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Edit 00699
Recipient Coverage Indicates Capitation Claims and Primary Care Physician Referred Services Only
HIPAA Claim Adjustment Reason Code: 38
Remark Code: N/A
HIPAA Healthcare Claim Status Code: 94
Entity Identifier Code: QC
Potential Causes:
- The Recipient is enrolled in a Managed Care Plan; therefore, Medicaid will not pay for any services covered by the plan. If the recipient is enrolled in a partially capitated Managed Care Plan, the appropriate referral information must be on the claim.
Solution:
- Check MEVS to determine the recipient’s enrollment status in a Managed Care Plan.
- If partially capitated, ensure the correct referral information is supplied. Enter the data in the loop and the segment provided below and resubmit.
- NYSDOH expects to receive the Referring Provider’s NPI for all claims that are the result of a referral. In the case of a restricted recipient, the recipient's Primary Care Provider must be reported.
Eligibility Response Examples
MEVS manual - Accepted Reason Codes
Other or Additional Payer |
Response/Return |
Service Types Returned |
Possible Causes |
R – OTHER OR ADDITIONALPAYER |
30 – MEDICAID |
ELIGIBLE CAPITATION GUARANTEE |
PCP: A response of “Eligible Capitation Guarantee” indicates guaranteed status under a Prepaid Capitation Program (PCP). The PCP provider is guaranteed the capitation rate for a period of time after a client becomes ineligible for Medicaid services. Clients enrolled in some PCPs are eligible for some fee-for-service benefits if referred by the PCP provider. To determine exactly what services are covered, contact the PCP designated in the insurance code field. |
Phone Message (ARU):
Eligible Capitation Guarantee
Plan Code: ex AB, E4, G7
Verifone Message:
PLAN ELIG & BENEFITS
--------------------------------------------
Plan: WELLCARE OF NEW YORK INC
Plan Code: WC/ AINPQRTVYZ
Elig/ Ben Info: Managed Care Coordinator
ePACES Message:
Eligibility Information:
Other/ Additional Payer
Medicare Managed Care Plan
Plan Name:
WELLCARE OF NEW YORK INC
Carrier Code:
WC/ AINPQRTVYZ
Loops and Segments
| 837 Institutional |
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 |
For 837P and 837D, 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.
Professional Only: For Ordered Services (DME), utilize Loop 2420E at the line level.
| 837 Professional AND 837 Demtal |
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)
154
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
(Professional only) 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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