Edit 00291

Recipient Ineligible (Coverage Code is Equal to 02)

HIPAA Claim Adjustment Reason Code: 16
    Remark Code: N30
HIPAA Healthcare Claim Status Code: 109
    Entity Identifier Code: QC

Potential Causes:
The patient is eligible for Outpatient Services only, which includes all ambulatory care prosthetics with no inpatient coverage. The claim submitted does not fall into that category.

Solution:
The provider should verify eligibility for the recipient using MEVS. Eligibility can be checked via ePACES, POS machine (VeriFone Omni 3750/Vx570), or the ARU (800-997-1111). If you need assistance using the ARU please contact the eMedNY Call Center at 800-343-900. If patient is not eligible, the provider needs to contact the patient’s County DSS for assistance.

See Accepted Reason Codes 48 and 54 in MEVS provider manual.