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Edit 00123
Amount Charged Is Less Than Medicare Approved Amount
HIPAA Claim Adjustment Reason Code: 16
Remark Code: MA92
HIPAA Healthcare Claim Status Code: 178
Entity Identifier Code: N/A
Potential Causes:
The amount charged cannot be less than the Medicare approved amount.
Solution:
Please check your information and resubmit. The amount charged needs to be equal to or greater
than the Medicare approved amount. The Medicare approved amount is derived by the
processing system and is not a reported entry on the 837. Add the Medicare Paid Amount, the
Deductible amount, and the Coinsurance Amount to derive the Medicare Approved Amount.
In the CAS (adjustment) segment, check the Deductible and/or Coinsurance amounts.
The Medicare data can be reported on either the Claim level or the Line level. The Medicare
coverage of the recipient can be checked using MEVS. If MEVS is showing Medicare coverage in
error, contact the Local Department of Social Services.
The Deductible/Coinsurance amounts may be reported on the Claim Level or Line Level. Enter
the data in the loop and the segment provided, and resubmit.
Claim Charge:
| 837 Institutional, 837 Professional, and 837 Dental (Claim Level) |
Loop 2300, CLM (Claim Information)
CLM02 = Amount Charged (Monetary Amount) |
| 837 Institutional (Line Level) |
Loop 2400, SV2 (Institutional Service Line)
SV203 = Amount Charged |
| 837 Professional (Line Level) |
Loop 2400, SV1 (Professional Service)
SV102 = Amount Charged |
| 837 Dental (Line Level) |
Loop 2400, SV3 (Dental Service)
SV302 = Amount Charged |
Deductible / Co-Insurance Amounts:
| 837 Institutional, 837 Professional and 837 Dental |
Claim Level 837 (I, P, D)
Loop 2320, CAS (Claim Adjustment)
CAS01 = PR (Claim Adjustment Group Code)
CAS02 = 1 (deductible) or 2 (co-insurance) (Claim Adjustment Reason Code)
CAS03 = Deductible/Co-insurance Amounts (Monetary Amount)
Line Level 837 (I, P, D) |
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