Edit 02059

Medicaid Days Invalid on Claims with Medicare HMO Days, Rebill Separately

HIPAA Claim Adjustment Reason Code: 125
            Remark Code: N61
HIPAA Healthcare Claim Status Code: 9
            Entity Identifier Code: N/A

Potential Causes:
The claim is indicating Medicare HMO involvement. It failed Edit 02059 because covered days were entered as both Medicaid days and Co-Insurance days.

Solution:
If your claim contains payer code ‘16’ in field SBR09 (Claim Filing Indicator Code), Loop 2320, SBR segment, then you are indicating that there was Medicare HMO involvement for this client. Please check to see if you entered multiple iterations of Loop 2300, QTY segment, with field QTY02 containing values for co-insurance days (Medicare HMO) and Medicaid days. If you did, then please resubmit the claim with only one iteration of the type of days covered.

Alternatively, if you are billing for both Medicaid full days and Medicare Co-Insurance days, then the claim must be split, and you should submit the two claims separately. Using the loops and segments below, please re-submit the claim with the correct fields populated.