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Edit 90505
Denied Per Medicaid Review – This procedure is included within another billed procedure
HIPAA Claim Adjustment Reason Code: 97
Remark Code: N/A
HIPAA Healthcare Claim Status Code: 103
Entity Identifier Code: N/A
Potential Causes:
The claim was denied by the Department of Health after pending for Medical Review.
Solution:
Check the Procedure Code, Recipient ID and Date of Service to ensure they are entered correctly. If they are entered correctly, contact the Department of Health for an explanation of the denial. Enter the data in the loop and the segment provided, and resubmit.
| 837 Institutional |
Loop 2010BA, NM1 (Subscriber Name)
NM108 = MI (Identification Code Qualifier)
NM109 = Recipient ID number (Identification Code)
And
Loop 2400, SV2 (Institutional Service Line) - (Non-Inpatient)
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)
And
SV202-1 = HC (Product/Service ID Qualifier)
SV202-2 = Procedure Code – Enter HCPCS procedure code (Product/Service ID)
And
Loop 2400, DTP (Service Line Date)
DTP01 = 472 (Date/Time Qualifier)
DTP02 = D8 (Qualifier to indicate date)
= RD8 (Qualifier to indicate date range)
DTP03 = Service Date in the format CCYYMMDD (Date Time Period) |
| 837 Professional |
Loop 2010BA, NM1 (Subscriber Name)
NM108 = MI (Identification Code Qualifier)
NM109 = Recipient ID number (Identification Code)
And
Loop 2400, SV1 (Professional Service)
SV101-1 = HC (Product/Service ID Qualifier)
SV101-2 = Procedure Code (Product/Service ID)
And
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) |
| 837 Dental |
Loop 2010BA, NM1 (Subscriber Name)
NM108 = MI (Identification Code Qualifier)
NM109 = Recipient ID number (Identification Code)
And
Loop 2300, DTP (Date-Service)
DTP01 = 472 (Date/Time Qualifier)
DTP02 = D8 (Date Time Period Format Qualifier)
DTP03 = Service Date in the format CCYYMMDD (Date Time Period)
And
Loop 2400, SV3 (Dental Service)
SV301-1 = AD (Product/Service ID Qualifier)
SV301-2 = Procedure Code (Product/Service ID)
And
Loop 2400, DTP (Date-Service)
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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