Edit 00727

Claim Duplicates Same or Similar Service Paid to You or Another Provider

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

Potential Causes:
You, or another provider, were previously paid for this client for the same or overlapping Dates of Service.

• This may also be caused when a procedure is billed with the modifiers RT and LT on two separate lines. 
• Depending on the procedure code, a 50 modifier (Bilateral) may be applicable.

Solution:
Check your current and previous remittance statements to see if you can find the paid claim for the service.

• Check the date of service and procedure code to ensure the proper date of service and procedure code was billed. 
• If you are not able to find the claim on your remittances, please contact the eMedNY Call Center at 1-800-343-9000. 
• If both procedures were medically necessary, resubmit the claim on paper and include relevant medical documentation. The paper claim will pend for medical review to the DOH Review Unit. 
• If the 50 modifier is not applicable, resubmit the claim on paper and include relevant medical documentation.  The procedure should be billed on one line with 2 units and double the amount charged for a single unit.

Institutional Rate Based Claims:

Potential Causes: A claim for the same Client was paid to you or another provider. The conflicting claim has the same or overlapping Dates of Service.

Solution:
Check the Dates of Service on your claim to be sure they are correct.

• Review this and previous remittances to determine if you were previously paid for the same or overlapping Dates of Service.
• If you are unable to find a conflicting claim within your remittances, please call 1-800-343-9000 to see if another provider is billing a similar claim causing the duplicate denial.

The Dates of Service are found in the following loop and segments: