Family Care Claim EOB Explanation Codes

Transcription

1 Family Care Claim EOB Explanation Codes WPS Code AG Explanation/Denial THIS SERVICE/SUPPLY REQUIRES PRIOR AUTHORIZATION. PLEASE RE-BILL WITH THE AUTHORIZATION NUMBER WITHIN 90 DAYS FROM THE DATE OF SERVICE OR 90 DAYS FROM MEDICARE'S OR THE PRIMARY CARRIER'S DETERMINATION. CONTACT THE CUSTOMER'S CARE Re submit the claim with the correct AUTH number or contact CMU to obtain an authorization and resubmit claim with new authorization. All must be within the timely filing limit. AH THE DOLLAR AMOUNT ASSIGNED TO THE AUTHORIZATION FOR THIS SERVICE HAS BEEN EXHAUSTED. PLEASE CONTACT THE CUSTOMER'S CARE The AUTH Frequency is Amount. The claim that is being processed is of a greater value than the amount of RATE remaining. The amount left on the AUTH will be paid out and the balance not covered will be denied using AH. BU DURING THE PROCESSING OF THIS CLAIM, THIS LINE WAS BUNDLED INTO ANOTHER LINE FOR PROCESSING. No action needed, informational only. CE THE EXPLANATION OF BENEFITS RECEIVED FROM THE PRIMARY INSURER DOES NOT REFLECT THE ORIGINAL PAID OR DENIED CHARGES. PLEASE SUBMIT A COPY OF THE ORIGINAL EXPLANATION. The EOB/EOMB with claim submitted has either different dates of service or different billed amounts. The provider needs to resubmit the claim with the correct EOB/EOMB within the timely filing limit. CI THE MODIFIER(S) BILLED ON THE CLAIM DO NOT MATCH THOSE AUTHORIZED. PLEASE RE-BILL WITH THE CORRECT MODIFIER(S) WITHIN 90 DAYS FROM THE DATE OF SERVICE OR 90 DAYS FROM MEDICARE'S OR THE PRIMARY CARRIER'S DETERMINATION. CONTACT THE CUSTOMER'S CARE 8/6/2014 1

2 The CMU has set up the modifier(s) on the authorization to be billed in a set order. The provider needs to re-bill within the timely filing limit with the modifier(s) in that set order. CN THE PROVIDER OF SERVICE WAS NOT AUTHORIZED TO PROVIDE THIS SERVICE. PLEASE CONTACT THE CUSTOMER'S CARE The Customer used the wrong provider location for services authorized. CW CLAIM HAS BEEN DENIED DUE TO COMMUNITY CARE CONNECTIONS OF WISCONSIN CCCW CONTRACT HAS NOT BEEN SIGNED AND RETURNED. PLEASE CONTACT CCCW PROVIDER NETWORK AT Claim has been denied as instructed by CCCW. CX THE PROCEDURE CODE, DIAGNOSIS CODE, AND/OR REVENUE CODE IS NOT VALID. PLEASE RESUBMIT WITH A VALID CODE. Resubmit claim with valid procedure code, diagnosis code, and/or revenue code. DU THIS CLAIM IS A DUPLICATE TO A PREVIOUSLY RECEIVED CLAIM THAT IS CURRENTLY BEING REVIEWED FOR PROCESSING. The charges received for processing are being considered. The denial informs the provider of the duplicate billing. EM WE NEED THE MEDICARE EXPLANATION OF BENEFITS TO PROCESS THIS CHARGE. Resubmit claim with the corresponding explanation of benefits for the services being billed. FC THIS PAYMENT CALCULATION WAS BASED ON THE FAMILY CARE OR MEDICAID FEE SCHEDULE. No action is needed. This code informs the provider that a cutback was taken. FW PERSONAL CARE AND HOME HEALTH CARE SERVICES MUST BE BILLED ON AN INSTITUTIONAL CLAIM FORMAT OR UB04 CLAIM FORM WITH THE 8/6/2014 2

3 APPROPRIATE REVENUE CODE AND THE AUTHORIZED CPT/HCPCS CODE. PLEASE RE-BILL USING THE INSTITUTIONAL CLAIM FORMAT OR UB04 CLAIM FORM. Wrong claim format was used when billing Personal Care and Home Health Care Services. Provider must rebill using the correct format. GK THE CLAIM WAS NOT SUBMITTED TO THE PRIMARY CARRIER IN A TIMELY MANNER. REQUEST A REVIEW FOR THE DELAY REASON TO THE PRIMARY CARRIER. WHEN THE PRIMARY CARRIER HAS REACHED THEIR CONCLUSION, SEND THE EXPLAINATION OF BENEFITS WITH THE CLAIM TO US FOR PROCESSING. The claim was not sent to the primary insurance carrier within their timely filing provision. A request for review must be submitted to the Primary Carrier with the delay in filing reason. ID PLEASE RESUBMIT TO THE PRIMARY CARRIER WITH THE INFORMATION THEY REQUESTED. WHEN THE PRIMARY CARRIER HAS DETERMINED THEIR BENEFITS, SEND THE CLAIM AND THE EXPLANATION OF BENEFITS FROM THE PRIMARY CARRIER TO US FOR PROCESSING. The Primary Insurance Carrier needed information before they could consider the services for benefits. The provider needs to resend the claim to the Primary Insurance Carrie with the needed documentation. I3 THESE CHARGES ARE NOT COVERED AS THEY WERE BILLED IN ERROR BY THE PROVIDER OF SERVICE. MA PLEASE RESUBMIT THIS CLAIM TO MEDICARE WITH THE INFORMATION THEY REQUESTED. WHEN MEDICARE HAS DETERMINED THEIR BENEFITS, SEND THE EXPLANATION OF MEDICARE BENEFITS TO US FOR PROCESSING. Medicare needed information before they could consider the services for benefits. The provider needs to resend the claim to Medicare with the needed documentation. MT THE CLAIM WAS NOT SUBMITTED TO MEDICARE IN A TIMELY MANNER. REQUEST A REVIEW WITH THE DELAY REASON GIVEN TO MEDICARE. WHEN 8/6/2014 3

4 MEDICARE HAS REACHED THEIR CONCLUSION, SEND THE EXPLANATION OF MEDICARE BENEFITS WITH THE CLAIM TO US FOR PROCESSING. The claim was not sent to the Medicare within their timely filing provision. A request for review must be submitted to Medicare with the delay in filing reason. NM THE AUTHORIZATION NUMBER IS INVALID WITH THE SERVICE/SUPPLY BILLED. PLEASE RE-BILL USING THE CORRECT FAMILY CARE AUTHORIZATION NUMBER WITHIN 90 DAYS FROM THE DATE OF SERVICE OR 90 DAYS FROM MEDICARE'S OR THE PRIMARY CARRIER'S DETERMINATION. CONTACT THE CUSTOMER'S CARE Re-bill using the correct AUTH code that was authorized by Family Care within the timely filing limit. NO THE CLAIM EXCEEDED THE NUMBER OF AUTHORIZED UNITS FOR THIS SERVICE. Contact Member s CMU to obtain an authorization and resubmit claim with new authorization. NP THE PROCEDURE/SUPPLY CODE DOES NOT MATCH THOSE AUTHORIZED. PLEASE RE-BILL WITH THE CORRECT CODE WITHIN 90 DAYS FROM THE DATE OF SERVICE OR 90 DAYS FROM MEDICARE'S OR THE PRIMARY CARRIER'S DETERMINATION. CONTACT THE CUSTOMER'S CARE Re-bill using the correct procedure code that was authorized by Family Care with in timely filing. OZ REIMBURSEMENT IS BEING RETAINED FOR THE REPAYMENT OF FUNDS DUE FAMILY CARE. This is the explanation used for the Off-Set process. S8 THE NPI NUMBER PROVIDED FROM THE CLAIMIS INVALID. PLEASE RESUBMIT THE CLAIM WITH THE CORRECT NPI NUMBER WITHIN 90 DAYS FROM THE DATE OF SERVICE OR 90 DAYS FROM MEDICARE'S OR THE PRIMARY CARRIER'S DETERMINATION. CONTACT THE CUSTOMER'S CARE 8/6/2014 4

5 Re-bill services/supplies including the provider s valid NPI number within the timely filing limit. SG THE NPI NUMBER IS MISSING FROM THE CLAIM. PLEASE RE- BILL WITH THE NPI NUMBER WITHIN 90 DAYS FROM THE DATE OF SERVICE OR 90 DAYS FROM MEDICARE'S OR THE PRIMARY CARRIER'S DETERMINATION. CONTACT THE CUSTOMER'S CARE Re-bill services/supplies including the provider s NPI number within timely filing. SI THE PROVIDER OF SERVICE WAS NOT AUTHORIZED TO PROVIDE THIS SERVICE. PLEASE CONTACT THE CUSTOMER'S CARE The AUTH shows a different provider or location was approved to perform the services. Best course of action would be to contact the Customer s Care Manager. SU IN ORDER TO PROCESS BENEFITS CORRECTLY, THIS LINE WAS SPLIT FOR PROCESSING. No action needed, informational only. WS THESE CHARGES WERE SUBMITTED UNDER AN INCORRECT CUSTOMER NUMBER. WE WILL PROCESS THESE CHARGES UNDER THE VALID NUMBER. TO AVOID DELAYS IN THE FUTURE, PLEASE USE THE CORRECT NUMBER AND VERIFY THAT THE PROVIDER HAS THE CORRECT NUMBER. No action needed, informational only. 4A REF ID ON CPRO FOR THIS PROVIDER LOCATION DOES NOT MATCH THE REF ID LISTED ON THE AUTH. WORKED BY PROVIDER DEVELOPMENT. No action is needed. Our Provider Development department will research the provider and make any changes required based on their investigation internal and external. This could involve calling the provider or CCCW. 4F THE CHARGE EXCEEDS THE AUTHORIZED CONTRACTED FEE FOR THIS SERVICE. The amount billed is greater than the allowable fee as determined by Family Care. 8/6/2014 5

6 18 WE'VE ALREADY PROCESSED THIS CHARGE. The charges received for processing have already been considered. The denial informs the provider of the duplicate billing. 22 OUR RECORDS SHOW THIS PATIENT HAS PRIMARY COVERAGE WITH ANOTHER INSURANCE COMPANY. PLEASE RESUBMIT WITH A COPY OF THE OTHER COMPANY'S EXPLANATION OF BENEFITS. The Explanation of Benefits (EOB) from the Primary Carrier was missing at the time the claim was submitted for benefit consideration. Please resubmit the claim with the corresponding explanation of benefits for the services being billed. The complete information must be received within the timely filing limit. 23 CLAIM DENIED/REDUCED BECAUSE CHARGES HAVE BEEN PAID BY ANOTHER PAYER AS PART OF COORDINATION OF BENEFITS, WHICH MAY INCLUDE MEDICARE PAYMENTS. COORDINATION OF BENEFITS WITH YOUR PRIMARY PLAN OF COVERAGE MAY RESULT IN EITHER A REDUCED PAYMENT OR NO PAYMENT. The Patient s primary carrier, whether it is Medicare or a private health care insurance, has made payment on the claim. The primary carrier allowed a greater fee amount than Family Care s fee schedule. This would result in Family Care making a reduced payment or no payment at all. 25 THE DATE OF SERVICE IS EITHER BEFORE OR AFTER THE DATE RANGE AUTHORIZED BY FAMILY CARE. AUTHORIZATIONS ARE OBTAINED THROUGH THE CUSTOMER'S CARE MANAGER. The dates of service billed are not within the AUTH number submitted. Check the dates to make sure they are correct. If the dates are not correct, resubmit a new claim within the timely filing limit. If the dates are correct, contact the patient s CMU to obtain a new authorization and resubmit claim with new authorization. 27 EXPENSE(S) INCURRED AFTER COVERAGE TERMINATED. SERVICES PROVIDED AFTER THE TERMINATION DATE, ARE NOT COVERED. Care with an explanation and any documentation that supports your appeal in 28 EXPENSE(S) INCURRED PRIOR TO COVERAGE. SERVICES PROVIDED PRIOR TO THE EFFECTIVE DATE, ARE NOT COVERED. 8/6/2014 6

7 Care with an explanation and any documentation that supports your appeal in 29 THE TIME LIMIT FOR FILING HAS EXPIRED. CHARGES MUST BE SUBMITTED ON A TIMELY BASIS IN ORDER TO BE CONSIDERED FOR PAYMENT. 46 NON-COVERED CHARGE(S). 8/6/2014 7