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Edit 01315
Federally Qualified Health Center (FQHC) Rate, Recipient Not Enrolled In Managed Care Plan
HIPAA Claim Adjustment Reason Code: 16
Remark Code: N30
HIPAA Healthcare Claim Status Code: 109
Entity Identifier Code: QC
Potential Causes:
The Rate Code used on the claim is for an FQHC facility, but the patient is not in a Medicaid Managed Care Plan. In order to bill that Rate Code, the patient must be in a Medicaid Managed Care Plan.
Solution:
Check to ensure the correct Rate Code was used on the claim. If the correct Rate Code was entered, then check the eligibility of the patient to ensure that they are in a Medicaid Managed Care Plan on the Date of Service billed. If the patient is not showing as being in a Plan on the Date of Service, then contact the Department of Social Services about the status of the patient’s enrollment in managed care.
| 837 Institutional |
Loop 2010BA, NM1 (Subscriber Name)
NM108 = MI (Identification Code Qualifier)
NM109 = Recipient ID number (Identification Code)
And
Loop 2300, DTP (Statement Dates)
DTP01 = 434 (Date/Time Qualifier)
DTP02 = RD8 (Date Time Period Qualifier)
DTP03 = Format CCYYMMDD-CCYYMMDD (Date Time Period)
And
Loop 2300, HI (Value Information) - (Inpatient of Clinic)
HI01-1 = BE (Value)
HI01-2 = 24 (Value Code)
HI01-5 = four digit Rate Code (monetary amount) |
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