Edit 00715

Procedure Conflicts with Previous Service

HIPAA Claim Adjustment Reason Code: 18
    Remark Code: N/A
HIPAA Healthcare Claim Status Code: 54
   Entity Identifier Code: N/A

Potential Causes:
The Rate Code or Procedure Code you are billing for conflicts with another previously paid claim found in claims history with the same or similar Rate or Procedure Code.

The procedure(s) cannot be billed on the same date of service or within a certain period of each other. 

The history claim may have been paid to a different provider.

• Dental Providers:  The claim denied based on the clinical standard set by the New York State Department of Health (NYSDOH). For additional information, please call NYSDOH at 1-800-342-3005, option 2.
• DME: Diapers and Liners – A patient can receive up to 250 units per month of diapers and liners combined, not to exceed 1750 units in a six month period. The claim denies if one or more providers are billing more units than allowed. Billing claims out of sequence can also cause this denial
• Oxygen: Oxygen rental must be billed every 30th day. Providers must not assume that they can bill on the same date of service each month to comply with frequency limits.

Solution:
Research previous payments with matching Dates of Service and Rate or Procedure Code(s) on your remittance statements.

• Check the Dates of Service and Rate or Procedure code(s) to ensure the proper dates and code(s) were billed.
•  The claim will not pend for manual review by NYSDOH. A new claim with documentation cannot be submitted when a claim is denied for edit 00715.
• If you are not able to find a corresponding paid claim on your remittances, please contact the eMedNY Call Center at 1-800-343-9000 to determine the applicable history claim (this may have been paid to another provider. If this is the case you may have to contact the other provider to coordinate care). 
• DME: Diapers and Liners – Go back through your remittances to verify the number of units billed to NYS Medicaid for the previous six months. Also, verify the order in which the Dates of Service were billed.
• Example: Billing June, July and August Dates of Service before billing for May can cause the claim for the May to deny because those three months, as well as the previous six months, will be included in the calculation of the total units dispensed.
• If you have checked units dispensed and claim submission dates and cannot find where you have exceeded the allowed amount, call the eMedNY call center at 800-343-9000 to see if there is another provider also billing for the same items for this patient in this period.
• Oxygen: Check your remittances to see what date of service was billed for the previous month. Claims are only payable if billed for a date of service at least 30 days after that.