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Edit 01027
Medicaid Coverage Code 09 Medicare Approved Amount Missing
HIPAA Claim Adjustment Reason Code: 16
Remark Code: MA92
HIPAA Healthcare Claim Status Code: 171
Entity Identifier Code: N/A
Potential Causes:
The Medicaid coverage of the recipient only allows payment of the claim if billing for the Medicare Deductible or Co-Insurance amounts and there was no Medicare information on the claim.
Solution:
Check the coverage of the recipient using MEVS. Contact the Local Department of Social Services to determine if the information is incorrect. Enter the Medicare paid amount and the deductible/coinsurance amounts due. Enter the data in the loop and the segment provided, and resubmit.
Deductible / Co-Insurance Amounts:
| 837 Institutional, 837 Professional and 837 Dental |
Claim Level
Loop 2320, CAS (Claim Adjustment)
CAS01 = PR (Claim Adjustment Group Code)
CAS01 = PR (Claim Adjustment Group Code)
CAS02 = 1 (deductible) or 2 (co-insurance) (Claim Adjustment Reason Code)
CAS03 = Deductible/Co-insurance Amounts (Monetary Amount)
Or
Line Level
Loop 2430, CAS (Service Adjustment)
CAS02 = 1 (deductible) or 2 (co-insurance) (Claim Adjustment Reason Code)
CAS03 = Deductible/Co-insurance Amounts (Monetary Amount) |
Note: the Claim Adjustment Group Code, Reason Code and Monetary Amount may be reported in any of CAS segments as defined in the CG. The above is only an example.
Medicare Paid Amount:
| 837 Institutional |
Loop 2320, AMT (Payer Prior Payment)
AMT01 = C4 (Amount Qualifier Code)
AMT02 = Medicare Paid Amount (Monetary Amount)
Or
Loop 2430, SVD (Service Line Adjudication Information)
SVD01 = Other Payer Identification
SVD02 = Medicare Paid Amount (Monetary Amount) |
| 837 Institutional, 837 Professional and 837 Dental |
Loop 2320, AMT (Coordination of Benefits (COB) Payer Paid Amount)
AMT01 = D (Payer Amount Paid)
AMT02 = Payer Paid Amount
Or
Loop 2430, SVD (Service Line Adjudication Information)
SVD01 = Other Payer Identification
SVD02 = Medicare Paid Amount (Monetary Amount) |
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