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Edit 00547
Recipient Ineligible (Coverage Code is Equal to 07)
HIPAA Claim Adjustment Reason Code: 16
Remark Code: N30
HIPAA Healthcare Claim Status Code: 250
Entity Identifier Code: N/A
Potential Causes:
The coverage of the patient is for emergency services only. If the service rendered is not an emergency service, then the patient is not covered. If the service is an emergency, then the provider must give us an emergency indicator.
Solution:
If the service is for an emergency, enter the appropriate emergency indicator in the following loop and segment and re-submit. If billing for dental services check to ensure the Procedure Code entered is a Procedure Code flagged as for Emergency services. If a service was performed that is not on the approved list for emergency services, then the claim cannot be billed. If you need a list of approved services for Dental Emergency contact the Department of Health Dental Unit.
| 837 Institutional |
Loop 2300, CL1 (Institutional Claim Code)
CL101 = 1 (Admission Type Code) – Emergency Indicator |
| 837 Professional |
Loop 2400, SV1 (Professional Service)
SV109 = Y (Yes/No Condition or Response Code) – Emergency Indicator |
| 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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