Edit 01141

Provider Exception IND Requires Pend (DOH)

HIPAA Claim Adjustment Reason Code: 133
    Remark Code: N/A
HIPAA Healthcare Claim Status Code: 46
    Entity Identifier Code: N/A

Potential Causes:
The State Audit Department has flagged the provider’s file so that all claims are pended for a State audit review. This edit can be applied for the Billing or Pay-to Provider and also, for Professional and Dental claims, the Rendering or Supervising provider if the conditions for Billing Provider override are met, as described in the NYSDOH Supplemental Companion Guides for the 837 Professional and 837 Dental.

Solution:
Call the State auditors to determine why the provider’s file has been flagged.