Edit 01205

Procedure Code only valid for Care at Home Recipient

HIPAA Claim Adjustment Reason Code: 16
    Remark Code: MA66
HIPAA Healthcare Claim Status Code: 454
    Entity Identifier Code: N/A

Potential Causes:
The Procedure Code on the claim is for a Care at Home Recipient, but the recipient’s file does not show the recipient as approved for Care at Home services.

Solution:
Check the Procedure Code entered to ensure the correct procedure was used. Verify the eligibility of the Recipient as a Care at Home recipient by contacting the Local department of Social Services. Enter the data in the loop and the segments provided, and resubmit.