Edit 02009


Recip Excp Code Must = 84 or 85 to Bill this Rate Code

HIPAA Claim Adjustment Reason Code: 16
    Remark Code: N30
HIPAA Healthcare Claim Status Code: 84
    Entity Identifier Code: N/A

Potential Causes:
The rate code submitted for this claim indicates that this is an OMH PROS (Office of Mental Health – Personalized Recovery Oriented Services) claim. The claim failed edit 02009 because the Recipient Exception Code on NYSDOH files does not indicate a value of 84 (CRS - Community Rehabilitation and Support) or 85 (CRS without Clinic) for this client

Solution:
The provider billed a rate code that is not valid for the PROS (Personalized Recovery Oriented Services) exception code of the client. The provider should check the rate code billed and if it is correct then they should check MEVS for the exception code of the client. If the exception code is incorrect they must contact the Local Department of Social Services regarding the PROS coverage on file for the client. If necessary, resubmit your claim using the loop and segment below.

837 Institutional

Loop 2300, HI (Value Information) HI01-1 = BE (Code List Qualifier Code) HI01-2 = 24 (Value Code) HI01-5 = 4 Digit Rate Code (Value Code Associated Amount – Rate Code)