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Restricted Recipient Inpatient Service Not Provided/Ordered/Referred By Primary Provider

HIPAA Claim Adjustment Reason Code: 38
    Remark Code: N/A
HIPAA Healthcare Claim Status Code: 85
    Entity Identifier Code: P3

Potential Causes:
The Recipient is a Restricted Recipient and the claim did not have the NPI of the provider to whom the patient is restricted as the Referring Provider. When a patient is a Restricted Recipient, the provider they are restricted to must be entered as the Referring Provider on the claim. If a recipient is restricted to a facility, the facility NPI cannot be used. The NPI of the practitioner in charge at the facility the patient is restricted to must be entered as the referring provider.

NOTE: The entry must be the NPI of a NYS Medicaid-enrolled physician.

Solution:
Determine to whom the recipient is restricted and contact that provider to verify that a referral was made. If the referral was made, then enter that provider’s NPI as the Referring Provider (but as noted above, the NPI must belong to an individual physician). If no referral was made the claim cannot be submitted.

- The NPI must have first been reported to NYS Dept. of Health. Contact the NYS Dept. of Health, Provider Enrollment to confirm.

- The NPI of the practitioner must be affiliated with the facility for this to work. If a recipient is restricted to a facility and the NPI of a practitioner from the facility was used as the referring provider, the practitioner’s NPI must first have been reported as affiliated with the facility. The Facilities Affiliated Practitioners NPI Application can be accessed by going to:

http://www.emedny.org

and clicking on "Enter Facilities Practitioner’s NPIs", located in the green box on the right of the page.

Enter the data in the loop and the segment provided, and resubmit.