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Edit 01314
Recipient Ineligible (Coverage Code is Equal to 18 (Family Planning))
HIPAA Claim Adjustment Reason Code: 96
Remark Code: N30
HIPAA Healthcare Claim Status Code: N/A
Entity Identifier Code: N/A
Potential Causes:
The recipient’s Medicaid eligibility covers Family Planning Services only and the Procedure Code/Diagnosis Code billed is not considered Family Planning by the Department of Health.
Solution:
Verify the recipient’s eligibility using MEVS (ePACES, POS machine (VeriFone Omni 3750/Vx570), or the ARU (800-997-1111). If the eligibility is for Family Planning Services only and the procedure or diagnosis code is not Family Planning related then this is not a valid claim for this recipient. Check the Procedure Code/Diagnosis Code entered to ensure the correct Procedure Code/Diagnosis Code was billed. If the service billed is for sterilization, then check to ensure a valid sterilization code was entered.
Reference material regarding family planning is available in the Medicaid Updates, which are available on http://www.health.state.ny.us click on Medicaid Update Index and choose Family Planning.
| 837 Institutional |
Loop 2300, HI (Principal, Admitting, E-Code and Patient Reason for Visit Diagnosis Information)
HI01-1 = BK (Code List Qualifier Code)
HI01-2 = Principal Diagnosis Code (Industry Code)
Loop 2300, HI (Condition Information)
HI01-1 = BG (Condition)
HI01-2 = A1 (Sterilization)
Loop 2400, SV2 (Institutional Service Line)
SV202-1 = HC (Product/Service ID Qualifier)
SV202-2 = Procedure Code – Enter HCPCS procedure code (Product/Service ID) |
| 837 Professional |
Loop 2300, NTE (Claim Note)
NTE01 = ADD (to indicate additional information)
NTE02 = AI (Sterilization)
Loop 2300, HI (Health Care Diagnosis Code)
HI01-1 = BK (Code List Qualifier Code)
HI01-2 = Diagnosis Code (Industry Code)
Loop 2400, SV1 (Professional Service)
SV101-1 = HC (Product/Service ID Qualifier)
SV101-2 = Procedure Code (Product/Service ID) |
See Accepted Reason Code 82 in the MEVS provider manual.
F |
LIMITATIONS |
82 (Family Planning) |
ELIGIBLE ONLY FAMILY PLANNING SERVICES |
The Family Planning Benefit Program provides Medicaid coverage for family planning services to persons of childbearing age with incomes at or below 200% of the federal poverty level. Eligible recipients (males and females) have access to all enrolled Medicaid family planning providers and family planning services currently available under Medicaid. |
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