Edit 02013


Invalid Rate Code Billed for Recip Excp Code 86

HIPAA Claim Adjustment Reason Code: 16
    Remark Code: N30
HIPAA Healthcare Claim Status Code: 109
    Entity Identifier Code: QC

Potential Causes:
The Recipient Exception Code on NYSDOH files indicates that this client has a code of 86 (IR/ORS - Intensive Rehabilitation/Ongoing Rehabilitation Services) for this client. The claim failed edit 02013 because the Rate Code submitted is not valid for this client with this type of coverage.

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)