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Edit / Error Knowledge Base > Select Edit Range > 01101 to 01200 >

 

Edit 01172

Prepaid Capitation Recipient - Service Covered Within Plan (Deny)

HIPAA Claim Adjustment Reason Code: 24
    Remark Code: N/A
HIPAA Healthcare Claim Status Code: 97
    Entity Identifier Code: N/A

Potential Causes:

  • The patient is in a Medicaid HMO (Medicaid Managed Care Plan) and the service billed is covered by the plan. You must bill the plan for this service. If the plan is not paying for some reason, neither will Medicaid.
  • The patient is enrolled with Family Health Plus rather than Medicaid.

Solution:

  • Verify eligibility of the patient using ePACES, ARU, or POS machine.

  • Verify that the claim was submitted with the correct Rate or Procedure Code as some services are “carved out” of some Managed Care plans and are paid for by Medicaid. If the information reported is correct, you must bill the recipient’s Managed Care Plan.

  • Some services are carved out of the Plan by Specialty. CSC assigns all Specialty Codes. The denial could be caused by an incorrect Specialty Code derivation. Specialty Code derivation is determined by the Rate Code, Type of Bill Code and Revenue Code for institutional providers. If you are unsure of the Type of Bill or Revenue Code to use, refer to the RATE CODE CROSSWALK.
  • Psychology services provided by fee-for service practitioners are “carved out” when the client is SSI.  The billing provider also needs to have the 192 (Psychiatry) specialty code to bypass the Managed Care Plan. To derive the Specialty Code, enter the number “7” in the SA exception code field.

  • When a client is enrolled in a Catholic Managed Care Plan, such as NYS Catholic Health Plan, Inc. (Fidelis), Family Planning services are “carved out”.  The family planning indicator must be marked.  The procedure code and diagnosis code must be classified as Family Planning. 

  • If you believe the service should be carved out, then contact the Managed Care office at (518) 474-5050 for policy and general questions on managed care plans.
  • Family Health Plus: If Patient is enrolled with Family Health Plus you will need to contact FHP for billing information.

Eligibility Response Examples

MEVS manual  - Accepted Reason Codes

Managed Care Plan

Response/Return

Service Types Returned

Possible Causes

MC – MANAGED CARE

30 – MEDICAID

ELIGIBLE PCP

A response of “Eligible PCP” indicates coverage under a Prepaid Capitation Program (PCP). This status means the client is PCP eligible as well as eligible for limited fee-for-service benefits. To determine exactly what services are covered, listen to the PCP services returned in the response. If further clarification is needed, contact the PCP designated in the insurance code field.



Other or Additional Payer

Response/Return

Service Types Returned

Possible Causes

R – OTHER OR ADDITIONALPAYER

30 – MEDICAID

ELIGIBLE CAPITATION GUARANTEE

PCP: A response of “Eligible Capitation Guarantee” indicates guaranteed status under a Prepaid Capitation Program (PCP). The PCP provider is guaranteed the capitation rate for a period of time after a client becomes ineligible for Medicaid services. Clients enrolled in some PCPs are eligible for some fee-for-service benefits if referred by the PCP provider. To determine exactly what services are covered, contact the PCP designated in the insurance code field.



Other or Additional Payer

Response/Return

Service Types Returned

Possible Causes

R – OTHER OR ADDITIONALPAYER

30 – MEDICAID

FAMILY HEALTH PLUS

Client is enrolled in the Family Health Plus Program (FHP) and receives most services through a FHP participating Managed Care Plan.

Eligibility Response Examples

    Phone Message (ARU):

        Eligible PCP
        Plan Code: examples - AB, E4, G7

    Verifone Message:

        PLAN  ELIG & BENEFITS
        --------------------------------------------
        Plan: WELLCARE OF NEW YORK INC
        Plan Code: WC/ AINPQRTVYZ
        Elig/ Ben Info: Managed Care Coordinator 

    Click here for more information on insurance coverage codes.

    ePACES Message:

        Eligibility Information:
        Managed Care Coordinator 

        Medicaid Managed Care Plan
        Plan Name:
        WELLCARE OF NEW YORK INC

        Carrier Code:
        WC/ AINPQRTVYZ

    Click here for more information on insurance coverage codes.

Eligibility Responses for Edit 01172 in combination with 00699:

NOTE (Edit 00699): If you receive edit 01172 in combination with edit 00699 this means that the patient no longer has Medicaid coverage and is only eligible for services covered by the HMO for that date period. Since the HMO services are prepaid they will retain the HMO coverage until the prepayment period expires. To determine exactly what services are covered, contact the (HMO) designated in the insurance code field.   Medicaid will not cover services that are not covered by the HMO.

     Phone Message (ARU):

        Eligible Capitation Guarantee
        Plan Code: examples - AB, E4, G7

    Verifone Message:

        PLAN  ELIG & BENEFITS
--------------------------------------------
        Plan: WELLCARE OF NEW YORK INC
         Plan Code: WC/ AINPQRTVYZ
         Elig/ Ben Info: Other/ Additional Payer

    Click here for more information on insurance coverage codes.

     ePACES Message:

        Eligibility Information:
        Other/ Additional Payer

        Medicaid Managed Care Plan
        Plan Name:
        WELLCARE OF NEW YORK INC

        Carrier Code:
        WC/ AINPQRTVYZ

    Click here for more information on insurance coverage codes.

Enter the data in the loop and the segments provided below and resubmit.

Loops and Segments

837 Institutional
Loop 2300, CLM (Claim Information)
CLM05 -1 = Place of Service Code (Facility Code Value)

Loop 2300, HI (Value Information)
HI01-1 = BE (Value)
HI01-2 = 24 (Value Code)
HI01-5 = four digit Rate Code (Monetary Amount)
Or
Loop 2400, SV2 (Institutional Service Line)
SV201 = Service Line Revenue Code

Loop 2400, SV2 (Institutional Service Line)
SV202-1 = HC (Product/Service ID Qualifier)
SV202-2 = Procedure Code – Enter HCPCS Procedure Code (Product/Service ID)

837 Professional
Loop 2300, CLM (Claim Information)
CLM05 -1 = Place of Service Code (Facility Code Value)

Loop 2400, SV1 (Professional Service)
SV101-1 = HC (Product/Service ID Qualifier)
SV101-2 = Procedure Code (Product/Service ID)

837 Dental
Loop 2300, CLM (Claim Information)
CLM05 -1 = Place of Service Code (Facility Code Value)

Loop 2400, SV3 (Professional Service)
SV301-1 = HC (Product/Service ID Qualifier)
SV301-2 = Procedure Code (Product/Service ID)


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