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Edit 00696
Provider On Claim Not Recipient Prepaid Capitation Plan Provider
HIPAA Claim Adjustment Reason Code: 38
Remark Code: N/A
HIPAA Healthcare Claim Status Code: 93
Entity Identifier Code: 1P
Potential Causes:
The recipient’s file does not show the Billing Provider as the Managed Care Plan in which the recipient has been enrolled. The State file shows the recipient as being enrolled in another plan.
Solution:
Verify the Billing Provider ID Number is the correct Provider ID Number for this Recipient. Verify the correct Recipient ID was used. Contact the County Department of Social Services about the status of the recipient for this Plan. Enter the data in the loop and the segments provided, and resubmit.
| 837 Institutional |
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
And
Loop 2010BA, NM1 (Subscriber Name)
NM108 = MI (Identification Code Qualifier)
NM109 = Recipient ID number (Identification Code) |
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