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Edit 00254
Service Code Not Equal To PA
HIPAA Claim Adjustment Reason Code: 15
Remark Code: M62
HIPAA Healthcare Claim Status Code: 84
Entity Identifier Code: N/A
Potential Causes:
The submitted Procedure Code with Modifier (or Rate Code if Institutional) does not match the Procedure Code and Modifier (or Rate Code) on the Prior Approval Number entered on the claim (or line).
Solution:
Check the Prior Approval Number entered on the claim (or line) to ensure that the correct PA number was entered. Depending on the claim type, check the Procedure Code and Modifier, or the Rate Code used on the claim. If all the information is correct then verify what information is on the NYSDOH file for the PA number used. If the PA number has incorrect data, then have the PA corrected and then resubmit. Enter the correct data in the loop and the segment provided, and resubmit.
Prior Approval:
| 837 Institutional |
Loop 2300, REF (Prior Authorization or Referral Number)
REF01 = G1 (Prior Authorization Number)
REF02 = Prior Authorization Number |
| 837 Professional |
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
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| 837 Dental |
Loop 2300: REF (Prior Authorization or Referral Number)
REF01 = G1 (Reference Identification Qualifier)
REF02 = Prior Approval Number (Reference Identification)
Or
Loop 2400, REF (Prior Authorization or Referral Number)
REF01 = G1 (Prior Authorization Number)
REF02 = Prior Authorization Number
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| 837 Institutional |
Procedure Code Claim Level :
Loop 2300, HI (Principal Procedure Information) - (Inpatient or Clinic)
HI01-1 = BR (Code List Qualifier Code)
HI01-2 = Principal Procedure Code (Industry Code)
Rate Code:
Loop 2300, HI (Value Information) - (Inpatient or Clinic)
HI01-1 = BE (Value)
HI01-2 = 24 (Value Code)
HI01-5 = four digit Rate Code (monetary amount)
Procedure Code Line Level:
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)
Loop 2400, SV2 (Institutional Service Line) - (Non-Inpatient)
SV202-3 = Procedure Modifier – Enter HCPCS procedure code modifier SV202-4 = Procedure Modifier – Enter HCPCS procedure code modifier SV202-5 = Procedure Modifier – Enter HCPCS procedure code modifier SV202-6 = Procedure Modifier – Enter HCPCS procedure code modifier
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| 837 Professional |
Loop 2400, SV1 (Professional Service)
SV101-1 = HC (Product/Service ID Qualifier)
SV101-2 = Procedure Code (Product/Service ID)
Loop 2400, SV1 (Professional Service)
SV101-3 = Procedure Modifier – Enter HCPCS procedure code modifier
SV101-4 = Procedure Modifier – Enter HCPCS procedure code modifier
SV101-5 = Procedure Modifier – Enter HCPCS procedure code modifier
SV101-6 = Procedure Modifier – Enter HCPCS procedure code modifier
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| 837 Dental |
Loop 2400, SV3 (Dental Service)
SV301-1 = AD (Product/Service ID Qualifier)
SV301-2 = Procedure Code (Product/Service ID)
Loop 2400, SV3 (Dental Service)
SV303-3 = Procedure Modifier – Enter HCPCS procedure code modifier
SV303-4 = Procedure Modifier – Enter HCPCS procedure code modifier
SV303-5 = Procedure Modifier – Enter HCPCS procedure code modifier
SV303-6 = Procedure Modifier – Enter HCPCS procedure code modifier
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