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Edit 01259
INVALID RATE FOR CLIENT NOT PCP ENROLLEE
HIPAA Claim Adjustment Reason Code: 16
Remark Code: N52
HIPAA Healthcare Claim Status Code: 109
Entity Identifier Code: N/A
Potential Causes:
The rate code billed is only valid for clients who are enrolled in a Medicaid Managed Care plan, when directly billing Medicaid for a carved out service.
Solution:
Confirm that the client is enrolled in a Medicaid Managed Care Plan as of the date of service. If they are not a different rate code must be used, as assigned for the provider’s use by NYSDOH.
| 837 Institutional |
Loop 2300, HI (Value Information)
HI01-1 = BE (Code List Qualifier Code)
HI01-2 = 24 (Industry Code)
HI01-5 = 4 Digit Rate Code (Monetary Amount)
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