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Edit 01340
Claim Provider not Equal Restriction Recipient File Provider
HIPAA Claim Adjustment Reason Code: 38
Remark Code: N/A
HIPAA Healthcare Claim Status Code: 109
Entity Identifier Code: 1P
Potential Causes:
The Billing Provider ID does not match the Provider ID on the patient’s State File as the provider who should be billing for this recipient.
Solution:
Check the Billing Provider ID to ensure it is correct. If correct then contact the Department of Social Services to have the patient’s State File information corrected. Enter the data in the loop and the segment provided, and resubmit.
Note:
Refer to the 837 Institutional Supplemental Companion Guide, Section 1. “Provider(s) Identified in the 837 Institutional Transaction” for more detailed information on NYSDOH’s requirements and uses of the information conveyed in the Billing Provider Name segment.
| 837 Institutional |
| Loop 2010AA, NM1 (Billing Provider Name)
NM101 = 85 (Pay to Provider)
NM108 = 24 (Employer’s Identification Number)
Or
NM108 = 34 (Social Security Number)
NM109 = (Employer’s Identification Number or Social Security Number
And
Loop 2010AA, REF (Billing Provider Secondary Identification Number)
REF01 = 1D (Medicaid Provider Number)
REF02 = Billing Provider ID Number
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