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Edit 00127
Medicare Paid Amount Reported Less Than Reasonable
HIPAA Claim Adjustment Reason Code: 16
Remark Code: MA92
HIPAA Healthcare Claim Status Code: 182
Entity Identifier Code: N/A
Potential Causes:
The Medicare Paid amount reported on the claim is considered less than reasonable when
compared to the derived Medicare Approved Amount.
Solution:
Check the Medicare Paid amount and the amounts entered as the Medicare Deductible and or
Coinsurance due. (Note: this edit is handled as a Manual Review. You may not be able to avoid
this edit depending on circumstances. If the amounts entered on the claim are accurate then you
must send to CSC a copy of the Medicaid Remittance and a copy of the Medicare Statement to
document that the figures entered on the claim are correct. Contact Provider Services for further
information). Enter the data in the loop and the segment provided, and resubmit.
Also note: 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.
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)
Loop 2430, CAS (Service 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) |
Note: the Claim Adjustment Group Code, Reason Code and Monetary Amount may be reported in any of CAS segments as defined in the CG. The above is only an example.
Medicare Paid Amount:
| 837 Institutional |
Claim Level
Loop 2320, AMT (Payer Prior Payment)
AMT01 = C4 (Amount Qualifier Code)
AMT02 = Medicare Paid Amount (Monetary Amount)
Line Level 837
Loop 2430, SVD (Line Adjudication Information)
SVD01 = Other Payer Identification
SVD02 = Medicare Paid Amount (Monetary Amount)
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| 837 Professional and 837 Dental |
Loop 2320, AMT (Coordination of Benefits (COB) Payer Paid Amount)
AMT01 = D (Payer Amount Paid)
AMT02 = Payer Paid Amount
Loop 2430, SVD (Service Line Adjudication Information)
SVD01 = Other Payer Identification
SVD02 = Medicare Paid Amount (Monetary Amount) |
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