Edit 01257

Graduate Medical Education Not Billable As A Separate Claim

HIPAA Claim Adjustment Reason Code: 16
    Remark Code: N52
HIPAA Healthcare Claim Status Code: 109
    Entity Identifier Code: QC

Potential Causes:
The Rate Code on the claim is for Graduate Medical Education (GME) but the recipient is not on file as being in a Medicaid Managed Care Plan. GME claims can only be billed if the patient is in a Medicaid Managed Care Plan.

Solution:
Check to ensure the correct Rate Code was used. If the correct Rate Code was entered, then verify that the patient is in a Medicaid Managed Care Plan. If there is a problem with the coverage of the recipient, contact the Department of Social services. Enter the data in the loops and segments provided and resubmit.