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Edit 00397
Amount is 10% or LS AMT on Procedure File
HIPAA Claim Adjustment Reason Code: 96
Remark Code: M54
HIPAA Healthcare Claim Status Code: 46
Entity Identifier Code: N/A
Potential Causes:
The Amount charged entry contained an amount that is 10% of the value of the Procedure Code or less.
Solution:
Check the amount entered as the Amount Charged. Verify the Procedure Code entered was the correct Procedure Code. Verify the value of the Procedure Code using the appropriate Medicaid Fee Schedule. Enter the data in the loop and the segment provided, and resubmit.
Amount Charged:
| 837 Institutional, 837 Professional, and 837 Dental Claim Level |
Loop 2300, CLM (Claim Information)
CLM02 = Amount Charged (Monetary Amount)
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| 837 Institutional Line Level |
Loop 2400, SV2 (Institutional Service Line)
SV203 = Amount Charged
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| 837 Professional Line Level |
Loop 2400, SV1 (Professional Service)
SV102 = Amount Charged
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| 837 Dental Line Level |
Loop 2400, SV3 (Dental Service)
SV302 = Amount Charged
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Procedure Code:
| 837 Institutional |
Loop 2300, HI (Principal Procedure Information) - (Inpatient of Clinic)
HI01-1 = BR (Code List Qualifier Code)
HI01-2 = Principal Procedure Code (Industry Code)
Or
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)
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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)
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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)
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Note: Dental Schools should use a facility code value of 03. All other codes will be denied for business reasons.
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