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Edit 000679
Restricted Recipient Service not provided/ordered/referred by Primary Physician
HIPAA Claim Adjustment Reason Code: 38
Remark Code: N/A
HIPAA Healthcare Claim Status Code: M49
Entity Identifier Code: 463
Potential Causes:
The Recipient ID Number entered on the claim is for a recipient who is restricted to a Primary Physician. The Billing Provider ID on the claim is not the provider the recipient is restricted to and the appropriate referring information from the Primary Physician was not submitted on the claim.
Solution:
Check the Recipient ID Number to ensure the correct Recipient ID was billed. Using MEVS, check the status of the Recipient to verify he/she is restricted. If the recipient is restricted, you can determine to whom the recipient is restricted to by calling the Local Department of Social Services. Then contact that provider to see if they referred the patient. If the referral was made, then enter the Primary Physician as the Referring Provider. Enter the data in the loop and the segment provided, and resubmit
| 837 Institutional |
BILLING PROVIDER:
Loop 2010AA, NM1 (Billing Provider Name)
NM101 = 85 (Pay to Provider)
NM108 = 24 (Employer’s Identification Number)
Or
NM108 = 34 (Social Security Number)
NM109 = (Employer’s Identification Number or Social Security Number
And
Loop 2010AA, REF (Billing Provider Secondary Identification Number)
REF01 = 1D (Medicaid Provider Number)
REF02 = Billing Provider ID Number
RECIPIENT ID:
Loop 2010BA, NM1 (Subscriber Name)
NM108 = MI (Identification Code Qualifier)
NM109 = Recipient ID number (Identification Code)
REFERRING PROVIDER:
Loop 2310C NM1 (Other Provider Name)
NM101 = 73 (Other Physician)
NM108 = 24 (Employer’s Identification Number)
Or
NM108 = 34 (Social Security Number)
NM109 = (Employer’s Identification Number or Social Security Number)
And
Loop 2310C, REF (Other Provider Secondary Identification)
REF01 = 0B (to indicate State License Number preceded by License type)
Or
REF01 = 1D (to indicate Medicaid Provider ID)
REF02 = Other Provider Secondary Identifier
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| 837 Professional |
For 837P NYSDOH processes Referring Provider information as follows: Two iterations of Loop 2310A may be required in certain cases. The first iteration processes Referring Provider information. The second iteration processes Other Referring Provider information if applicable in certain cases.
For Ordered Services (DME), utilize Loop 2420E at the line level.
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BILLING PROVIDER:
Loop 2010AA, NM1 (Billing Provider Name)
NM101 = 85 (Pay to Provider)
NM108 = 24 (Employer’s Identification Number)
Or
NM108 = 34 (Social Security Number)
NM109 = (Employer’s Identification Number or Social Security Number
And
Loop 2010AA, REF (Billing Provider Secondary Identification Number)
REF01 = 1D (Medicaid Provider Number)
REF02 = Billing Provider ID Number
RECIPIENT ID:
Loop 2010BA, NM1 (Subscriber Name)
NM108 = MI (Identification Code Qualifier)
NM109 = Recipient ID number (Identification Code)
REFERRING PROVIDER:
First Iteration:
Loop 2310A, NM1 (Referring Provider Name)
NM101 = DN (to indicate Referring Provider)
NM108 = 24 (Employer’s Identification Number)
Or
NM108 = 34 (Social Security Number)
NM109 = Employer’s Identification Number or Social Security Number
And
Loop 2310A, REF (Referring Provider Secondary Identifier)
REF01 = 0B (to indicate State License Number preceded by License type)
= 1D (to indicate Medicaid Provider ID)
REF02 = Referring Provider Secondary Identifier
Second Iteration (if applicable):
Loop 2310A, NM1 (Referring Provider Name)
NM101 = P3 (to indicate Primary Care Provider)
NM108 = 24 (Employer’s Identification Number)
Or
NM108 = 34 (Social Security Number)
NM109 = Employer’s Identification Number or Social Security Number
And
Loop 2310A, REF (Referring Provider Secondary Identifier)
REF01 = 0B (to indicate State License Number preceded by License type)
= 1D (to indicate Medicaid Provider ID)
REF02 = Referring Provider Secondary Identifier
For Ordering Provider (DME):
Loop 2420E, NM1 (Ordering Provider Name)
NM101 = DK (to indicate Ordering Physician)
NM108 = 24 (Employer’s Identification Number)
Or
NM108 = 34 (Social Security Number)
NM109 = Employer’s Identification Number or Social Security Number
And
Loop 2420E, REF (Ordering Provider Secondary Identification)
REF01 = 0B (to indicate State License Number preceded by License type)
= 1D (to indicate Medicaid Provider ID)
REF02 = Ordering Provider Secondary Identifier
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