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Edit 01283
Upper Dollar Limit Exceeded
HIPAA Claim Adjustment Reason Code: 96
Remark Code: M54
HIPAA Healthcare Claim Status Code: 585
Entity Identifier Code: N/A
Potential Causes:
The Medicare Approved and Paid Amounts are higher than the limits set by DOH.
Solution:
Check to ensure that the Medicare Paid amount and the Medicare Deductible/Coinsurance amounts entered are correct.
Note: The Medicare Approved Amount is system derived by adding the Medicare Paid Amount to the Medicare Deductible/Coinsurance amounts(s) to arrive at the Medicare Approved Amount.
If the amounts entered are correct, then this edit must be resolved through the CSC Pend Resolution Unit (Edit Review Panel) by sending in a hard copy of the Medicare EOB to document that the Medicare figures given on the claim are correct. In addition, a hard copy of the Medicaid Remittance showing the corresponding pended claim must accompany the Medicare EOB. For further information contact the Call Center. If a claim was denied for this edit, it means the referenced documentation was received and the figures on the hard copy Medicare EOB were different than the figures on the claim. Enter the data in the loops and the segments provided, and resubmit.
| 837 Institutional |
Loop 2320, CAS (Claim Level Adjustment)
CAS01 = PR (Claim Adjustment Group Code)
CAS02 = 1 (deductible) or 2 (co-insurance) (Claim Adjustment Reason Code)
CAS03 = Deductible/Co-insurance Amounts (Monetary Amount)
Loop 2430, CAS (Service Line Adjustment)
CAS01 = PR (Claim Adjustment Group Code)
CAS02 = 1 (deductible) or 2 (co-insurance) (Claim Adjustment Reason Code)
CAS03 = Deductible/Co-insurance Amounts (Monetary Amount)
Loop 2320, AMT (Payer Prior Payment)
AMT01 = C4 (Amount Qualifier Code)
AMT02 = Medicare Paid Amount or Other Insurance Paid Amount (Monetary Amount)
Loop 2430, SVD (Line Adjudication Information)
SVD01 = Other Payer Identifier
SVD02 = Medicare Paid Amount or Other Insurance Paid Amount (Monetary Amount)
SVD05 = Other Covered Days
Loop 2320, MIA (Medicare Inpatient Adjudication Information)
MIA01 = Other Payer Covered Days
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| 837 Professional and 837 Dental |
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Loop 2320, CAS (Claim Level Adjustment)
CAS01 = PR (Claim Adjustment Group Code)
CAS02 = 1 (deductible) or 2 (co-insurance) (Claim Adjustment Reason Code)
CAS03 = Deductible/Co-insurance Amounts (Monetary Amount)
Loop 2430, CAS (Service Line Adjustment)
CAS01 = PR (Claim Adjustment Group Code)
CAS02 = 1 (deductible) or 2 (co-insurance) (Claim Adjustment Reason Code)
CAS03 = Deductible/Co-insurance Amounts (Monetary Amount)
Loop 2320 AMT (Coordination of Benefits (COB) Payer Paid Amount
AMT01 = D (Payer Amount Paid)
AMT02 = Payer Paid Amount
Loop 2430, SVD (Line Adjudication Information)
SVD01 = Other Payer Identifier
SVD02 = Medicare Paid Amount or Other Insurance Paid Amount (Monetary Amount)
SVD05 = Other Covered Days
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