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Edit 00866
Medicaid Coverage Code 10; Recipient Ineligible For This Service
HIPAA Claim Adjustment Reason Code: 16
Remark Code: N30
HIPAA Healthcare Claim Status Code: 109
Entity Identifier Code: QC
Potential Causes:
The Recipient’s coverage is for all services except Long Term Care and this claim is considered Long Term Care by the state, therefore the coverage of the recipient does not include this type of claim.
Solution:
The Rate Code is used to determine if the claim is for Long Term Care. Check the Rate Code entered to ensure the correct Rate Code is being used. If the rate Code is correct, then the claim is not a valid Medicaid claim for the coverage assigned to the patient. Contact the Local Department of Social Services for information about the coverage assigned to the recipient. Enter the data in the loop and the segment provided, and resubmit.
See Accepted Reason Code 54 in the MEVS provider manual.
F |
LIMITATIONS |
54 (Long Term Care) |
ELIGIBLE EXCEPT NURSING FACILITY SERVICES |
Client is eligible to receive all Medicaid services except nursing home services provided in an SNF or inpatient setting. All pharmacy, physician, ambulatory care services and inpatient hospital services, not provided in a nursing home, are covered. |
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