Edit 01155

Utilization Threshold Service Authorization Exhausted

HIPAA Claim Adjustment Reason Code: 15
    Remark Code: N54
HIPAA Healthcare Claim Status Code: 84
    Entity Identifier Code: N/A

Potential Causes:
The service authorization that was on file was used on a different claim. The previously paid claim was for this recipient, by this provider, and for the same date of service. The paid claim would have been paid on the same or earlier remittance as the claim with this edit. If the claim is for Mental Health clinic, then two visits are allowed on the same day but the provider must get two service authorizations, one for each visit being billed. If a laboratory is sending in procedures on a claim, the requested amount of service authorizations was not an adequate amount.

Solution for claims requiring Service Authorization:
Review this and other remittance statements for the previously paid claim. If the claim is for a Mental Health clinic service, obtain a service authorization for the other visit and resubmit the claim.

If the claim is for a laboratory service, verify with Medicaid Eligibility Verification System (MEVS) how many service units (procedures) were entered when obtaining the service authorization and request another service authorization for the additional service units.

Solution for Service Authorization exempt claims:
If the claim should have been exempt from service authorization, please be sure that the correct exempting information is entered on the claim.