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Edit 00152
Recipient File Indicates Medicare/No Medicare Present
HIPAA Claim Adjustment Reason Code: 22
Remark Code: N/A
HIPAA Healthcare Claim Status Code: 85
Entity Identifier Code: MR
Potential Causes:
The patient’s state file is showing the patient as having Medicare but the claim has no reference to Medicare.
Solution:
Please enter your prior payer information in either the Claim Level or Service Level segments of the 837 transaction. Note: NYSDOH will process Medicare or other insurance information as received by the submitter in a Remittance Advice. Any adjustment amount from one adjustment should be reported only once. Please do not repeat a claim level adjustment at the line level. Furthermore, do not report the total of the line level adjustments in a claim level CAS segment.
Lastly, i f Medicare has denied payment, then 0FILL must be entered. 0FILL is used to indicate that a payer has denied the claim or has paid zero. Refer to the 837 Supplemental Companion Guide(s) section on "Cost Avoidance Override/Zero Fill" for more detailed information on NYSDOH’s requirements and uses of the SBR04 Free-form Name information as reported in the SBR segment. Please see the data field(s) for the 0FILL entry in the loops and segments below. (For more information on 0FILL – please review the 837 Supplemental Guides and/or the 837 Transaction Companion Guides located at NYHIPAADESK.COM
(http://www.emedny.org/hipaa/emedny_transactions/transactions.html).
Enter the appropriate Medicare information in the following Loops and segments and resubmit.
| 837 Institutional, 837 Professional, and 837 Dental (Claim Level) |
Loop 2000B, SBR (Subscriber Information)
SBR04 = 0FILL or MEDICAID (Free Form Name)
SBR09 = Claim Filing Indicator Code
Loop 2320, CAS (Claim Level Adjustment)
CAS01 = PR (Claim Adjustment Group Code)
CAS02 = 1 (deductible) and/or 2 (co-insurance) (Adjustment Reason Code)
CAS03 = Deductible/Co-insurance Amounts (Adjustment Amount)
Loop 2320, AMT (Payer Prior Payment)
AMT01 = C4 (Amount Qualifier Code)
AMT02 = Amount paid by Medicare (Other Patient Payer Paid Amount)
Loop 2330B, NM1 (Other Payer Name)
NM109 = Payer Code from Other Payer (Other Payer Primary Identifier)
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837 Institutional, 837 Professional, and 837 Dental (Line Level) |
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Loop 2000B, SBR (Subscriber Information)
SBR04 = 0FILL or MEDICAID (Free Form Name)
SBR09 = Claim Filing Indicator Code
Loop 2320, AMT (Payer Prior Payment)
AMT01 = C4 (Amount Qualifier Code)
AMT02 = Amount paid by Medicare (Other Patient Payer Paid Amount)
Loop 2330B, NM1 (Other Payer Name)
NM109 = Payer Code from Other Payer (Other Payer Primary Identifier)
Loop 2430, SVD (Service Line Adjudication Information)
SVD01 = Same Code Entered in Loop 2330B NM109 (Payer Identifier)
SVD02 = Amount Paid by Medicare (Service Line Paid Amount)
Loop 2430, CAS (Service Line Adjustment)
CAS01 = PR (Claim Adjustment Group Code)
CAS02 = 1 (deductible) and/or 2 (co-insurance) (Adjustment Reason Code)
CAS03 = Deductible/Co-insurance Amounts (Adjustment Amount)
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