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Edit 00165
Recipient Age Greater Than Maximum for Procedure (PEND)
HIPAA Claim Adjustment Reason Code: 6
Remark Code: N/A
HIPAA Healthcare Claim Status Code: 475
Entity Identifier Code: N/A
Potential Causes:
The age of the recipient exceeds the maximum age allowed for the Procedure Code entered on the claim.
Solution:
Check the Procedure Code entered on the claim to ensure the correct Procedure Code was used. Refer to the Coding Manual for the Procedure Code used, for the age restrictions on certain Procedure Codes. Check the Recipient ID Number used on the claim to ensure the right number was used. The age of the recipient can be verified using MEVS. If the date of Birth of the recipient is incorrect, contact the Local Department of Social Services. Enter the data in the loop and the segment provided, and resubmit
| 837 Institutional |
Loop 2300, HI (Principal Procedure Information) - (Inpatient of Clinic)
HI01-1 = BR (Code List Qualifier Code)
HI01-2 = Principal Procedure Code (Industry Code)
Or
Loop 2400, SV2 (Institutional Service Line) - (Non-Inpatient)
SV202-1 = HC (Product/Service ID Qualifier)
SV202-2 = Procedure Code – Enter HCPCS procedure code (Product/Service ID) |
| 837 Professional |
Loop 2400, SV1 (Professional Service)
SV101-1 = HC (Product/Service ID Qualifier)
SV101-2 = Procedure Code (Product/Service ID) |
| 837 Dental |
Loop 2400, SV3 (Dental Service)
SV301-1 = AD (Product/Service ID Qualifier)
SV301-2 = Procedure Code (Product/Service ID) |
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