Edit 00175

Service Provider ID Number not on NYS Master File

HIPAA Claim Adjustment Reason Code: 38
            Remark Code: N191
HIPAA Healthcare Claim Status Code: 153
            Entity Identifier Code: SJ

Potential Causes:
The Service Provider ID Number is not on the State file as a valid provider number or you may have entered a License Number without the 0B qualifier. Note: If you enter a License Number with the 1D qualifier (which is incorrect), our internal system will interpret it as a Provider ID Number.

Solution:
If an MMIS Provider ID was entered as a Service Provider ID Number, verify that the claim was submitted with the qualifier 1D. Also, please ensure that the number entered is 8 digits in length. If a License Number was entered then follow the instructions below:

License Number Note:
837 Institutional:
The entry of a License Number requires a three-character Profession Code and, depending on the claim type, two zeros to precede the License Number.
837 Professional:
When the claim level Rendering Provider Secondary Identification loop is sent, NYSDOH expects to receive the State License Number or the NYS Medicaid Provider ID. A State License Number must be preceded by the three-character Profession Code and in most cases, two zeros (exceptions exist for nurses, midwifes, and eye-care providers with prescribing privilege). Refer to the License to Profession Code Mapping document on nyhipaadesk.com for more information about using a license to identify a medical provider.
837 Dental:
When Loop 2310B is sent, NYSDOH expects to receive the Rendering Provider REF segment populated with the State License Number or the NYS Medicaid Provider ID. A State License Number must be preceded by the three-character Profession Code and two zeros. Refer to the License to Profession Code Mapping document on nyhipaadesk.com for more information about using a license to identify a medical provider.