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Edit 01122
Medicaid Coverage Code 14 - 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 J, which is the prenatal care program. The coverage only allows billing for prenatal care services under this coverage. For a hospital inpatient claim, before the Inpatient delivery is billed, the coverage must be changed to L. If it is not changed to an L, then the Inpatient claim fails this edit.
Solution:
Check the recipient’s eligibility using MEVS. If the eligibility code is “J” (Prenatal Care), the patient is only covered for prenatal care services.
See Accepted Reason Code 30 in the MEVS provider manual.
F |
LIMITATIONS |
30 (Medicaid) |
PRESUMPTIVE ELIGIBILITY PRENATAL B |
Client is eligible to receive only ambulatory prenatal care services. The following services are excluded: inpatient hospital, long-term home health care, long-term care, hospice, alternate level care, ophthalmic, DME, therapy (physical, speech, and occupational), abortion, and podiatry. |
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