Edit 01174

Prepaid Capitation Recipient – Service Covered Within Plan Pend for State Review

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 and the service billed is covered by the plan the patient is in. The provider must bill the plan for this service.

Solution:
Verify that the claim was submitted with the correct Rate or Procedure Code as some services are “carved out” of managed care and are paid for by Medicaid. If the information reported is correct, the provider 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. If you are unsure of the Type of Bill or Revenue Code to use, refer to the 837 Institutional Supplemental Guide or the Rate Code Crosswalk (located at http://www.nyhipaadesk.com) or the Department of Health web site (http://www.health.state.ny.us/).

If the claim is pended, you should wait for the Manual review process to be completed. If the claim is denied after Manual Review, then follow the above instructions.