Edit 01335

Recipient Has Medicare On File, The Managed Long Term Care (MLTC) Rate Code Billed is Invalid

HIPAA Claim Adjustment Reason Code: 16
    Remark Code: M49
HIPAA Healthcare Claim Status Code: 463
    Entity Identifier Code: N/A

Potential Causes:
The recipient state file is indicating that the recipient has Medicare. The Rate Code entered on the claim is to be used when a recipient has no Medicare.

Solution:
Check the Rate Code entered to ensure the correct Rate Code was used. Verify the Medicare coverage of the recipient using MEVS. If the Medicare coverage of the patient is incorrect then contact the Department of Social Services. Enter the data in the loop and the segment provided, and resubmit.