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Edit 01121
Medical Assistance Coverage Code “L”, 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 “L”, which is the Prenatal Care Program and the claim contains a Condition Code that is indicating an Abortion. Abortion is not an allowable service when the eligibility of the recipient is through the Prenatal Care Program.
Solution:
Check the eligibility of recipient using MEVS. If the eligibility code is “L” (Prenatal Care) and the service performed is an Abortion, then the claim cannot be submitted; it is not a covered service under the program. If an Abortion was not performed then remove the Abortion Condition Code.
| 837 Institutional |
Loop 2300, HI (Condition Information)
HI01-1 = BG (Condition)
HI01-2 = Condition Code |
| 837 Professional |
Loop 2300, NTE (Claim Note)
NTE01 = ADD (to indicate additional information)
NTE02 = Abortion Code (see 837I Supplemental Guide – Section 12.) |
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