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.

• If billing Mental Health Services for an SSI patient, refer to the March 2010 Medicaid Update for more information.

• 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

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.

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