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Edit 00129
Rate Code not on Rate File
HIPAA Claim Adjustment Reason Code: 16
Remark Code: M49
HIPAA Healthcare Claim Status Code: 463
Entity Identifier Code: N/A
Potential Causes:
For healthcare claims submitted electronically, the rate code reported on the claim is not on the provider’s rate file or is not valid at the location identified in the claim by zip code. For paper claims and non-healthcare electronic claims an incorrect rate code and/or location code may have been sent.
Solution:
This edit only applies to Institutional claims. For electronic healthcare claims, verify that the submitted rate code and service location zipcode are correct. In the case of a paper claim or non-healthcare electronic claim, verify that the rate code and/or location code are correct. Make any needed corrections, and re-submit.
| 837 Institutional |
Loop 2300, HI (Value Information)
HI01-1 = BE (Code List Qualifier Code)
HI01-2 = 24 (Industry Code)
HI01-5 = 4 Digit Rate Code (Monetary Amount)
- and -
Loop 2010AA, N4 (Billing Provider City/State/Zip Code)
N403 = Zip Code of the service location
- or -
For non-healthcare claims:
Loop 2010AA, REF (Billing Provider Secondary Identification)
REF01 = LU (Reference Identification Qualifier)
REF02 = Location Code (Reference Identification)
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