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Edit 01154
No Utilization Threshold Service Authorization Record on File
HIPAA Claim Adjustment Reason Code: 15
Remark Code: N54
HIPAA Healthcare Claim Status Code: 84
Entity Identifier Code: N/A
Potential Causes:
The claim submitted requires a Service Authorization and no Service Authorization was on file for the billing provider and Medicaid client. If a Service Authorization was obtained, the Service Authorization went on file after the claim was processed, or an incorrect Specialty Code was assigned to the claim.
Solution:
Check the identifier used in the Billing Provider Name loop to insure that it belongs to the same provider entity as the Service Authorization. If the Service Authorization is under a different provider then re-bill the claim with the correct provider identifier.
Check the date the Service Authorization was received. If the Service Authorization was not processed before the time the claim was submitted, the claim will be pended and will recycle, and could pay in the subsequent payment cycle.
Call the eMedNY Call Center to check the claim’s Specialty Code to insure the correct Specialty Code was assigned.
The Specialty Code is system-derived. Derivation problems, when reported, are resolved as priority issues. Please check with Provider Services to see when you should resubmit the claim.
| 837 Institutional and 837 Professional – NPI used |
Loop 2010AA
NM1 (Billing Provider Name)
NM101 = 85 (Qualifier for Billing Provider)
NM108 = XX (National Provider Identifier)
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| 837 Institutional and 837 Professional – Medicaid Provider ID used |
Loop 2010AA, NM1 (Billing Provider Name)
NM101 = 85 (Qualifier for Billing Provider)
NM108 = 24 (Employer’s Identification Number)
NM109 = Employer’s Identification Number
- or -
NM108 = 34 (Social Security Number)
NM109 = Social Security Number
- and -
Loop 2010AA, REF (Billing Provider Secondary Identification Number)
REF01 = 1D (Medicaid Provider Number)
REF02 = Billing Provider Medicaid ID
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