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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.
E |
EXCLUSIONS |
48 (Hospital Inpatient) and 54 (Long Term Care) |
ELIGIBLE ONLY OUTPATIENT CARE |
Client is eligible for all ambulatory care, including prosthetics; no inpatient coverage. |
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