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Edit 01354
Medicaid Coverage Code = 23 - Recipient Ineligible for this Service
HIPAA Claim Adjustment Reason Code: 96
Remark Code: N30
HIPAA Healthcare Claim Status Code: 109
Entity Identifier Code: QC
Potential Causes:
The Medicaid coverage code that the county has on file for this client does not match the services that were billed for.
Solution:
Ensure that the rate code, procedure code, or service date(s) submitted are correct. If the submitted fields are correct, contact the Local Department of Social Services to determine what services are billable for this client. If the submitted fields are incorrect, resubmit using the loops and segments below.
| 837 Institutional |
Loop 2300, DTP (Statement Dates)
DTP01 = 434 (Date/Time Qualifier)
DTP02 = D8 or RD8 (Date Time Period Qualifier)
DTP03 = Format CCYYMMDD or CCYYMMDD-CCYYMMDD (Date Time Period)
Loop 2300, HI (Value Information)
HI01-1 = BE (Code List Qualifier Code)
HI01-2 = 24 (Industry Code)
HI01-5 = 4 Digit Rate Code (Monetary Amount)
Loop 2400, SV2 (Institutional Service Line)
SV202-1 = HC (Product/Service ID Qualifier)
SV202-2 = Procedure Code – Enter HCPCS procedure code (Product/Service ID)
Loop 2400, DTP (Service Line Date)
DTP01 = 472 (Date/Time Qualifier)
DTP02 = D8 (Date Expressed in Format CCYYMMDD) or RD8 (Range of Dates Expressed in Format CCYYMMDD – CCYYMMDD)
DTP03 = Service Date or Range of Dates
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| 837 Professional |
Loop 2400, SV1 (Professional Service)
SV101-1 = HC (Product/Service ID Qualifier)
SV101-2 = Procedure Code (Product/Service ID)
Loop 2400, DTP (Date – Service Date)
DTP01 = 472 (Date/Time Qualifier)
DTP02 = D8 (Date Time Period Format Qualifier)
DTP03 = Service Date in the format CCYYMMDD (Date Time Period)
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