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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:
- Managed Care Plans – The State file shows the patient in a managed care plan on the date of service however the managed care plan billed on this claim is not the one on file.
- All other providers – The state file shows the patient in a managed care plan on the date of service.
Solution:
- Typically this edit means there is a discrepancy on the recipient’s file. Contact the Department of Social Services to have the Managed Care Plan information corrected on the recipient’s file.
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