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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 submit the claim with an emergency indicator.
Solution:
If a recipient has coverage for Emergency Services only, the emergency indictor must be entered on the claim and the diagnosis or procedure code must be considered an emergency by NYS DOH in order for the claim to be paid. If there are multiple diagnosis or procedure codes, then all of the diagnosis and or procedure codes must be indicated as emergency by NYS DOH for the claim to be paid when the recipient has coverage for emergency services only. If billing for Dental services, ensure the Procedure Code entered is 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. 800-342-3005.
| 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) |
See Accepted Reason Code 86 in the MEVS provider manual.
F |
LIMITATIONS (contd.) |
86 (Emergency) |
EMERGENCY SERVICES ONLY |
Client is eligible for emergency services from the time first given treatment for the emergency medical condition until such time as the medical condition requiring emergency care is no longer an emergency. An emergency is defined as a medical condition (including emergency labor and delivery) manifesting itself by acute symptom of sufficient severity (including severe pain), such that the absence of immediate medical attention could reasonably be expected to place the patient’s health in serious jeopardy, serious impairment of bodily functions or serious dysfunction of any body organ or part.
See also Medicaid Update July 2008: Payment Edits Policy for Treatment of an Emergency Medical Condition |
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