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Edit 00249
Provider ID for PA Service Not Equal File
HIPAA Claim Adjustment Reason Code: 16
Remark Code: N54
HIPAA Healthcare Claim Status Code: 91
Entity Identifier Code: 1P
Potential Causes:
The provider identifier on the Prior Approval Number does not belong to the same entity as the Billing Provider identifier on the claim.
Solution:
Check the Prior Approval Number entered on the claim to ensure the correct Prior Approval Number was used. Refer to the Prior Approval Roster to ensure the Prior Approval Number was issued to the correct provider. Check to see the claim was billed using the correct Billing Provider identifier. Enter the data in the loop and the segment provided, and resubmit.
| 837 Institutional and 837 Professional – NPI used |
Loop 2010AA
NM1 (Billing Provider Name)
NM101 = 85 (Qualifier for Billing Provider)
NM108 = XX (National Provider Identifier)
- and -
Loop 2300
REF (Prior Authorization or Referral Number)
REF01 = G1 (Prior Authorization Number)
REF02 = Prior Authorization Number (or Prescription/Order Number for DME on the 837P)
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| 837 Institutional and 837 Professional – Medicaid Provider ID used |
Loop 2010AA, NM1 (Billing Provider Name)
NM101 = 85 (Qualifier for Billing Provider)
NM108 = 24 (Employer’s Identification Number)
NM109 = Employer’s Identification Number
- or -
NM108 = 34 (Social Security Number)
NM109 = Social Security Number
- and -
Loop 2010AA, REF (Billing Provider Secondary Identification Number)
REF01 = 1D (Medicaid Provider Number)
REF02 = Billing Provider Medicaid ID
- and -
Loop 2300, REF (Prior Authorization or Referral Number)
REF01 = G1 (Prior Authorization Number)
REF02 = Prior Authorization Number
- or -
Loop 2400, REF (Prior Authorization or Referral Number)
REF01 = G1 (Prior Authorization Number)
REF02 = Prior Authorization Number or Prescription/Order Number for DME
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