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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 Medicaid eligibility of the recipient 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 eligibility of the recipient using MEVS. 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.
| 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)
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| 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)
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