Edit 01319

Recipient Exception Invalid for Home Community Based Services (HCBS) Waiver Program

HIPAA Claim Adjustment Reason Code: 16
            Remark Code: N30
HIPAA Healthcare Claim Status Code: 109
            Entity Identifier Code: QC

Potential Causes:
The Local Department of Social Services (LDSS) must approve the client for this Waiver Program and indicate that as an exception code for the client.

Solution:
Contact the LDSS to verify that the client is approved for the waiver program and that the appropriate exception has been entered into the system.

If the claim is not for HCBS Waiver program, then check the rate code entered to ensure that the proper service is being billed. Please refer to the Section on Value Codes in the New York State Medicaid 837 Institutional Supplemental Companion Guide for more detailed information on NYSDOH's requirements and uses of the codes conveyed in the HI, Value Information segment. Enter the data in the loop and the segment provided and resubmit.