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Edit 01123
Medical Assistance Coverage “I” – 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 eligibility of the Patient is for Prenatal Care Services only and the claim is not for Prenatal care services.
Solution:
Check to ensure the correct Rate Code was used. Check the eligibility of the Patient using MEVS. If the eligibility of the patient is incorrect, contact the Department of Social Services. Enter the data in the loops and segments provided below and resubmit.
| 837 Institutional |
Loop 2300, HI (Value Information)
HI01-1 = BE (Code List Qualifier Code)
HI01-2 = 24 (Industry Code)
HI01-5 = 4 Digit Rate Code (Monetary Amount) |
Loop 2300, HI (Value Information) - (Inpatient of Clinic)
HI01-1 = BE (Value)
HI01-2 = 24 (Value Code)
HI01-5 = four digit Rate Code (monetary amount) |
See Accepted Reason Code 30 in the MEVS provider manual.
F |
LIMITATIONS |
30 (Medicaid) |
PRESUMPTIVE ELIGIBILITY PRENATAL A |
Client is eligible to receive all Medicaid services except inpatient care, institutional long-term care, alternate level care, and long-term home health care. |
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