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Edit 000791
DRG Equals 470 (Grouper Was Unable to Determine a Valid DRG)
HIPAA Claim Adjustment Reason Code: A8
Remark Code: N/A
HIPAA Healthcare Claim Status Code: 256
Entity Identifier Code: N/A
Potential Causes:
The system was unable to determine a valid DRG based on the information given on the claim. The information for DRG assignment includes the Admitting Diagnosis Code, Principle Diagnosis Code, Patient information and the various dates entered. This edit can also be failed if patient information on the State Recipient Eligibility file is different than the claim information. (A common cause for this edit, however, is if the claim is for a newborn baby claim and the claim was submitted without the birth weight in grams.)
Solution:
Check all the entries that are part of the possible causes as listed above to ensure the accuracy of the data. Check the patient data entered using MEVS to ensure all patient data on the claim matches the information on the recipient file. Be sure to compare the date of birth on file to the admission date on the claim. If billing for a newborn baby, ensure the birth weight in grams is on the claim. Also check to ensure the correct recipient number is used. All newborn baby claims must be submitted using the Recipient ID number of the baby. The mother’s ID number cannot be used on the baby claim. You may have to call Provider Services for additional assistance with this edit. Enter the data in the loop and the segment provided, and resubmit.
| 837 Institutional |
Loop 2010BA, NM1 (Subscriber Name)
NM108 = MI (Identification Code Qualifier)
NM109 = Recipient ID Number (Subscriber Primary Identifier)
Loop 2010BA, DMG (Subscriber Demographic Information)
DMG01 = D8 (Date Time Period Format Qualifier)
DMG02 = Recipient Date of Birth (Subscriber Birth Date)
DMG03 = Gender of recipient (F = female, M = male) (Subscriber Gender Code)
Loop 2300, DTP (Statement Dates)
DTP01 = 434 (Date/Time Qualifier)
DTP02 = RD8 (Date Time Period Format Qualifier) (Indicates date range)
DTP03 = Format CCYYMMDD- CCYYMMDD (Date Time Period)
Loop 2300, DTP (Admission Date/Hour)
DTP01 = 435 (Admission) (Date Time Qualifier)
DTP02 = DT (Date Time Period Format Qualifier) (Indicates Date and Time expressed in Format CCYYMMDDHHMM)
DTP03 = Admission Date and Hour
Loop 2300 HI (Principal, Admitting, E-Code and Patient Reason For Visit Diagnosis Information)
HI01-1 = BK (Principal Diagnosis) (Code List Qualifier Code)
HI01-2 = ICD-9-CM or 7999
Loop 2300, HI (Principal Procedure Information)
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