|
|
 |
Edit 00939
Ordering/Referring Provider Excluded Prior to Service/Order Date
HIPAA Claim Adjustment Reason Code: 183
Remark Code: N/A
HIPAA Healthcare Claim Status Code: 91
Entity Identifier Code: DK
Potential Causes:
The Ordering Referring Provider has been excluded from participating in Medicaid prior to Service Date.
Solution:
Check the Date of Service and the Referring Provider information to ensure it is correct. If the Referring Provider information is correct then the provider entered is excluded from Medicaid. (NOTE: NYSDOH expects to receive the Referring Provider for all claims that are the result of a referral. In the case of a restricted recipient, the recipient's Primary Care Provider must be reported.) Enter the data in the loops and segments provided, and resubmit.
| 837 Institutional |
Loop 2300, DTP (Statement Dates)
DTP01 = 434 (Date/Time Qualifier)
DTP02 = D8 or RD8 (Date Time Period Qualifier)
DTP03 = Format CCYYMMDD or CCYYMMDD-CCYYMMDD (Date Time Period)
Loop 2310C NM1 (Other Provider Name)
NM101 = 73 (Other Physician)
NM108 = 24 (Employer’s Identification Number)
Or
NM108 = 34 (Social Security Number)
NM109 = (Employer’s Identification Number or Social Security Number)
And
Loop 2310C, REF (Other Provider Secondary Identification)
REF01 = 0B (to indicate State License Number preceded by License type)
Or
REF01 = 1D (to indicate Medicaid Provider ID)
REF02 = Other Provider Secondary Identifier
And
Loop 2400, DTP (Service Line Date)
DTP01 = 472 (Date/Time Qualifier)
DTP02 = D8 (Qualifier to indicate date)
= RD8 (Qualifier to indicate date range)
DTP03 = Service Date in the format CCYYMMDD (Date Time Period)
|
|
For 837P NYSDOH processes Referring Provider information as follows: Two iterations of Loop 2310A may be required in certain cases. The first iteration processes Referring Provider information. The second iteration processes Other Referring Provider information if applicable in certain cases.
For Ordered Services (DME), utilize Loop 2420E at the line level.
| 837 Professional |
First Iteration:
Loop 2310A, NM1 (Referring Provider Name)
NM101 = DN (to indicate Referring Provider)
NM108 = 24 (Employer’s Identification Number)
Or
NM108 = 34 (Social Security Number)
NM109 = Employer’s Identification Number or Social Security Number
And
Loop 2310A, REF (Referring Provider Secondary Identifier)
REF01 = 0B (to indicate State License Number preceded by License type)
= 1D (to indicate Medicaid Provider ID)
REF02 = Referring Provider Secondary Identifier
Second Iteration (if applicable):
Loop 2310A, NM1 (Referring Provider Name)
NM101 = P3 (to indicate Primary Care Provider)
NM108 = 24 (Employer’s Identification Number)
Or
NM108 = 34 (Social Security Number)
NM109 = Employer’s Identification Number or Social Security Number
And
Loop 2310A, REF (Referring Provider Secondary Identifier)
REF01 = 0B (to indicate State License Number preceded by License type)
= 1D (to indicate Medicaid Provider ID)
REF02 = Referring Provider Secondary Identifier
For Ordering Provider (DME):
Loop 2420E, NM1 (Ordering Provider Name)
NM101 = DK (to indicate Ordering Physician)
NM108 = 24 (Employer’s Identification Number)
Or
NM108 = 34 (Social Security Number)
NM109 = Employer’s Identification Number or Social Security Number
And
Loop 2420E, REF (Ordering Provider Secondary Identification)
REF01 = 0B (to indicate State License Number preceded by License type)
= 1D (to indicate Medicaid Provider ID)
REF02 = Ordering Provider Secondary Identifier
And
Loop 2400, DTP (Date-Service Date)
DTP01 = 472 (Date/Time Qualifier)
DTP02 = D8 (Date Time Period Format Qualifier)
DTP03 = Service Date in the format CCYYMMDD (Date Time Period)
|
For 837D, NYSDOH processes Referring Provider information as follows: Two iterations of Loop 2310A may be required in certain cases. The first iteration processes Referring Provider information. The second iteration processes Other Referring Provider information if applicable in certain cases.
| 837 Dental |
Loop 2300, DTP (Date-Service)
DTP01 = 472 (Date/Time Qualifier)
DTP02 = D8 (Date Time Period Format Qualifier)
DTP03 = Service Date in the format CCYYMMDD (Date Time Period)
First Iteration:
Loop 2310A, NM1 (Referring Provider Name)
NM101 = DN (to indicate Referring Provider)
NM108 = 24 (Employer’s Identification Number)
Or
NM108 = 34 (Social Security Number)
NM109 = Employer’s Identification Number or Social Security Number
And
Loop 2310A, REF (Referring Provider Secondary Identifier)
REF01 = 0B (to indicate State License Number preceded by License type)
= 1D (to indicate Medicaid Provider ID)
REF02 = Referring Provider Secondary Identifier
Second Iteration (if applicable):
Loop 2310A, NM1 (Referring Provider Name)
NM101 = P3 (to indicate Primary Care Provider)
NM108 = 24 (Employer’s Identification Number)
Or
NM108 = 34 (Social Security Number)
NM109 = Employer’s Identification Number or Social Security Number
And
Loop 2310A, REF (Referring Provider Secondary Identifier)
REF01 = 0B (to indicate State License Number preceded by License type)
= 1D (to indicate Medicaid Provider ID)
REF02 = Referring Provider Secondary Identifier
And
Loop 2400, DTP (Date-Service)
DTP01 = 472 (Date/Time Qualifier)
DTP02 = D8 (Date Time Period Format Qualifier)
DTP03 = Service Date in the format CCYYMMDD (Date Time Period)
|
|
|
