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Edit 01208
Assisted Living Program (ALP) Recipient/Service included in Per Diem
HIPAA Claim Adjustment Reason Code: 16
Remark Code: M97
HIPAA Healthcare Claim Status Code: 585
Entity Identifier Code: N/A
Potential Causes:
The patient is in an ALP program and the service billed is included in the rate paid to the ALP Provider.
Solution:
Check that the Rate Code or Procedure Code entered is correct. If the correct service was billed then contact the ALP facility for payment. Call the Local Department of Social Services to determine the ALP Facility the Recipient resides in. If an incorrect Rate Code or Procedure Code was billed then correct the entry and re-bill. Enter the data in the loop and the segment provided, and resubmit.
| 837 Institutional |
Loop 2300, HI (Value Information) - (Inpatient of Clinic)
HI01-1 = BE (Value)
HI01-2 = 24 (Value Code)
HI01-5 = four digit Rate Code (Monetary Amount) |
| 837 Professional |
Loop 2400, SV1 (Professional Service)
SV101-1 = HC (Product/Service ID Qualifier)
SV101-2 = Procedure Code (Product/Service ID) |
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