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Edit 00164
Provider not Member of Group
HIPAA Claim Adjustment Reason Code: 16
Remark Code: N55
HIPAA Healthcare Claim Status Code: 132
Entity Identifier Code: QV
Potential Causes:
The individual provider indicated on the claim is not a member of the Group ID indicated on the claim.
Solution:
Enroll the individual provider to be part of the group. Check the Billing provider and Group ID entries to ensure that they are accurate. Institutional providers should not report Group ID numbers. Enter the data in the loops and the segments provided, resubmit.
| 837 Dental and 837 Professional GROUP PROVIDER |
Loop 2010AB, NM1 (Pay-To-Provider’s Name)
NM101 = 87 (Pay to Provider)
NM108 = 24 (Employer’s Identification Number)
NM108 = 34 (Social Security Number)
NM109 = (Employer’s Identification Number or Social Security Number
Loop 2010AB, REF (Pay-To-Provider Secondary Identification Number)
REF01 = 1D (Medicaid Provider Number)
REF02 = Medicaid Group ID Number
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Refer to the 837 Dental and Professional Supplemental Companion Guide, Section 1. “Provider(s) Identified in the 837 Dental and Institutional Transaction” for more detailed information on NYSDOH’s requirements and uses of the information conveyed in the Billing Provider Name segment.
| 837 Dental and 837 Professional BILLING PROVIDER |
Loop 2010AA, NM1 (Billing Provider Name)
NM101 = 85 (Pay to Provider)
NM108 = 24 (Employer’s Identification Number)
NM108 = 34 (Social Security Number)
NM109 = (Employer’s Identification Number or Social Security Number
Loop 2010AA, REF (Billing Provider Secondary Identification Number)
REF01 = 1D (Medicaid Provider Number)
REF02 = Billing Provider ID Number
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