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Edit 00747
Claim Type Not For Prior Approval Record Class
HIPAA Claim Adjustment Reason Code: 15
Remark Code: N/A
HIPAA Healthcare Claim Status Code: 252
Entity Identifier Code: N/A
Potential Causes:
The submitted claim type classification (example Nursing Home claim, Dental claim, Physician claim) does not match the claim type the Prior Approval was issued for. The PA was issued for a different type of claim than what was submitted.
Solution:
Check the Prior Approval Number entered on the claim (or line) to ensure that the correct PA number was entered. Depending on the claim type, check the Procedure Code and Modifier, or the Rate Code used on the claim. If all the information is correct then verify what information is on the NYSDOH file for the PA number used. If the PA number has incorrect data, then have the PA corrected and then resubmit. Enter the correct data in the loop and the segment provided, and resubmit.
Prior Approval:
| 837 Institutional |
Loop 2300, REF (Prior Authorization or Referral Number)
REF01 = G1 (Prior Authorization Number)
REF02 = Prior Authorization Number
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| 837 Professional |
Loop 2300, REF (Prior Authorization or Referral Number)
REF01 = G1 (Prior Authorization Number)
REF02 = Prior Authorization Number
Or
Loop 2400, REF (Prior Authorization or Referral Number)
REF01 = G1 (Prior Authorization Number)
REF02 = Prior Authorization Number
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| 837 Dental |
Loop 2300: REF (Prior Authorization or Referral Number)
REF01 = G1 (Reference Identification Qualifier)
REF02 = Prior Approval Number (Reference Identification)
Or
Loop 2400, REF (Prior Authorization or Referral Number)
REF01 = G1 (Prior Authorization Number)
REF02 = Prior Authorization Number
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| 837 Institutional |
Procedure Code Claim Level:
Loop 2300, HI (Principal Procedure Information) - (Inpatient or Clinic)
HI01-1 = BR (Code List Qualifier Code)
HI01-2 = Principal Procedure Code (Industry Code)
Rate Code:
Loop 2300, HI (Value Information) - (Inpatient or Clinic)
HI01-1 = BE (Value)
HI01-2 = 24 (Value Code)
HI01-5 = four digit Rate Code (monetary amount)
Procedure Code Line Level:
Loop 2400, SV2 (Institutional Service Line) - (Non-Inpatient)
SV202-1 = HC (Product/Service ID Qualifier)
SV202-2 = Procedure Code – Enter HCPCS procedure code (Product/Service ID)
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| 837 Professional |
Loop 2400, SV1 (Professional Service)
SV101-1 = HC (Product/Service ID Qualifier)
SV101-2 = Procedure Code (Product/Service ID)
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| 837 Dental |
Loop 2400, SV3 (Dental Service)
SV301-1 = AD (Product/Service ID Qualifier)
SV301-2 = Procedure Code (Product/Service ID)
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