|
|
 |
Edit 01152
Restricted Recipient/Medicaid Managed Care Service Not Provided/Ordered/Referred By Primary Provider
HIPAA Claim Adjustment Reason Code: 38
Remark Code: N/A
HIPAA Healthcare Claim Status Code: 85
Entity Identifier Code: P3
Potential Causes:
The recipient is on file as a Restricted Recipient/Managed Care Service, and the Provider ID that was entered as the Ordering/Referring Provider is not the Provider listed as the Primary Provider on the recipients file.
Solution:
Check the Recipient ID number to ensure the correct Recipient ID was entered. Verify that the Provider ID Number that was entered as the Ordering/Referring Provider is correct. Note: A License Number (qualifier 0B cannot be used for this type of claim). Enter the data in the loop and the segment provided, and resubmit.
Recipient ID:
| 837 Institutional 837 Professional |
Loop 2010BA, NM1 (Subscriber Name)
NM109 = Recipient ID number (Identification Code)
NM108 = MI (Identification Code Qualifier) |
Referring Provider ID:
| 837 Institutional |
Loop 2310C NM1 (Other Provider Name)
NM108 = 24 (Employer’s Identification Number)
NM101 = 73 (Other Physician)
Or
NM108 = 34 (Social Security Number)
NM109 = (Employer’s Identification Number or Social Security Number)
And
REF01 = 1D (to indicate Medicaid Provider ID)
REF02 = Other Provider Secondary Identifier |
For 837P, NYSDOH processes Referring Provider information as follows: Two iterations of Loop 2310A may be required in certain cases. The first iteration processes Referring Provider information. The second iteration processes Other Referring Provider information if applicable in certain cases.
For Ordered Services (DME), utilize Loop 2420E at the line level.
| 837 Professional |
First Iteration:
Loop 2310A, NM1 (Referring Provider Name)
NM101 = DN (to indicate Referring Provider)
NM108 = 24 (Employer's Identification Number)
Or
NM108 = 34 (Social Security Number)
NM109 = Employer's Identification Number or Social Security Number
And
Loop 2310A, REF (Referring Provider Secondary Identifier)
REF01 = 1D (to indicate Medicaid Provider ID)
REF02 = Referring Provider Secondary Identifier
Second Iteration (if applicable):
Loop 2310A, NM1 (Referring Provider Name)
NM101 = P3 (to indicate Primary Care Provider)
NM108 = 24 (Employer's Identification Number)
Or
NM108 = 34 (Social Security Number)
NM109 = Employer's Identification Number or Social Security Number
And
Loop 2310A, REF (Referring Provider Secondary Identifier)
REF01 = 1D (to indicate Medicaid Provider ID)
REF02 = Referring Provider Secondary Identifier
(Professional only) For Ordering Provider (DME):
Loop 2420E, NM1 (Ordering Provider Name)
NM101 = DK (to indicate Ordering Physician)
NM108 = 24 (Employer's Identification Number)
Or
NM108 = 34 (Social Security Number)
NM109 = Employer's Identification Number or Social Security Number
And
Loop 2420E, REF (Ordering Provider Secondary Identification)
REF01 = 1D (to indicate Medicaid Provider ID)
REF02 = Ordering Provider Secondary Identifier
|
|
