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Edit 01171
Prepaid Capitation Recipient - Service Inappropriate for Enrollee
HIPAA Claim Adjustment Reason Code: 24
Remark Code: N/A
HIPAA Healthcare Claim Status Code: 97
Entity Identifier Code: N/A
Potential Causes:
The service billed is not a CARVEOUT service and is covered by the Managed Care Plan only. Only certain services (known as CARVEOUT services)are paid directly to the Service Provider by Medicaid for clients enrolled in Medicaid Managed Care Plans. The claim could have been billed in this manner, or it is possible that key fields on the claim were simply filled out incorrectly by the Manage Care Plan, causing the claim to fail this edit.
Solution:
Verify the MEVS (Medicaid Eligibility Verification System) coverage code to see what services are covered by the Managed Care Plan. Check the claim to ensure that the proper Procedure Code, Rate Code and Date of Service were billed. Enter the data in the loops and the segments provided and resubmit.
(In the event that the Service Provider submitted this claim, please submit the claim to the Managed Care Plan.)
| 837 Institutional |
Loop 2300, DTP (Statement Dates)
DTP01 = 434 (Date/Time Qualifier)
DTP02 = D8 or RD8 (Date Time Period Qualifier)
DTP03 = Format CCYYMMDD or CCYYMMDD thru CCYYMMDD (Statement From or To Date)
Loop 2300, HI (Value Information)
HI01-1 = BE (Code List Qualifier Code)
HI01-2 = 24 (Value Code)
HI01-5 = 4 Digit Rate Code (Value Code Associated Amount)
Loop 2400, SV2 (Institutional Service Line)
SV202-1 = HC (Product/Service ID Qualifier)
SV202-2 = HCPCS Procedure Code (Procedure Code)
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| 837 Professional |
Loop 2400, DTP (Date – Service Date)
DTP01 = 472 (Date/Time Qualifier)
DTP02 = D8 (Date Time Period Format Qualifier)
DTP03 = Service Date in the format CCYYMMDD (Service Date)
Loop 2400, SV1 (Professional Service)
SV101-1 = HC (Product or Service ID Qualifier)
SV101-2 = HCPCS Procedure Code (Procedure Code)
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| 837 Dental |
Loop 2300, DTP (Date – Service)
DTP01 = 472 (Date/Time Qualifier)
DTP02 = D8 or RD8 (Date Time Period Format Qualifier)
DTP03 = Service Date in the format CCYYMMDD or CCYYMMDD thru CCYYMMDD (Service Date)
Loop 2400, SV3 (Dental Service)
SV301-1 = AD (Product/Service ID Qualifier)
SV301-2 = American Dental Association Codes (Procedure Code)
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