Be Used.
881	ICD-9-CM Diagnosis Code 6 Is Invalid
882	ICD-9-CM Diagnosis 7 Is Invalid
883	ICD-9-CM Diagnosis 8 Is Invalid
884	ICD-9-CM Diagnosis Code 9 Is Invalid
885	The Use Of This Drug For The Intended Purpose Is Not Covered By ,Consistent With Wisconsin Administrative Code Hfs 107.10(4) And 1396r-8(d)
886	Denied. The Service Billed Does Not Match The Prior Authorized Service.
887	Default Prescribing Physician Number XX5555555 Was Indicated. Valid Numbers Are Important For DUR Purposes. Please Obtain A Valid Number For Future Use.
888	Default Prescribing Physician Number XX9999991 Was Indicated. Valid Numbers Are Important For DUR Purposes. Please Verify That Physician Has No DEA Number.
889	Prescriber Number Supplied Is Not On Current Provider File. Valid Numbers AreImportant For DUR Purposes. Please Ask Prescriber To Update DEA Number On TheProvider File.
890	Claim Corrected. Revenue Code 0001 Can Only Be Indicated Once.
891	Claim Corrected. A Total Charge Was Added To Your Claim.
892	Payment Reflects Allowed Services In Accordance With Pre And Post Operative Guidelines.
893	Service Denied. Please Select A Procedure Code In The 58980-58988 Range That Best Describe’s The Procedure Being Performed.
894	Rendering Provider may not submit claims for reimbursement as both the Surgeonand Assistant Surgeon For The Same Member On The Same DOS.
895	Two different providers cannot be reimbursed for the same procedure for the same member on the same Date Of Service(DOS).
896	Active Treatment Dose Is Only Approved Once In Six Month Period.
898	Claims With Dollar Amounts Greater Than 9 Digits.
899	Service Denied. Case Planning And/or On-going Monitoring For Both Targeted Case Managementand Child Care Coordination Are Not Allowed In The Same Month.
900	Due To Non-covered Services Billed, The Claim Does Not Meet The Outlier Trim Point.
901	The From Date Of Service(DOS) and To Date Of Service(DOS) must be in the same calendar month and year.
902	You Must Bill Medicare, ESRD Patient.
903	The Member Has Received A 93 Day Supply Within The Past Twelve Months.
904	Other Insurance Or Medicare Response Not Received Within 120 Days For ProviderBased Bill.
905	Per Provider, Second Opinion Obtained
906	This Adjustment/reconsideration Request Was Initiated By . It Corrects Claim Information Found During Research Of An OBRA Drug Rebate Dispute.
907	Our Records Indicate You Have Billed More Than One Unit Dose Dispensing Fee For This Calendar Month. Reimbursement For This Detail Does Not Include Unit DoseDispensing Fee.
908	This Payment Is To Satisfy The Amount Indicated On The Administrative Claiming Reimbursement Summary Report. This Report Was Mailed To You Separately.
909	Denied. Effective With Claims Received On And After 10/01/03 , Occurrence Codes 50 And 51 Are Invalid. Please Resubmit Using Newborns Name And Number.
910	Payment Recouped. Medicare Claim Copy And EOMB Have Been Submitte d For Processing Of Coinsurance And Deductible. No Action Required.
911	Service(s) Denied By DHS Transportation Consultant. Prescribing Provider UPIN Or Provider Number Missing From Claim And Attachment.
912	Denied. PDN Codes W9045/w9046 Are Not Payable On The Same Date As PDN Codes W9030/W9031 For The Same Provider And Member.
913	Service Denied. Prescribing Provider UPIN Or Provider Number Missing.
914	Service Not Covered For Members Medical Status Code.
915	Denied. Revenue Codes 0110 (N6) And 0946 (N7) Are Not Payable When Billed On The Same Dateof Service As Bedhold Days.
916	Pharmaceutical Care Codes Are Billable On Non-compound Drug Claims Only.
917	Denied. Care Does Not Meet Criteria For Complex Case Reimbursement. Resubmit Using Valid Rn/lpn Procedure Codes And A Valid PA Number.
918	Medicare Disclaimer Code invalid. Member is not Medicare enrolled and/or provider is not Medicare certified.
919	Billing Provider does not have required Certification Addendum on file.
920	Other Coverage Code is missing or invalid.
921	Service(s) Approved By DHS Transportation Consultant.
922	Duplicate ingredient billed on same compound claim.
923	Reimbursement for this procedure and a related procedure is limited to once per Date Of Service(DOS).
924	Request Denied. The Medical Records Submitted With The Current Request Conflict Or Disagree With Our Medical Records On This Member.
925	This procedure is limited to once per day.
926	Denied. Preventive Medicine Code Billed Is Allowed For Health Check Agencies Only With The Appropriate Healthcheck Modifier.
927	Claim Denied. Total Rental Payments For This Item Have Exceeded The Maximum Allowable Forthe Purchase Of This Item.
928	A six week healing period is required after last extraction, prior to obtaining impressions for denture.
929	Denied. Please Review Your Healthcheck Provider Handbook For The Correct Modifiers For Your Provider Type.
930	Reimbursement Based On Members County Of Residence
931	Condition Code is missing/invalid or incorrect for the Revenue Code submitted.
932	Only Healthcheck Modifiers Can Be Billed With Healthcheck Services.
933	Service is covered only during the first month of enrollment in the Home and Community Based Waiver.
934	Denied. Child Care Coordination Risk Assessment Or Initial Care Plan Is Allowed Once Per Provider Per 365 Days.
935	Invalid Billing Of Procedure Code.
936	Approved. To Continue Treatment With Two Anti-ulcer Drugs Beyond Authorized Limit Please Submit Request On Paper With Clinical Documentation Clearly Indicating medical necessity.
937	This claim is being denied because it is an exact duplicate of claim submitted.
938	Treatment With More Than One Drug Per Class Of Ulcer Treatment Drug At The Same Time Is Not Allowed Through Stat PA.
939	Denied. Units Billed Are Inconsistent With The Billed Amount. Please Correct And Re-bill.
940	DME rental is limited to 90 days without Prior Authorization.
941	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.
942	this Procedure Code Is Denied As Mutually Exclusive To Another Code Billed On This Claim.
943	This Procedure Code Is Denied As Incidental/Integral To Another Procedure CodeBilled On This Claim.
944	Quantity Billed is not equally divisible by the number of Dates of Service on the detail.
945	Services on this claim have been split to facilitate processing.on On Your Part Is Required.
946	This Unbundled Procedure Code Remains Denied. Please Refer To The Original R&S.
947	This Mutually Exclusive Procedure Code Remains Denied. Please Refer To The Original R&S.
948	This Incidental/integral Procedure Code Remains Denied. Please Refer To The Original R&S.
949	Claimcheck’s Editing And Your Supporting Documentation Was Reviewed By The DHS Medical Consultant. Reimbursement For This Service Has Been Approved.
950	Denied. Do Not Bill Intraoral Complete Series Components Separately. Send An Adjustment/reconsideration Request On The Previously Paid X-ray Claim For This
951	Services Can Only Be Authorized Through One Year From The Prescription Date.
952	Claimcheck’s Editing And Your Supporting Documentation Was Reviewed By The DHS Medical Consultant. Additional Reimbursement Is Denied.
953	Billing Provider Received Payment From Both Medicare And For Clai m. An Adjustment/reconsideration Request Has Been Made To The Billing Providers Account.
954	Denied. Dispensing Two Lens Replacements On Same Date Of Service(DOS) Not Allowed.
955	Per Information From Insurer, Claims(s) Was (were) Paid.
956	Per Information From Insurer, Claim(s) Was (were) Not Submitted.
957	Other Payer Coverage Type is missing or invalid.
958	Denied. Please Re-submit This Claim With The Insurance EOB Showing A Denial OrPartial Payment.
959	Denied. The Insurance EOB Does Not Correspond To The Dates Of Service/servicesBeing Billed.
960	Denied. These Supplies/items Are Included In The Purchase Of The Dme Item Billed On The Same Date Of Service(DOS).
961	Speech therapy limited to 35 treatment days per lifetime without prior authorization.
962	Member does not have commercial insurance for the Date(s) of Service.
963	Physical therapy limited to 35 treatment days per lifetime without prior authorization.
964	Denied. Medicare Disclaimer Code Used Inappropriately.
965	Occupational therapy limited to 35 treatment days per lifetime without prior authorization.
966	Home Health, Personal Care And Private Duty Nursing Services Are Subject To A Monthly Cap. Services In Excess Of This Cap Are Not Reimbursable for this Member.
967	This Claim Has Been Excluded From Home Care Cap To Allow For Acute Episode. Provider Is Responsible For Averaging Costs During Cal Year Not To Exceed YrlyTotal (12 x $2325.00).
968	Denied. Services For Members With Medical Status Code TR, SH, SJ, TS Or ST NotAllowed For Your Provider Type, Or For Your Provider Type without a TB Diagnosis.
969	Member enrolled in Tuberculosis-Related Services Only Benefit Plan. Services not allowed for your Provider Type or for your Provider Type without a TB diagnosis.
970	More than 50 hours of personal care services per calendar year require prior authorization.
971	Denied. Exceeds The 35 Treatment Days Per Spell Of Illness. Please Request Prior Authorization For Additional Days.
972	Denture Repair And/or Recement Bridge Must Be Submitted On A Paper Claim With ADescription Of Service And Documentation Of A Healthcheck Screen Attached.
973	Per Information From Insurer, Requested Information Was Not Supplied By The Provider.
974	Denied. Providers May Only Bill For Assessments And Care Plans Twice Per Calendar Year.
975	Per Information From Insurer, Prior Authorization Was Not Requested/approved Prior To Providing Services.
976	Resubmit On Paper For Special Handling.
977	Claim Or Adjustment/reconsideration Request Should Include An Operative Or Pathology Report For This Procedure.
978	Abortion Dx Code Inappropriate To This Procedure
979	Pharmaceutical Care Code must be billed with a payable drug detail or if a prescription was not filled, the quantity dispensed must be zero.
980	Service Denied. Invalid Procedure Code For Dx Indicated.
981	Service Denied. Resubmit With All Appropriate Diagnoses Or Use Correct HCPCS Code.
982	Reimbursement Is Limited To The Average Monthly Nursing Home Cost And Services Above That Amount Are Considered Non-covered Services.
983	Rqst For An Acute Episode Is Denied. Services Requested Do Not Meet The Criteria for an Acute Episode. Reimb Is Limited to the Average Monthly NH Cost and Services Above that Amount Are Considered non-Covered Services.
984	Rqst For An Exempt Denied. Recip Does Not Meet The Reqs For An Exempt. Reimb Is Limited To The Average Montly NH Cost And Services Above that Amount Are Considered non-Covered Services.
985	Rqst For An Acute Episode Is Denied. Member Has Already Been Granted Actute Episode for 3 Months In This Cal Yr. Reimb Is Limited To Average Monthy NH Cost And Services Above That Are Consider Non-covered Services.
986	Req For Acute Episode Is Denied. The Services Requested Do Not Meet Criteria For An Acute Episode. Reimburse Is Limited To Average Monthly NHCost And Services Above That Amount Are Consider non-Covered Services.
987	Surgical Procedure Code is not related to Principal Diagnosis Code. DRG cannotbe determined. Reimbursement determination has been made under DRG 981, 982, or 983. Recoding/adjusting claim may result in a different DRG code assignmentand reimbursement.
988	Claim Is For A Member With Retro Ma Eligibility. Wis Adm Code 106.04(3)(b) Requires Providers To Reimburse The Person/party (eg, County) That Previously
989	Claim Denied. Attachment was not received within 35 days of a claim receipt.
990	Denied. Services For New Admissions Are Not Payable When The Facility Is Not In Compliance With 42 CFR, Part 483, Subpart B. Refer To Notice From DHS.
991	Non-payable Informational Pcc Detail
992	Denied/Cutback. The disposable medical supply Procedure Code has a quantity limit as indicated in the DMS Index. Prior Authorization is required to exceed this limit.
993	Claim Denied/cutback. This Dms Item Is Limited To 12 Per 30 Days, Per Provider, Without Prior Authorization.
994	Compound drugs require a minimum of two components with at least one payable FowardHealth covered drug.
995	Claim Denied. Resubmit Your Services Using The Appropriate Modifier After YouReceive A Update Providing Additional Billing Information.
996	Pharmacuetical care limitation exceeded. Refer To Your Pharmacy Handbook For Policy Limitations.
997	PA Received With Web Pcst Summary Sheet.
998	SMV Mileage Exceeding 40 Miles In Urban Counties Or 70 Miles In Rural CountiesRequires Prior Authorization.
999	Rural Health Clinics May Only Bill Revenue Codes On Medicare Crossover Claims
1000	Claim Pended For Examiner Review
1001	COB- Benefit Plan
1002	COB — Payer
1100	The amount in the Other Insurance field is invalid.
1101	Quantity Billed is invalid.
1102	The Admit Date is invalid.
1103	The Number of Covered Days is required.
1104	A number is required in the Covered Days field.
1105	One or more Occurrence Code Date(s) is invalid in positions nine through 24.
1106	Interim billing criteria not met.
1107	Admit Date and From Date Of Service(DOS) must match.
1108	An amount in the Gross Amount Due field and/or Usual and Customary Charge field is required.
1109	Rendering Provider is not a certified provider for .
1110	Rendering Provider is not a certified provider for Wisconsin Chronic Disease Program.
1111	Rendering Provider is not a certified provider for Wisconsin Well Woman Program.
1112	A National Provider Identifier (NPI) is required for the Rendering Provider listed in the header.
1113	Services are not payable. Member is in a divestment penalty period.
1114	Denied. The Dispense As Written (Daw) Indicator Is Not Allowed For The National Drug Code.
1115	Denied. This National Drug Code Has Diagnosis Restrictions.
1116	The Revenue Code requires an appropriate corresponding Procedure Code.
1117	The National Drug Code (NDC) has an age restriction.
1118	The National Drug Code (NDC) has a quantity restriction.
1119	One or more Diagnosis Codes has an age restriction.
1120	One or more Diagnosis Codes has a gender restriction.
1121	Member does not meet the age restriction for this Procedure Code.
1122	Family Planning Funding 90% .
1123	Family Planning Funding Fed Match
1124	Family Planning Funding Error
1125	A federal drug rebate agreement for this drug is not on file for the Date Of Service(DOS)(DOS).
1126	Second modifier code is invalid for Date Of Service(DOS) (DOS).
1127	Third modifier code is invalid for Date Of Service(DOS).
1128	A tooth number or letter is required.
1129	Occurrence Code is required when an Occurrence Date is present.
1130	One or more Condition Code(s) is invalid in positions eight through 24.
1131	The Primary Occurrence Code is invalid.
1132	A Primary Occurrence Code Date is required.
1133	Principal Surgical Code Date is invalid.
1134	First Occurrence Span Code is invalid.
1135	One or more From Date Of Service(DOS) (DOS) is invalid for Occurrence Span Codes in positions three through 24.
1136	The Area of the Oral Cavity is invalid.
1137	Value Code is invalid.
1138	Value Code amount is invalid.
1139	Header From Date Of Service(DOS) is after the date of receipt of the claim.
1140	A WCDP drug rebate agreement for this drug is not on file for the Date Of Service(DOS).
1141	Member enrolled in Medicare Part D for the Dispense Date Of Service(DOS). Prescription Drug Plan (PDP) payment/denial information required on the claim to WCDP.
1142	This Modifier has been discontinued by CMS or AMA for the Date Of Service(DOS)(s).
1143	Accomodation Code(s) is not payable.
1144	This National Drug Code (NDC) has been terminated by CMS for the Date Of Service(DOS).
1145	Area of the Oral Cavity is required for Procedure Code.
1146	The Second Other Provider ID is missing or invalid.
1147	Admit Diagnosis Code (dx) is invalid.
1148	Second Diagnosis Code (dx) is invalid.
1149	Third Diagnosis Code (dx) is invalid.
1150	Fourth Diagnosis Code (dx) is invalid.
1151	The Fifth Diagnosis Code (dx) is invalid.
1152	The Sixth Diagnosis Code (dx) is invalid.
1153	The Seventh Diagnosis Code (dx) is invalid.
1154	The Eighth Diagnosis Code (dx) is invalid.
1155	The Ninth Diagnosis Code (dx) is invalid.
1156	Primary Diagnosis Code (dx) is invalid.
1157	One or more Diagnosis Code(s) is invalid in positions 10 through 25.
1158	Primary Diagnosis Code is required.
1159	One or more Diagnosis Code(s) is invalid for the Date(s) of Service.
1160	Primary Diagnosis Code is not on file.
1161	Secondary Diagnosis Code (dx) is not on file.
1162	Third Diagnosis Code (dx) (dx) is not on file.
1163	Fourth Diagnosis Code (dx) is not on file.
1164	Fifth Diagnosis Code (dx) is not on file.
1165	Sixth Diagnosis Code (dx) is not on file.
1166	Seventh Diagnosis Code (dx) is not on file.
1167	Eighth Diagnosis Code (dx) is not on file.
1168	Ninth Diagnosis Code (dx) is not on file.
1169	One or more Diagnosis Code(s) in positions 10 through 25 is not on file.
1170	Tenth diagnosis is invalid.
1171	Eleventh diagnosis is invalid.
1172	Twelfth diagnosis is invalid
1173	Tenth diagnosis is not on file.
1174	The procedure code is not reimbursable for a Family Planning Waiver member.
1175	The Patient Status Code is invalid.
1176	Denied. Claim/adjustment/reconsideration Request Received After 730 Days From Date(s) of Service.
1177	Patient Location is invalid.
1178	Service is not reimbursable for Date(s) of Service.
1179	Valid quantity billed is required.
1180	Prescription Date is after Dispense Date Of Service(DOS).
1181	Dispense Date Of Service(DOS) exceeds Prescription Date by more than one year.
1182	Incorrect Or Invalid National Drug Code Billed.
1183	Header From Date Of Service(DOS) is after the header To Date Of Service(DOS).
1184	The Header and Detail Date(s) of Service conflict.
1185	The Procedure Code is not payable by Wisconsin Chronic Disease Program for theDate(s) of Service.
1186	The Procedure Code is not payable by Wisconsin Well Woman Program for the Date(s) of Service.
1187	The Revenue Code is not payable for the Date(s) of Service.
1188	The Revenue Code is not payable by Wisconsin Chronic Disease Program for the Date(s) of Service.
1189	The Revenue Code is not payable by Wisconsin Well Woman Program for the Date(s) of Service.
1190	One or more Diagnosis Code(s) is not payable for the Date Of Service(DOS).
1191	One or more Diagnosis Code(s) is not payable for the Date Of Service(DOS).
1192	One or more Diagnosis Code(s) is not payable by Wisconsin Well Woman Program for the Date(s) of Service.
1193	Dispense Date Of Service(DOS) is after Date of Receipt of claim.
1194	Billed Amount is not equally divisible by the number of Dates of Service on the detail.
1195	The Procedure Code is not reimbursable for the Rendering Provider Type and/or Specialty.
1196	Denied. Member In TB Benefit Plan. Services Not Allowed For Your Provider T
1197	The Procedure Code has Place of Service restrictions.
1198	A National Drug Code (NDC) is required for this HCPCS code.
1199	Multiple National Drug Codes (NDCs) are not allowed for this HCPCS code or NDCand HCPCS code are mismatched.
1200	The National Drug Code (NDC) submitted with this HCPCS code is CMS terminated or not covered by the program.
1201	Invalid quantity for the National Drug Code (NDC) submitted with this HCPCS code.
1202	Prescriber ID is required.
1203	Out of State Billing Provider not certified on the Dispense Date.
1204	Billing Provider is not certified for the Date(s) of Service.
1205	Out Of State Billing Provider Not Enrolled For Entire Detail DOS Span.
1207	A National Provider Identifier (NPI) is required for the Billing Provider.
1208	Multiple Service Location Found For the Billing Provider NPI
1209	Rendering Provider is required.
1210	Missing Processor Control Number (PCN) for SeniorCare member over 200% FPL or invalid PCN for WCDP member, member or SeniorCare member at or below 200% FPL.
1211	The Surgical Procedure Code has Diagnosis restrictions.
1212	This National Drug Code (NDC) has Encounter Indicator restrictions.
1213	The Procedure Code has Encounter Indicator restrictions.
1214	This Revenue Code has Encounter Indicator restrictions.
1215	This Diagnosis Code Has Encounter Indicator restrictions.
1216	This Surgical Code Has Encounter Indicator restrictions.
1217	The Surgical Procedure Code is restricted.
1218	The Procedure Code is restricted.
1219	Revenue Encounter Billing Rule edit.
1220	Fourth position modifier is invalid.
1221	Diag Restriction On ICD9 Coverage Rule edit.
1224	Prospective DUR alert
1227	The Other Payer ID qualifier is invalid for .
1228	The Other Payer Amount Paid qualifier is invalid for .
1229	Compound drugs not covered under this program.
1230	The Medicare copayment amount is invalid.
1231	Principle Surgical Procedure Code Date is missing.
1232	Non-preferred Drug Is Being Dispensed. Please Refer To The PDL For Preferred Drugs In This Therapeutic Class.
1233	The Submission Clarification Code is missing or invalid.
1234	This National Drug Code (NDC) is not covered.
1235	Diagnosis Codes Assigned Must Be At The Greatest Specificity Available.
1236	Pricing Adjustment/ Health Provider Shortage Area (HPSA) incentive payment was not applied because provider and/or member is not HPSA eligible.
1237	The Billing Provider’s taxonomy code is invalid.
1238	The Rendering Provider’s taxonomy code in the header is invalid.
1239	The Procedure Code has Diagnosis restrictions.
1240	Pharmaceutical care indicates the prescription was not filled. A quantity dispensed is required.
1241	Only preferred drugs are covered for the member?s program
1242	Only generic drugs are covered for the member?s program
1243	Only non-innovator drugs are covered for the member’s program.
1244	Eleventh diagnosis is not on file.
1245	Twelfth diagnosis is not on file.
1246	Rendering Provider indicated is not certified as a rendering provider.
1247	Tax amount nonreimuburseable.
1248	Other payer patient responsibility grouping submitted incorrectly.
1249	Other Amount Submitted Not Reimburseable.
1250	Valid Place of Service is required.
1254	DME rental beyond the initial 60 day period is not payable without prior authorization.
1255	DME rental beyond the initial 180 day period is not payable without prior authorization.
1256	Member is enrolled in Medicare Part A on the Date(s) of Service.
1257	Member is enrolled in Medicare Part B on the Date(s) of Service.
1258	Service(s) paid in accordance with program policy limitation.
1259	Header Billing Provider certification is cancelled for the Date Of Service(DOS).
1260	The sum of the Accommodation Days is not equal to the sum of Covered plus Non-Covered Days.
1261	Detail To Date Of Service(DOS) is invalid.
1262	Detail To Date Of Service(DOS) is required.
1263	Header and/or Detail Dates of Service are missing, incorrect or contain futuredates.
1264	Admit Diagnosis is required.
1265	The Admit Type code is required.
1266	Patient Status Code is incorrect for Long Term Care claims.
1267	The Patient Status code is required.
1268	Medicare Paid, Coinsurance, Copayment and/or Deductible amounts do not balance.
1269	The sum of the Medicare paid, deductible(s), coinsurance, copayment and psychiatric reduction amounts does not equal the Medicare allowed amount.
1270	The header total billed amount is required and must be greater than zero.
1271	The Total Billed Amount is missing or incorrect.
1272	Total billed amount is less than the sum of the detail billed amounts.
1273	Quantity Billed is invalid for the Revenue Code.
1274	The total billed amount is missing or is less than the sum of the detail billed amounts.
1275	Quantity Billed is restricted for this Procedure Code.
1276	Claim or Adjustment received beyond 730-day filing deadline.
1277	Member is not enrolled in the program submitted in the Plan ID field for the Dispense Date Of Service(DOS) or an invalid Plan ID was submitted.
1278	Place of Service code is invalid.
1279	Procedure not payable for Place of Service.
1280	Rendering Provider Type and/or Specialty is not allowable for the service billed.
1281	Surgical Procedure Code billed is not appropriate for member’s gender.
1282	PA required for payment of this service. Procedure Code and modifiers billed must match approved PA.
1283	Prior Authorization (PA) required for payment of this service.
1284	Rendering Provider is not certified for the From Date Of Service(DOS).
1285	The Prescriber ID is invalid.
1286	Days supply is required.
1287	Quantity dispensed is required.
1288	Submitted rendering provider NPI in the header is invalid.
1289	Type of Bill indicates services not reimbursable or frequency indicated is notvalid for the claim type.
1290	Type of Bill is invalid for the claim type.
1291	Valid Source of Admission is required.
1293	Prescription Date is required.
1294	Header Bill Date is before the Header From Date Of Service(DOS).
1295	This NDC is invalid.
1296	Services billed are included in the nursing home rate structure.
1297	Member is enrolled in a commercial health insurance on the Dispense Date Of Service(DOS).
1298	Member ID is not on file.
1301	This procedure is duplicative of a service already billed for same Date Of Service(DOS).
1302	This service is duplicative of service provided by another provider for the same Date(s) of Service.
1303	Program guidelines or coverage were exceeded.
1304	The dental procedure code and tooth number combination is allowed only once per lifetime.
1305	The dental procedure code and tooth number combination is allowed only once per lifetime.
1306	Add-on codes are not separately reimburseable when submitted as a stand-alone code.
1307	Enhanced payment for providing services in a natural environment is limited toone service per discipline per day.
1308	This service was previously paid under an equivalent Procedure Code.
1309	This drug has been paid under an equivalent code within seven days of this Date Of Service(DOS).
1310	1 PC Dispensing Fee Allowed Per Date Of Service(DOS)
1311	This service was previously paid.
1312	This service has been paid for this recipeint, provider and tooth number within 3 years of this Date Of Service(DOS).
1313	Pharmaceutical Care is not covered by the Wisconsin Chronic Disease Program.
1314	New Negative Contra Audit.
1315	Patient reason for visit is invalid.
1316	External cause of injury is invalid.
1317	A Revenue Code is required.
1318	Fifth Other Surgical Code is invalid.
1319	First Other Surgical Code is invalid.
1320	Fourth Other Surgical Code is invalid.
1321	Incorrect or invalid NDC/Procedure Code/Revenue Code billed for Date Of Service(DOS).
1322	Incorrect or invalid NDC/Procedure Code/Revenue Code billed.
1323	One or more Other Procedure Codes in position six through 24 are invalid.
1324	One or more Surgical Code(s) is invalid in positions six through 23.
1325	Other Procedure Code is invalid.
1326	Principal Procedure Code is invalid.
1327	Principal Surgical Code is invalid.
1328	Procedure code is invalid.
1329	The Revenue Code is invalid.
1330	Second Other Surgical Code is invalid.
1331	Revenue Code is invalid.
1332	The Revenue Code is not reimbursable for the Date Of Service(DOS).
1333	Third Other Surgical Code is invalid.
1334	Header From Date Of Service(DOS) is invalid.
1335	Header To Date Of Service(DOS) is invalid.
1336	Header To Date Of Service(DOS) is required.
1337	A valid Prior Authorization is required for Brand Medically Necessary Drugs.
1339	The Diagnosis Code and/or Procedure Code and/or Place of Service is not reimbursable for temporarily enrolled pregnant women.
1340	Reimbursement rate is not on file for member’s level of care.
1341	Billing Provider ID is missing or unidentifiable.
1342	Dosings for Narcotic Treatment Service program are limited to six per Sunday thru Saturday calendar week.
1343	The Narcotic Treatment Service program limitations have been exceeded. Refer to the Onine Handbook.
1344	Header Rendering Provider number is not found.
1345	Submitted referring provider NPI in the header is invalid.
1346	Billing Provider is not certified for the Dispense Date.
1347	Billing provider number is not found.
1348	Billing Provider Type and Specialty is not allowable for the service billed.
1349	LTC hospital bedhold quantity must be equal to or less than occurrence code 75span date range(s).
1350	Denied. Prescriber ID Qualifier must equal 01
1351	NDC- National Drug Code billed is not appropriate for member’s gender.
1352	NDC- National Drug Code is not allowed for the member on the Date Of Service(DOS).
1353	NDC- National Drug Code is invalid.
1354	NDC- National Drug Code is not on file.
1355	NDC- National Drug Code is required.
1356	NDC- National Drug Code is invalid for the Dispense Date Of Service(DOS).
1357	NDC- National Drug Code is not covered on a pharmacy claim.
1358	NDC- National Drug Code is restricted by member age.
1359	Member is enrolled in QMB-Only benefits. Only Medicare crossover claims are reimbursable.
1360	Rendering Provider is not a certified provider for .
1361	Rendering Provider is not a certified provider for Wisconsin Chronic Disease Program.
1362	The Dispense As Written (DAW) indicator is not allowed for the National Drug Code.
1363	The National Drug Code (NDC) is not on file for the Dispense Date Of Service(DOS).
1364	The National Drug Code (NDC) is not payable for the Provider Type and/or Specialty.
1365	The National Drug Code (NDC) is not a benefit for the Date Of Service(DOS).
1366	The National Drug Code (NDC) is not payable for a Family Planning Waiver member.
1367	This National Drug Code (NDC) has diagnosis restrictions.
1369	Pharmacuetical care limitation exceeded.
1370	Member is assigned to a Hospice provider. All services should be coordinated with the Hospice provider.
1371	Member is assigned to a Lock-in primary provider. All services should be coordinated with the primary provider.
1372	Member is assigned to an Inpatient Hospital provider. All services should be coordinated with the Inpatient Hospital provider.
1373	Denied/Cutback. RN Home Health visits and Supervisory visits are not reimbursable on the same Date Of Service(DOS) for same provider.
1374	An ICD-9-CM Diagnosis Code of greater specificity must be used for the Diagnosis Code in posistion 10 through 24.
1375	Submitted rendering provider NPI in the detail is invalid.
1376	Submitted referring provider NPI in the detail is invalid.
1377	The Procedure Code has Diagnosis restrictions.
1378	The Revenue Code is not payable for the Date Of Service(DOS).
1379	The services are not allowed on the claim type for the Member’s Benefit Plan.
1380	The Surgical Procedure Code is not payable for /BadgerCare Plus for the Date Of Service(DOS).
1381	The Surgical Procedure Code is not payable for Wisconsin Chronic Disease Program for the Date Of Service(DOS).
1382	One or more Diagnosis Code(s) is not payable for the Date Of Service(DOS).
1383	The first occurrence span from Date Of Service(DOS) is after the to Date Of Service(DOS).
1384	The second occurrence span from Date Of Service(DOS) is after to to Date Of Service(DOS).
1385	Dispense Date Of Service(DOS) is invalid.
1386	Billing Provider is required to be Medicare certified to dispense for dual eligibles.
1387	Other Coverage Indicator is invalid.
1388	The Procedure Code is not reimbursable for the Rendering Provider Type and/or Specialty.
1389	These services are not allowed for members enrolled in Tuberculosis-Related Services Only Benefit Plan.
1392	Compound Drugs require a minimum of two ingredients with at least one payable BadgerCare Plus covered drug.
1393	Discharge Date is before the Admission Date.
1394	From Date Of Service(DOS) is before Admission Date.
1395	Admission Date is on or after date of receipt of claim.
1397	The Fifth Condition Code is invalid.
1398	The Fourth Condition Code is invalid.
1399	The Primary Condition Code is invalid.
1400	The Second Condition Code is invalid.
1401	The Seventh Condition Code is invalid.
1402	The Sixth Condition Code is invalid.
1403	The Third Condition Code is invalid.
1404	Fifth Occurrence Code is invalid.
1405	One or more Occurrence Code(s) is invalid in positions nine through 24.
1406	Seventh Occurrence Code is invalid.
1407	Sixth Occurrence Code is invalid.
1408	The Fourth Occurrence Code is invalid.
1409	Eighth Occurrence Code is invalid.
1410	The Second Occurrence Code is invalid.
1411	The Third Occurrence Code is invalid.
1412	A Fourth Occurrence Code Date is required.
1413	A Second Occurrence Code Date is required.
1414	A Third Occurrence Code Date is required.
1415	Eighth Occurrence Code Date is invalid.
1416	Eighth Occurrence Code Date is required.
1417	Fifth Occurrence Code Date is invalid.
1418	Fifth Occurrence Code Date is required.
1419	One or more Date(s) of Service is missing for Occurrence Span Codes in positions 9 through 24.
1420	One or more To Date(s) of Service is invalid for Occurrence Span Codes in positions three through 24.
1421	Seventh Occurrence Code Date is invalid.
1422	Seventh Occurrence Code Date is required.
1423	Sixth Occurrence Code Date is invalid.
1424	Sixth Occurrence Code Date is required.
1425	The Fourth Occurrence Code Date is invalid.
1426	The Primary Occurrence Code Date is invalid.
1427	The Second Occurrence Code Date is invalid.
1428	The Third Occurrence Code Date is invalid.
1429	Fifth Other Surgical Code Date is required.
1430	First Other Surgical Code Date is invalid.
1431	First Other Surgical Code Date is required.
1432	Fourth Other Surgical Code Date is invalid.
1433	Fourth Other Surgical Code Date is required.
1434	One or more Surgical Code Date(s) is invalid in positions seven through 24.
1435	One or more Surgical Code Date(s) is missing in positions seven through 24.
1436	Fifth Other Surgical Code Date is invalid.
1437	Second Other Surgical Code Date is invalid.
1438	Second Other Surgical Code Date is required.
1439	Third Other Surgical Code Date is invalid.
1440	Third Other Surgical Code Date is required.
1441	One or more Occurrence Span Code(s) is invalid in positions three through 24.
1442	Second Occurrence Span Code is invalid.
1443	One or more From Date(s) of Service is missing for Occurrence Span Codes in positions three through 24.
1444	One or more To Date(s) of Service is missing for Occurrence Span Codes in positions three through 24.
1445	The From Date Of Service(DOS) for the First Occurrence Span Code is invalid.
1446	The From Date Of Service(DOS) for the First Occurrence Span Code is required.
1447	The From Date Of Service(DOS) for the Second Occurrence Span Code is invalid.
1448	The From Date Of Service(DOS) for the Second Occurrence Span Code is required.
1449	The To Date Of Service(DOS) for the First Occurrence Span Code is invalid.
1450	The To Date Of Service(DOS) for the First Occurrence Span Code is required.
1451	The To Date Of Service(DOS) for the Second Occurrence Span Code is invalid.
1452	The To Date Of Service(DOS) for the Second Occurrence Span Code is required.
1453	Value Code amount is missing.
1455	Service (Procedure Code/Modifier Combination) is not reimbursable for Date Of Service(DOS).
1456	Detail Quantity Billed must be greater than zero.
1457	Header To Date Of Service(DOS) is after the ICN Date.
1458	The detail From Date Of Service(DOS) is after the detail To Date Of Service(DOS).
1459	The detail From Date Of Service(DOS) is invalid.
1460	The detail From Date Of Service(DOS) is required.
1461	The detail From or To Date Of Service(DOS) is missing or incorrect.
1463	The Revenue Code is not payable by Wisconsin Chronic Disease Program for the Date Of Service(DOS).
1465	The Procedure Code is not payable by Wisconsin Well Woman Program for the Date(s) of Service.
1466	One or more Diagnosis Code(s) is not payable by Wisconsin Chronic Disease Program for the Date Of Service(DOS).
1468	Compound Ingredient Quantity must be greater than zero.
1492	The Billing Provider’s taxonomy code is missing.
1493	The Rendering Provider’s taxonomy code in the header is not valid.
1494	The Rendering Provider’s taxonomy code is missing in the header.
1496	The Rendering Provider’s taxonomy code is missing in the detail.
1497	The Rendering Provider’s taxonomy code in the detail is not valid.
1498	Processed Per Policy
1499	Processed Per Policy
1503	A Rendering Provider number is required.
1504	Performing Provider number is not found.
1505	The Billing Provider’s taxonomy code in the header is invalid.
1506	A National Provider Identifier (NPI) is required for the Performing Provider listed in the header.
1507	A Rendering Provider is not required but was submitted on the claim.
1508	This claim was processed using a program assigned provider ID number, (e.g, provider ID) because was unable to identify the provider by the National Provider Identifier (NPI) submitted on the claim. Please submit future claims with the appropriate NPI, taxonomy and/or Zip +4 Code.
1509	Billing Provider indicated is not certified as a billing provider.
1510	Rendering Provider indicated is not certified as a rendering provider.
1511	The Surgical Procedure Code is not payable for the Date Of Service(DOS).
1512	The Procedure Code/Modifier combination is not payable for the Date Of Service(DOS).
1514	Fourth Modifier is invalid.
1515	The Primary Diagnosis Code is inappropriate for the Surgical Procedure Code.
1516	The Primary Diagnosis Code is inappropriate for the Revenue Code.
1517	The Secondary Diagnosis Code is inappropriate for the Procedure Code.
1518	Diagnosis Code is restricted by member age.
1519	The Primary Diagnosis Code is inappropriate for the Procedure Code.
1520	The Secondary Diagnosis Code is inappropriate for the Procedure Code.
1521	Procedure Code is not allowed on the claim form/transaction submitted.
1522	Surgical Procedure Code is not allowed on the claim form/transaction submitted.
1523	Admit Diagnosis Code is invalid for the Date(s) of Service.
1524	Billed amount exceeds prior authorized amount.
1525	Family Planning related
1526	Services billed exceed prior authorized amount.
1527	Prior Authorization (PA) is required for payment of this service. Procedure Code and modifiers billed must match approved PA.
1528	The Revenue Code is not payable by Wisconsin Well Woman Program for the Date Of Service(DOS).
1529	A more specific Diagnosis Code(s) is required.
1530	Claim contains duplicate segments for Present on Admission (POA) indicator.
1531	Indicator for Present on Admission (POA) is not a valid value.
1532	Claim count of Present on Admission (POA) indicators does not match count of non-admitting and non-emergency diagnosis codes.
1533	Real time pharmacy claims require the use of the NCPDP Plan ID. This claim did not include the Plan ID, therefore we assigned TXIX as the Plan ID for this claim.
1534	ACCOM REV CODE QTY BILLED NOT EQUAL TO DTL DOS
1535	Effective 04/01/09, the BadgerCare Plus Core Plan will limit coverage for Hypoglycemics-Insulin to Humalog and Lantus.
1536	Effective 04/01/09, the BadgerCare Plus Core Plan will limit coverage for Glucocorticoids-Inhaled to Flovent.
1537	Effective 04/01/09, the BadgerCare Plus Core Plan will limit coverage for Brochodilators-Beta Agonists to Proventil HFA and Serevent.
1538	Denied. Member eligibility file indicates that BadgerCare Plus Benchmark, CorePlan or Basic Plan member. Please submit claim to BadgerRX Gold.
1539	Denied. A dispense as written indicator is not allowed for this generic drug.
1540	Contingency Plan for CORE and HIRSP Kids — Suspend all non-pharmacy claims.
1541	The procedure code has Family Planning restrictions.
1542	The revenue code has Family Planning restrictions.
1543	The drug code has Family Planning restrictions.
1544	The service is not reimbursable for the members benefit plan.
1545	The diagnosis code is not reimbursable for the claim type submitted.
1546	This claim is a duplicate of a claim currently in process. There is no action required. Please watch future remittance advice. Do not resubmit.
1547	No Rendering Provider Status Found for the From and To Date Of Service(DOS).
1548	Claim date(s) of service modified to adhere to Policy
1549	Sum of detail Medicare paid amounts does not equal header Medicare paid amount.
1550	Transplant services not payable without a transplant aquisition revenue code.
1551	The provider type and specialty combination is not payable for the procedure code submitted.
1552	This procedure is age restricted. Member’s age does not fall within the approved age range.
1553	The procedure code and modifier combination is not payable for the member’s benefit plan.
1554	The claim type and diagnosis code submitted are not payable for the member’s benefit plan.
1555	A valid Prior Authorization is required. Follow specific Core Plan policy for PA submission.
1556	This National Drug Code is not covered under the Core Plan or Basic Plan for the diagnosis submitted.
1557	This drug is a Brand Medically Necessary (BMN) drug. BMN prior authorization may be submitted for Mental Health drugs for which a Core Plan transitioned member has been previously grandfathered.
1558	This drug is not covered for Core Plan members. Prior authorization requests for this drug are not accepted.
1559	Core Plan — Denied due to Member eligibility file indicates BadgerCare Plus Core Plan member. Please submit claim to HIRSP or BadgerRX Gold.
1560	Birth to 3 enhancement is not reimbursable for place of service billed.
1561	Eight hour limitation on evaluation/assessment services in a 1 year period has been exceeded. Prior Authorization is needed for additional services.
1562	A valid procedure code is required on WWWP institutional claims.
1563	When diagnoses 800.00 through 999.9 are present, an etiology (E-code) diagnosis must be submitted in the E-code field.
1564	Payment may be reduced due to submitted Present on Admission (POA) indicator.
1565	100 Days Supply Opportunity. Policy override must be granted by the Drug Authorization and Policy Override Center to dispense less than a 100 day supply.
1566	Denied/Cutback. One BMI Incentive payment is allowed per member, per renderingprovider, per calendar year.
1567	Denied/Cutback. CORE Plan Members are limited to 25 non-emergency outpatient hospital visits per enrollment year.
1568	Prior authorization is required for Advair or Symbicort if no other Glucocorticoid Inhaled product has been reimbursed within 90 days.
1569	PDN services billed on this claim exceed 12 hours/day per nurse
1570	PDN services billed on this claim exceed 60 hours/week per nurse
1571	PDN services billed on this claim exceed 24 hours/day per member
1572	Denied. Home Health services for CORE plan members are covered only following an inpatient hospital stay. Hospital discharge must be within 30 days of from Date Of Service(DOS).
1573	The total of amounts billed for the DOS on the claim exceeds the allowed dailylimit for PDN services.
1574	This diabetic supply has been paid under an equivalent code on this Date Of Service(DOS).
1575	Denied. Purchase of a blood glucose monitor includes the first 30 days of supplies for the monitor.
1576	Prior authorization is required for Maxalt when Maxalt or sumatriptan productshave not been reimbursed within 365 days.
1577	Denied. Procedure code 00942 is allowed only when provided on the same date ofservice as procedure code 57520.
1578	Transplants and transplant-related services are not covered under the Basic Plan.
1579	An xray or diagnostic urinalysis is reimbursable only when performed on the same Date Of Service(DOS) and billed on the same claim as the initial office visit.
1580	Pharmaceutical care is not covered for the program in which the member is enrolled. This member is eligible for Medication Therapy Management services. A traditional dispensing fee may be allowed for this claim.
1581	The Travel component for this service must be billed on the same claim as the associated service.
1582	Cannot bill for both Assay of Lab and other handling/conveyance of specimen.
1583	Diagnosis code V038 or V0382 is required on an cliam when billing procedure code 90732 only or 90732 and G0009 together for the same Date Of Service(DOS).
1584	Service billed is bundled with another service and cannot be reimbursed separately.
1585	Revenue code 0850 thru 0859 is not allowed when billed with revenue codes 0820thru 0829, 0830 thru 0839, or 0840 thru 0849.
1586	Condition code 20, 21 or 32 is required when billing non-covered services.
1587	Revenue code submitted with the total charge not equal to the rate times number of units.
1588	The quantity billed of the NDC is not equally divisible by the NDC package size.
1589	Do not leave blank fields between the multiple occurance codes.
1590	Service not allowed, billed within the non-covered occurrence code date span.
1591	Service not allowed, benefits exhausted occurrence code billed.
1592	CPT/HCPCS codes are not reimbursable on this type of bill.
1593	Condition code 30 requires the corresponding clinical trial diagnosis V707.
1594	This service is not payable for the same Date Of Service(DOS) as another service included on this claim.
1595	Quantity indicated for this service exceeds the maximum quantity limit established.
1596	This service is not covered under the ESRD benefit.
1600	ICD-9-CM Diagnosis code in diagnosis code field(s) 1 through 9 is missing or incorrect.
1601	Errors in one of the following data elements exceed their field size: Statement covered FROM Date, Admission date, Date Of Service(DOS), Revenue code.
1602	Occurance code or occurance date is invalid.
1603	Condition code must be blank or alpha numeric A0-Z9.
1604	The attending physician NPI/UPIN ID and name are either required and are missing or a NPI/UPIN beginning with NPP has been used.
1605	The first position of the attending UPIN must be alphabetic.
1606	Modifier is invalid.
1607	A Date Of Service(DOS) is required with the revenue code and HCPCS code billed.
1608	The use of value code is incorrect.
1609	A HCPCS code is required when condition code A6 is included on the claim.
1610	Intermittent Peritoneal Dialysis hours must be entered for this revenue code.
1611	Value codes 48 — Homoglobin Reading and 49 — Hematocrit Reading, must have a zero in the far right position.
1612	The revenue code and HCPCS code are incorrect for the type of bill.
1613	The revenue code and HCPCS code are incorrect for the type of bill.
1614	The diagnosis code on the claim requires Condition code A6 be present on the Type of Bill.
1615	Revenue code is not valid for the type of bill submitted.
1616	The Revenue code on the claim requires Condition code 70 to be present for this Type of Bill.
1617	Revenue code submitted is no longer valid.
1618	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. Please show the appropriate multichanel HCPCS code rather than the individual HCPCS code.
1619	Condition codes 71, 72, 73, 74, 75, and 76 cannot be present on the same ESRD claim at the same time.
1620	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.
1621	If condition codes 71 through 76 exist on the claim, then revenue codes 082X, 083X, 084X, 085X or 088X must also be present.
1622	Revenue codes 0822, 0823, 0825, 0832, 0833, 0835, 0842, 0843, 0845, 0852, 0853, or 0855 exist on the ESRD claim that does not contain condition code 74.
1623	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.
1624	The condition code is not allowed for the revenue code.
1625	The value code 48 (Hemoglobin reading) or 49 (Hematocrit) is required for the revenue code/HCPCS code combination.
1626	This revenue code requires value code 68 to be present on the claim.
1627	The submitted claim contains value code 68 and 48 or 49 but does not contain revenue code 0634 or 0635 and HCPCS Q4055. -OR- The claim contains value code 49but does not contain revenue code 0636 and HCPCS Q4054. -OR- The claim contains value code 48, 49, or 68 but does not contain revenue codes 0634 or 0635.
1628	Revenue code 082X is present on an ESRD claim which also contains revenue code088X (X frequency non equal to 9).
1629	Revenue Code 082X is present on an ESRD claim which also contains revenue codes 083X, 084X, or 085X.
1630	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.
1631	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.
1632	A value code of A8 or A9 is required.
1633	Medically Unbelievable Error. The Maximum limitation for dosages of EPO is 500,000 UI’s (value code 68) per month and the maximum limitation for dosages of ARANESP is 1500 MCG (1 unit=1 MCG) per month. Please correct and resubmit.
1634	Excessive height and/or weight reported on claim. 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.
1635	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.
1636	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.
1637	The statement coverage FROM date on a hemodialysis ESRD claim (revenue code 0821, 0880, or 0881) was greater than the hemodialysis termination date in the provider file.
1638	The number of treatments/days reflected by the units entered with revenue code0821, 0831, 0841, 0851, 0880, 0881 exceeds the number of days included in the FROM and TO dates entered on this claim.
1639	X-rays and some lab tests are not billable on a 72X claim.
1640	Payment has been reduced or denied because the maximum allowance of this ESRD service has been reached.
1641	The number of units billed for dialysis services exceeds the routine limits.
1642	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.
1643	This is a duplicate claim. Please adjust quantities on the previously submitted and paid claim.
1644	Valid Other Payer Date required.
1645	Other Payer Date can not be after claim receipt date.
1646	Valid NCPDP Other Payer Reject Code(s) required.
1647	Other Payer Date is Invalid
1648	Repackaged National Drug Codes (NDCs) are not covered.
1649	Revenue code requires submission of associated HCPCS code
1650	Provider is not eligible for reimbursement for this service. Member must receive this service from the state contractor if this is for incontinence or urological supplies. If not, the procedure code is not reimbursable.
1651	Saved for E4333 — Either or both the Diagnosis or ICD-9 Surgical Procedure Code(s) do not correspond with the Member’s Age
1652	Saved for E4334 — Either or both the Diagnosis or ICD-9 Surgical Procedure Code(s) do not correspond with the Member’s Gender
1653	Invalid POA indicator on HAC code.
1654	Procedure Not Payable for the Wisconsin Well Woman Program.
1655	A split claim is required when the service dates on your claim overlaps your Federal fiscal year end (FYE) date.
1656	Condition code 80 is present without condition code 74. Please verify billing. Reference: Transmittal 477, change request 3720 issued February 18, 2005.
1657	Revenue code billed with modifier GL must contain non-covered charges.
1658	HCPCS procedure codes G0008, G0009 or G0010 are allowed only with revenue code0771.
1659	More than one PPV or Influenza vaccine billed on the same Date Of Service(DOS) for the same member is not allowed.
1660	Claim contains an unclassified drug HCPCS procedure code or a drug HCPCS procedure code included in the composite rate. Additional information is needed for unclassified drug HCPCS procedure codes. Separate reimbursement for drugs included in the composite rate is not allowed.
1661	The HCPCS procedure code listed for revenue code 0624 is either invalid or non-reimburseable.
1662	Date of service is on or after July 1, 2010 and TOB is 72X, value code D5 mustbe present.
1663	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. If the KT/V reading was not performed, then the value code D5 with 9.99 must be present without the occurrence code 51.
1664	Modifier V8 or V9 must be sumbitted with revenue code 0821, 0831, 0841, or 0851.
1665	Unable To Process Your Adjustment Request due to Member ID Not Present.
1666	Unable To Process Your Adjustment Request due to Financial Payer Not Indicated.
1667	Unable To Process Your Adjustment Request due to Provider ID Not Present.
1668	Unable To Process Your Adjustment Request due to Claim ICN Not Found.
1669	Unable To Process Your Adjustment Request due to Original ICN Not Present.
1670	Unable To Process Your Adjustment Request due to Member Not Found.
1671	Unable To Process Your Adjustment Request due to Provider Not Found.
1672	Unable To Process Your Adjustment Request due to Original Claim ICN Not Found.
1673	Unable To Process Your Adjustment Request due to Claim Has Already Been Adjusted.
1674	Unable To Process Your Adjustment Request due to A Different Adjustment Is Pending For This Claim.
1675	Unable To Process Your Adjustment Request due to This Claim Is In Post Pay Billing For Third Party Liability Payment.
1676	Unable To Process Your Adjustment Request due to Claim Can No Longer Be Adjusted. Contact Provider Services For Further Information.
1677	Unable To Process Your Adjustment Request due to The Claim Type Of The Adjustment Does Not Match The Claim Type Of The Original Claim.
1678	Unable To Process Your Adjustment Request due to Member ID Number On The Claim And On The Adjustment Request Do Not Match.
1679	Unable To Process Your Adjustment Request due to Provider ID Number On The Claim And On The Adjustment Request Do Not Match.
1680	Modifier V5, V6, or V7 must be included on the latest line item Date Of Service(DOS) billing revenue code 0821.
1681	Condition Code 73 for self care cannot exceed a quantity of 15.
1682	The initial rental of a negative pressure wound therapy pump is limited to 90 days; member lifetime.
1683	Additional rental of a negative pressure wound therapy pump is limited to 90 days in a 12 month period.
1684	The canister, dressings and related supplies are included as part of the reimbursement for the negative pressure wound therapy pump.
1685	Billing Provider Type and Specialty is not allowable for the Place of Service.
1686	This service is not payable with another service on the same Date Of Service(DOS) due to National Correct Coding Initiative.
1687	An NCCI-associated modifier was appended to one or both procedure codes.
1688	Service Denied. Diagnosis 635-635.92 May Only Be Used When Billing For Abortion Procedures. Please Correct And Resubmit.
1689	Does not reimburse both the global service and the individual component parts of the service for the same Date Of Service(DOS).
1690	Quantity indicated for this service exceeds the maximum quantity limit established by the National Correct Coding Initiative.
1691	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.
1692	Adjustment and original claim do not have the same finanical payer
1693	6355 replacing 635R diagnosis (For use of Category of Service only)
1694	6360 replacing 635S diagnosis (For use of Category of Service only)
1695	6365 replacing 635T diagnosis (For use of Category of Service only)
1937	is unable to is process this claim at this time. An Alert willbe posted to the portal on how to resubmit.
2037	Member ID has changed. No action required.
2040	NDC is obsolete for Date Of Service(DOS).
2222	Policy not currently enforced.
2268	SeniorCare member enrolled in Medicare Part D. Claim is excluded from Drug Rebate Invoicing.
3001	This Member is enrolled in Wisconsin or BadgerCare Plus for Date(s) of Service. WCDP is the payer of last resort.
3002	Denied due to The Member WCDP Id Number Is Incorrect Or Not On Our Current Eligibility File.
3003	Denied due to The Member’s Last Name Is Missing.
3004	Denied due to The Member’s Last Name Is Incorrect.
3005	Denied due to The Member’s First Name Is Missing Or Incorrect.
3006	Denied due to Member Not Eligibile For All/partial Dates. Please Rebill Only CoveredDates.
3008	This Claim Has Been Manually Priced Based On Family Deductible.
3009	Claim Denied. No Financial Needs Statement On File.
3101	Denied due to Provider Number Missing Or Invalid.
3200	Denied due to Procedure Or Revenue Code(s) Are Missing On The Claim.
3201	Denied due to NDC Code Is Missing.
3202	Denied due to Procedure/Revenue Code Is Not Allowable.
3203	Denied due to Prescription Number Is Missing Or Invalid.
3204	Denied due to Service Is Not Covered For The Diagnosis Indicated.
3205	Denied due to NDC Is Not Allowable Or NDC Is Not On File.
3206	Denied due to Diagnosis Code Is Not Allowable.
3207	Denied due to Procedure Is Not Allowable For Diagnosis Indicated.
3208	Denied due to Procedure Billed Not A Covered Service For Dates Indicated.
3209	Suspend Claims With DOS On Or After 7/9/97.
3210	Denied due to Diagnosis Not Allowable For Claim Type.
3211	Denied due to Per Division Review Of NDC.
3212	Prescriber ID and Prescriber ID Qualifier do not match.
3268	WCDP member enrolled in Medicare Part D. Claim is excluded from Drug Rebate Invoicing.
3300	Denied. Other Insurance Disclaimer Code Invalid.
3301	Denied. Discrepancy Between The Other Insurance Indicator And OI Paid Amount.
3302	Denied. Accident Related Service(s) Are Not Covered By WCDP.
3303	Denied. Member’s File Shows Other Insurance. Submit Claim To Other Insurance Carrier.
3304	Not A WCDP Benefit. For Review, Forward Additional Information With R&S To WCDP.
3305	Medicare Disclaimer Code Invalid.
3306	Denied due to Medicare Allowed Amount Required.
3308	Denied due to From Date Of Service(DOS)/date Filled Is Missing/invalid.
3310	Denied due to Claim Or Adjustment Received After The Late Billing Filing Limit.
3311	Denied due to Statement Covered Period Is Missing Or Invalid.
3312	Denied due to Statement From Date Of Service(DOS) Is After The Through Date Of Service(DOS).
3313	Denied due to Claim Contains Future Dates Of Service.
3314	Denied due to Detail Dates Are Not Within Statement Covered Period.
3315	Denied due to Provider Is Not Certified To Bill WCDP Claims.
3316	Denied due to Detail Fill Date Is A Future Date.
3317	Denied due to Not A Benefit Of WCDP.
3318	Denied due to Add Dates Not In Ascending Order Or DD/DD/DD Format.
3319	Denied due to Not Covered By WCDP.
3321	Denied due to Member Is Eligible For Medicare. Please Bill Medicare First.
3323	Denied due to Take Home Drugs Not Billable On UB92 Claim Form. Rebill On Pharmacy Claim Form.
3400	Denied due to Quantity Billed Missing Or Zero.
3402	Denied due to Detail Billed Amount Missing Or Zero.
3403	Denied due to Medicare Allowed, Deductible, Coinsurance And Paid Amounts Do Not Balance.
3405	Denied due to Medicare Allowed Amount Is Greater Than Total Billed Amount.
3406	Denied due to Some Charges Billed Are Non-covered. Please Rebill Inpatient Dialysis Only.
3500	Denied due to Detail From And Through Date Of Service(DOS) Are Not In The Same Calendar Month.
3501	Denied due to Greater Than Four Dates Of Service Billed On One Detail.
3502	Denied due to Detail Add Dates Not In MM/DD Format.
3503	Denied due to Provider Signature Is Missing.
3504	Denied due to Provider Signature Date Is Missing Or Invalid.
3505	Denied due to Services Billed On Wrong Claim Form.
3506	Denied due to Claim Exceeds Detail Limit.
3507	Previously Denied Claims Are To Be Resubmitted As New Day Claims.
3509	Adjustment Requested Member ID Change. Claim Denied In Order To Reprocess WithNew ID.
3601	Denied due to Discharge Diagnosis 1 Missing Or Invalid
3602	Denied due to Diagnosis Pointer To Diagnosis Code 1 Invalid
3603	Denied due to Diagnosis Pointer To Diagnosis Code 2 Invalid
3604	Denied due to Diagnosis Pointer To Diagnosis Code 3 Invalid
3605	Denied due to Diagnosis Pointer To Diagnosis Code 4 Invalid
3606	Denied due to Diagnosis Pointer To Diagnosis Code 5 Invalid
3610	Denied due to Diagnosis Pointer(s) Are Invalid
3700	Claim Previously/partially Paid. Please Review Remittance And Status Report.
3701	Claim Previously/partially Paid. Please Review Remittance And Status Report.
3702	Claim Previously/partially Paid. Please Review Remittance And Status Report.
3704	Claim Previously/partially Paid. Please Review Remittance And Status Report.
3705	Claim Previously/partially Paid. Please Review Remittance And Status Report.
3706	Claim Previously/partially Paid. Please Review Remittance And Status Report.
3707	Claim Previously/partially Paid. Please Review Remittance And Status Report.
3801	Billed Amount On Detail Paid By WWWP. Billed Amount Is Equal To The Reimbursement Rate.
3802	Allowed Amount On Detail Paid By WWWP. Billed Amount Is Greater Than Reimbursement Rate.
3803	Billed Amount On Detail Paid By WWWP.
3804	Claim Has Been Adjusted Due To Previous Overpayment. Money Will Be Recouped From Your Account.
3805	Amount Paid On Detail By WWWP Is Less Than Billed Or Reimbursement Rate Due ToPrior Payment By Other Insurance.
3806	Claim Detail Denied As Duplicate. CPT Code And Service Date For Member Is Identical To Another Claim Detail On File For Provider On Claim.
3807	Claim Detail Pended As Suspect Duplicate. CPT Code And Service Date For Memberis Identical To Another Claim Detail On File For Another WWWP Provider.
3808	Claim Detail Denied For Invalid CPT, Invalid CPT/modifier Combination, Or Invalid Type Of Quantity Billed. Billed Procedure Not Covered By WWWP.
3809	Claim Detail Denied. CPT Or CPT/modifier Combination Is Not Valid On This Date Of Service(DOS).
3810	Claim Denied For Invalid Diagnosis Code Or Diagnosis Code/CPT Combination. The Diagnosis Is Not Covered By WWWP.
3811	Claim Denied. The Diagnosis Code Is Not Valid On This Date Of Service(DOS).
3812	Claim Denied For No Provider Agreement On File Or Not Certified For Date Of Service(DOS).
3813	Claim Denied For No Client Enrollment Form On File.
3814	No matching Reporting Form on file for the detail Date Of Service(DOS).
3815	Claim Detail Denied Due To Required Information Missing On The Claim.
3816	Claim Is Pended For 60 Days. No Complete Program Enrollment Form Is On File For This Client Or The Client Is Not Eligible For The Date Of Service(DOS) On The Clai im. If required information is not received within 60 days, the claim will be
3817	Claim Is Pended For 60 Days. No Complete WWWP Participation Agreement Is On File For This Provider. If Required Information Is Not Received Within 60 Days,the claim will be denied.
3818	Claim Is Pended For 60 Days. Information Required For Claim Processing Is Missing. A Separate Notification Letter Is Being Sent. If Required Information Is not received within 60 days, the claim detail will be denied.
3819	Claim Detail Is Pended For 60 Days. No Matching, Complete Reporting Form Is On File For This Client. If A Reporting Form Is Not Submitted Within 60 Days, The claim detail will be denied.
3820	Claim Denied For Future Date Of Service(DOS).
3821	Claim Denied. WWWP Does Not Process Interim Bills.
3822	Claim Denied For Invalid Billing Type Frequency Code, Claim Type, Or SubmittedAdjustment Provider Number Does Not Match Original Claim’s Provider Number.
3823	Detail Denied. To Date Of Service(DOS) Precedes From Date Of Service(DOS).
7001	Claim Generated An Informational ProDUR Alert
7002	Denied For ProDUR Reasons
7003	Drug-Drug Interaction prospective DUR alert
7004	DD Prospective DUR alert; EOB Not Used
7005	Drug-Disease (reported) prospective DUR alert
7006	MC Prospective DUR alert; EOB Not Used
7007	Drug-Disease (inferred) prospective DUR alert
7008	DC Prospective DUR alert; EOB Not Used
7009	Therapeutic Duplication prospective DUR alert
7010	Drug-Pregnancy prospective DUR alert
7011	Early Refill prospective DUR alert
7012	Additive Toxicity prospective DUR alert
7013	Drug-Age prospective DUR alert
7014	PA Prospective DUR alert; EOB Not Used
7015	Late Refill prospective DUR alert
7016	High Dose prospective DUR alert
7017	Suboptimal Regiment prospective DUR alert
7018	Insufficient Quantity prospective DUR alert
7019	Early Refill Alert. Policy override must be granted by the Drug Authorizationand Policy Override Center to dispense early.
7020	Reserved for Future Use.
7021	Reserved for Future Use.
7022	Reserved for Future Use.
7200	Denied by Claimcheck based on program policies.
7201	Denied by Claimcheck based on program policies.
7211	Procedure Is Invalid For Patient’s Age
7212	Procedure Added Due To Alt Code Replacement (age)
7213	Procedure Is Invalid For Patient’s Sex
7214	Procedure Added Due To Alt Code Replacement (sex)
7215	Procedure Code Is Incidental
7217	Procedure Code Has Been Rebundled
7218	Procedure Added Due To Rebundling
7219	Procedure Is Mutually Exclusive
7233	Denied Duplicate- Includes Unilateral Or Bilat
7234	Denied Duplicate/ Is Bilateral
7235	Denied Duplicate/ Only Done XX Times In Lifetime
7236	Denied Duplicate/ Only Done XX Times In A Day
7237	Denied Duplicate (rebundled)
7238	Procedure Added Due To Duplicate Rebundling
7239	Procedure Is A Possible Duplicate
7256	Modifier invalid for Procedure Code billed.
7257	Incidental modifier is required for secondary Procedure Code.
7258	Review Modifier 51
7259	Split Decision Was Rendered On Expansion Of Units.
7290	Invalid modifier removed from primary procedure code billed.
7291	Incidental modifier was added to the secondary procedure code.
7503	Reason for Service submitted does not match prospective DUR denial on originalclaim.
7504	Denied. Professional Service code is invalid.
7505	Denied. Result of Service code is invalid.
7506	Denied. Prospective DUR denial on original claim can not be overridden.
7507	Denied. Result of Service submitted indicates the prescription was not filled.
7508	Denied. Result of Service submitted indicates the prescription was filled witha different quantity. Quantity submitted matches original claim.
8000	Resolution review.
8001	Was Unable To Process This Request Due To Illegible Information.
8002	Unable To Process This Request Due To Either Missing, Invalid OrMismatched National Provider Identifier # (NPI)/Provider Name/POP ID.
8003	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).
8004	Was Unable To Process This Request. The Resident Or CNA’s Name Is Missing.
8005	Was Unable To Process This Request. All Requests Must Have A 9 Digit Social Security Number.
8006	Is Unable To Process This Request Because The Signature/date Field Is Blank
8007	The Screen Date Is Either Missing Or Invalid. The Screen Date Must Be In MM/DD/CCYY Format.
8008	OBRA-nurse And/or Level 1.
8009	Invalid Admission Date. Either The Date Was Not In MM/DD/CCYY Format Or It’s AFuture Date.
8010	This Is Not A Reimbursable Level I Screen. Did You check More Than One Box?If So, Correct And Resubmit.
8011	Request Denied Because The Screen Date Is After The Admission Date. This Is Not A Preadmission Screen And Is Not Reimbursable.
8012	Request Denied Due To Late Billing. A Reimbursement Request For A Level I Screen Must Be Received At Within A Year Of The Screen Date.
8013	Request Denied Because The Screen Was Done More Than 90 Days Prior To The Admission Date.
8014	This CNA’s Social Security Number, SSN, Is Not On The EDS Nurse Aide Registry File. This Individual Is Either Not On The Registry Or The SSN On The Request D oesn’t Match The SSN That’s Been Inputted On The Registry.
8015	The Reimbursement Code Assigned To This Certification Segment Does Not Authorize a NAT Payment.
8016	The Reimbursement Code Assigned To This Certification Segment Does Not Authorize a Training Payment. The CNA Is Only Eligible For Testing Reimbursement.
8017	Unable To Process This Request Because The Competency Test Date And TrainingCompletion Date Fields Are Blank.
8018	Competency Test Date Is Not A Valid Date. It Must Be In MM/DD/YY Format AndCan Not Be A Future Date.
8019	Training Completion Date Is Not A Valid Date. It Must Be In MM/DD/YY FormatAnd Can Not Be A Future Date.
8020	The Competency Test Date On The Request Does Not Match The CNA’s Test Date OnThe WI Nurse Aide Registry. For Newly Certified CNAs, Date Of Inclusion Is T heir Test Date.
8021	WI Can Not Issue A NAT Payment Without A Valid Hire Date.
8022	CNAs Eligibility For Nat Reimbursement Has Expired. The Timeframe Between Certification, Test, Date And Hire Date Exceeds A Year.
8023	NF’s Eligibility For Reimbursement Has Expired. A NAT Reimbursement Request Must Be Submitted To WI Within A Year Of The CNA’s Hire Date.
8024	NF’s Eligibility For Reimbursement Has Expired. If A CNA Obtains his/her Certification After They’ve Been Hired By A NF, A NF Has A Year From Their Certification, Test, Date To Submit A Reimbursement Request To .
8025	Request For Training Reimbursement Denied. Timeframe Between The CNA’s Training Date And Test Date Exceeds 365 Days. Training Completion Date Must Be Within A Year Of The CNA’s Certification, Test, Date.
8026	NF’s Eligibility For Reimbursement Has Expired. Requests For Training Reimbursement Denied Due To Late Billing.
8027	Training Request Denied Because Either The Training Date On The Request Is After The CNA’s Certification Test Date Or It’s Not Within A Year Of That Date.
8028	CNAs Eligibility For Training Reimbursement Has Expired. Training CompletionDate Exceeds The Current Eligibility Timeline.
8029	NF’s Eligibility For Reimbursement Has Expired. Training Reimbursement DeniedDue To late Billing. Request was not submitted Within A Year Of The CNA’s Hire Date.
8030	The Reimbursement Code Assigned To This CNA Does Not Authorize A NAT Payment.
8032	This Is A Duplicate Request. Has Already Issued A Payment To Your NF For This Level L Screen. Check Your Current/previous Payment Reports forPayment
8033	This Is A Duplicate Request. Has Already Issued A Payment To Your NF For A Level I Screen With The Same Admission Date.
8034	Multiple Requests Received For This Ssn With The Same Screen Date. A Payment Has Already Been Issued To A Different Nf.
8035	Multiple Screens Performed Within A Fifteen Day Time Frame For This SSN. Will Only Pay For One. A Payment Has Already Been Issued For This SSN
8036	A Training Payment Has Already Been Issued To A Different NF For This CNA.
8037	A Training Payment Has Already Been Issued To Your NF For This CNA.
8038	Reimbursement For Training Is One Time Only. A Training Payment Has Already Been Issued For This Cna.
8039	A Payment For The CNA’s Competency Test Has Already Been Issued.
8040	The training Completion Date On This Request Is After The CNA’s CertificationTest Date. Training Completion Date Must Be Prior To And Within A Year Of The CNA’s Certification Date.
8041	Reimbursement For This Certification, Test, Segment Has Been Issued To AnotherNF.
8042	Reimbursement For This Certification, Test, Segment Has Already Been Issued ToYour NF.
8183	Patient Liability Adjustments
8186	Mass Adjustment/ Provider Rate Process.
8188	MASS ADJUSTMENT/ VOID TRANSACTIONS
8192	This claim has been adjusted due to Medicare Part D coverage.
8193	This claim has been adjusted due to a change in the member’s enrollment.
8194	This claim has been adjusted because a service on this claim is not payable inconjunction with a separate paid service on the same Date Of Service(DOS) due to National Correct Coding Initiative.
8200	TPL Private Health Insurance/ Carrier
8201	TPL Private Health Insurance/ Provider
8202	TPL Private Health Insurance/ Member
8203	Auto Liability/ Carrier
8204	Auto Liability/ Provider
8205	Auto Liability/ Member
8206	Non-auto Liability/ Carrier
8207	Non-auto Liability/ Provider
8208	Non-auto Liability/ Member
8209	Worker’s Comp/ Carrier
8210	Worker’s Comp/ Provider
8211	Worker’s Comp/ Member
8212	Probate’s Estate
8213	Income Pension Trust Recoveries
8214	Victim’s Restitution
8215	Absent Parents
8216	TPL Error
8217	Due To Miscellaneous Or Unspecified Reason
8222	Adjustment/Resubmission was initiated by Provider
8225	Capitation/ Death Of Member
8226	Capitation/ Member Incarcerated
8227	Capitation/ Epsdt Claim
8228	Capitation/ Member Enrolled In Error
8229	Capitation/ Family Planning
8230	Capitation/ Incorrect Rate Catego
8231	Capitation/ Demographic Change
8232	Capitation/ Other
8233	Adjustment/Resubmission was initiated by DHS
8234	Adjustment/Resubmission was initiated by EDS
8240	Adjustment Generated Due To SUR Review
8241	Adjustment Generated Due To Change In Patient Liability
8242	Adjustment Generated Due To Rate Change
8244	Payout Processed Due To Disproportionate Share
8245	Point Of Sale
8246	Point Of Sale Reversal
8299	Adjustment To Crossover Paid Prior To Aim Implementation Date. This Claim HasBeen Manually Priced Using The Medicare Coinsurance, Deductible, And Psyche RedUction Amounts As Basis For Reimbursement.
8410	Financial Check Void/Stop Pay
8515	This Claim Has Been Denied Due To A POS Reversal Transaction.
8901	Other Commercial Insurance Response not received within 120 days for provider based bill.
8902	Other Medicare Part A Response not received within 120 days for provider basedbill.
8903	Other Medicare Part B Response not received within 120 days for provider basedbill.
8904	Other Medicare Managed Care Response not received within 120 days for providerbased bill.
8999	Supersuspended For Missing Disposition
9000	Pricing Adjustment/ The submitted charge exceeds the allowed charge. Claim paid at the program allowed amount.
9001	Pricing Adjustment/ Reimbursement reduced by the member’s copayment amount.
9002	Pricing Adjustment/ Payment amount increased based on ambulatory surgery centers access payment policies.
9003	Pricing Adjustment/ Third party liability amount applied is greater than the amount paid by the program.
9004	Pricing Adjustment/ Amount paid is zero.
9005	This claim is eligible for electronic submission. Up to a $1.10 reduction has been applied to this claim payment.
9006	Access payment included.
9007	Access payment not available for Date Of Service(DOS) on this date of process.
9008	Pricing Adjustment/ Payment amount decreased based on Pay for Performance policies.
9013	Pricing Adjustment. The Pharmaceutical Care Code (PCC) does not have a rate on file for the Date Of Service(DOS). Traditional dispensing fee may be allowed.
9020	Service paid in accordance with program requirements.
9801	Claim Paid At Per Diem Rate
9802	Claim Paid at % of Billed Charges
9803	Pricing Adjustment/ Medicare benefits are exhausted. Claim paid at program allowed rate.
9804	Dispensing fee denied. Missing or invalid level of effort submitted and/or reason for service, professional service, or result of service code billed in error.
9805	Pricing Adjustment/ Payment reduced due to the inpatient or outpatient deductible.
9806	Pricing Adjustment/ Payment reduced due to benefit plan limitations.
9807	Header Billing Provider used as Detail Performing Provider
9808	Header Performing Provider used as Detail Performing Provider
9809	Pricing Adjustment/ Maximum Allowable Fee pricing used.
9810	Pricing Adjustment/ Repackaging dispensing fee applied.
9811	Pricing Adjustment/ Pharmaceutical Care dispensing fee applied.
9812	Pricing Adjustment/ Level of effort dispensing fee applied.
9813	Pricing Adjustment/ Traditional dispensing fee applied.
9814	Pricing Adjustment. A Pharmaceutical Care Code (PCC) must include a valid diagnosis code. Traditional dispensing fee may be allowed.
9815	Refer to the DME area of the Online Handbook for claims submission requirements for compression garments. The topic of Requirements for Compression Garments can be found in the Claims Section, Submission Chapter.
9816	Pricing Adjustment/ Payment amount increased based on hospital access paymentpolicies.
9817	Billing provider number was used to adjudicate the service(s)
9818	Repackaging allowance is not allowed for unit dose NDCs.
9900	The National Drug Code (NDC) was reimbursed at a generic rate.
9902	Pricing Adjustment/ Inpatient Per-Diem pricing.
9905	Pricing Adjustment/ Medicare Pricing information
9906	Pricing Adjustment/ Medicare pricing cutbacks applied.
9907	Pricing Adjustment/ Third party liability deducible amount applied.
9908	Pricing Adjustment/ Pharmacy pricing applied.
9909	Pricing Adjustment/ Paid according to program policy.
9910	Pricing Adjustment/ Pharmacy dispensing fee applied.
9911	Pricing Adjustment/ Long Term Care pricing applied.
9912	Pricing Adjustment/ Ambulatory Surgery pricing applied.
9914	Pricing Adjustment/ Revenue code flat rate pricing applied.
9915	Pricing Adjustment/ Medicare crossover claim cutback applied.
9916	Pricing Adjustment/ Usual & Customary Charge (UCC) rate pricing applied.
9918	Pricing Adjustment/ Maximum allowable fee pricing applied.
9919	Pricing Adjustment/ Provider Level of Care (LOC) pricing applied.
9920	Pricing Adjustment/ Resource Based Relative Value Scale (RBRVS) pricing applied.
9921	Pricing Adjustment/ Prior Authorization pricing applied.
9922	Pricing Adjustment/ Spenddown deductible applied.
9923	Pricing Adjustment/ Patient Liability deduction applied.
9926	Pricing Adjustment/ Claim has pricing cutback amount applied.
9928	Pricing Adjustment/ Amount paid is zero
9929	Pricing Adjustment/ Anesthesia pricing applied.
9932	Pricing Adjustment/ DRG pricing applied.
9933	Pricing Adjustment/ Ambulatory Payment Classification (APC) pricing applied.
9934	Pricing Adjustment/ Prescription reduction applied.
9935	Pricing Adjustment/ Maximum Flat Fee pricing applied.
9936	Pricing Adjustment/ Maximum Flat Fee Level 2 pricing applied.
9937	Pricing Adjustment/ Usual & Customary Charge (UCC) flat fee pricing applied.
9938	Pricing Adjustment/ Usual & Customary Charge (UCC) Flat Fee Level 2 pricing applied.
9941	Pricing Adjustment–UB92 Hospice LTC Pricing
9942	Quantity reduced based on DHS policy
9943	Pricing Adjustment/ SeniorCare claim cutback because of Patient Liability and/or other insurace paid amounts.
9944	Pricing Adjustment/ Incentive Pricing
9948	NDC was reimbursed at AWP (Average Wholesale Price) (Average Wholesale Price) rate.
9949	NDC was reimbursed at State Maximum Allowable Cost (SMAC) rate.
9950	NDC was reimbursed at Employer Medical Assistance Contribution (EMAC) rate.
9951	NDC was reimbursed at brand WAC (Wholesale Acquisition Cost) (Wholesale Acquisition Cost) rate.
9952	NDC was reimbursed at generic WAC (Wholesale Acquisition Cost) rate.
9999	Processed Per Policy

EOB Codes List and Detail Information

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

What is Explanation of Benefits Codes (EOB) in Medical Billing?

Explanation of Benefits (EOB) is a document health insurance companies provide to policyholders detailing the costs and coverage related to a specific medical service or procedure. It summarizes the insurance company’s payment and the policyholder’s financial responsibility for the healthcare services rendered.

When a policyholder receives medical services, the healthcare provider submits claim to the insurance company for reimbursement. After processing the claim, the insurance company generates an EOB and sends it to the policyholder. The EOB typically includes the following information:

Patient and Policy Information: This section contains the policyholder’s name, policy number, and other relevant personal details.

Provider Information: The EOB specifies the name and contact information of the healthcare provider who rendered the services.

Service Details: It includes the date of service, the description of the procedure or service performed, and the corresponding medical codes such as CPT codes (including radiology CPT codes) and ICD-10 codes.

Allowed Amount: The EOB indicates the amount the insurance company considers an eligible expense for the covered service. This amount is determined based on the policyholder’s insurance plan, network provider agreements, and any applicable deductibles or copayments.

Covered Amount: This section of the EOB specifies the portion of the allowed amount that the insurance company will pay for the service. It may also indicate any coinsurance or copayment the policyholder is responsible for.

Denied Amount: If the insurance plan does not cover any portion of the claim, the EOB will show the denied amount and the reason for denial.

Patient Responsibility: The EOB provides a breakdown of the policyholder’s financial responsibility, including any deductibles, copayments, or coinsurance that must be paid out of pocket.

Total amount Billed: This section shows the total amount billed by the healthcare provider for the service.

Total amount Paid: The EOB specifies the total amount paid by the insurance company to the healthcare provider.

Summary and Summary Codes: The EOB may include a summary of the payment details, such as the remaining balance due, if any. It may also include summary codes that provide additional information on the claim’s status.

The Explanation of Benefit Codes or EOB codes are important for policyholders to understand the coverage and costs associated with their healthcare services. It helps them verify the accuracy of the insurance company’s payment and ensure they are billed correctly for their expenses. By reviewing the EOB, policyholders can identify discrepancies or potential billing errors and take appropriate actions, such as contacting their insurance company or healthcare provider for clarification or dispute resolution.

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