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Edit 00156
Primary/Principal Diagnosis Invalid for Gender of Recipient
HIPAA Claim Adjustment Reason Code: 10
Remark Code: N/A
HIPAA Healthcare Claim Status Code: 86
Entity Identifier Code: N/A
Potential Causes:
The Diagnosis Code entered on the claim is incorrect for the gender of the patient.
Solution:
Please check your Diagnosis Code information and resubmit. Check the gender of the patient on
file using the MEVS system. If the gender of the patient is incorrect on MEVS, contact the
Department of Social Services. Enter the data in the loop and the segment provided, and
resubmit.
| 837 Institutional, and 837 Professional |
Loop 2010BA, DMG (Subscriber Demographic Information)
DMG01 = D8 (Date Time Period Format Qualifier)
DMG02 = Recipient Date of Birth (Date Time Period)
DMG03 = Gender of recipient (F = female, M = male) (Gender Code) |
Note: A gender must be indicated. Medicaid does not recognize a gender of U (unknown).
| 837 Institutional |
Loop 2300 HI (Health Care Diagnosis Code)
HI01-1 = BK (Principal Diagnosis)
HI01-2 = Principal Diagnosis
And
Loop 2400 SV1 (Professional Service)
SV107 -1 = Primary Diagnosis Code Pointer |
| 837 Professional |
Loop 2300 HI (Health Care Diagnosis Code)
HI01-1 = BK (Principal Diagnosis)
HI01-2 = Principal Diagnosis
And
Loop 2400 SV1 (Professional Service)
SV107-1 = Primary Diagnosis Code Pointer |
Note: Diagnosis Code: NYSDOH expects to receive the Primary Diagnosis Code pointer in Loop
2400, SV2, and SV107-1. NYSDOH will be unable to determine the appropriate Diagnosis Code
without this pointer.
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