Edit 02015


Medicare Coinsurance > 0 and Medicare Payment = 0

HIPAA Claim Adjustment Reason Code: 16
    Remark Code: MA04
HIPAA Healthcare Claim Status Code: 286
    Entity Identifier Code: N/A

Potential Causes:
A Medicare Paid Amount of zero and a Medicare Coinsurance Amount that is greater than zero were entered on the same claim. If Medicare paid zero or denied the claim, than there can be no Coinsurance Amount.

Solution:
After reviewing the Remittance Advice that you received from Medicare, check your submitted claim to ensure that you intended to submit the Medicare Coinsurance Amount. You can only populate this field if Medicare had paid an amount for this claim. Conversely, if Medicare denied the claim, or paid zero for the claim, then you cannot submit a Medicare Coinsurance Amount. After verifying your Medicare information, re-submit the claim using the loops and the segments provided. (Note: It is probable that you will use only one of the "boxes" below, depending on your Medicare claim information.)

Medicare Coinsurance Amount:

837 Institutional, Professional and Dental

Claim Level Loop 2320, CAS (Claim Level Adjustment) CAS01 = PR ((Patient Responsibility)(Claim Adjustment Group Code)) CAS02 = 2 ((Coinsurance) (Adjustment Reason Code)) CAS03 = Coinsurance Amount (Adjustment Amount) Line Level Loop 2430, CAS (Service Line Adjustment) CAS01 = PR ((Patient Responsibility) (Claim Adjustment Group Code)) CAS02 = 2 ((Coinsurance) (Claim Adjustment Reason Code)) CAS03 = Coinsurance Amount (Adjustment Amount)

Medicare Paid Amount (Institutional):

837 Institutional

Claim Level Loop 2320, AMT (Payer Prior Payment) AMT01 = C4 ((Prior Payment - Actual) (Amount Qualifier Code)) AMT02 = Medicare Paid Amount (Other Payer Patient Paid Amount) Line Level Loop 2430, SVD (Service Line Adjudication Information) SVD01 = Payer Identifier SVD02 = Medicare Paid Amount (Service Line Paid Amount)

Medicare Paid Amount (Professional and Dental):

837 Professional and Dental

Claim Level Loop 2320, AMT (Coordination of Benefits (COB) Payer Paid Amount) AMT01 = D ((Payer Amount Paid) (Amount Qualifier Code)) AMT02 = Medicare Paid Amount (Other Payer Patient Paid Amount) Line Level Loop 2430, SVD (Service Line Adjudication Information) SVD01 = Payer Identifier SVD02 = Medicare Paid Amount (Service Line Paid Amount)