Edit 02016

Medicare Managed Care (MCO) Qualifier 16 Conflicts with Medicare Part A or Part B Qualifiers

HIPAA Claim Adjustment Reason Code: 129
            Remark Code: N4
HIPAA Healthcare Claim Status Code: 479
            Entity Identifier Code: N/A

Potential Causes:
This edit was failed because the provider submitted payer code 16 (Medicare HMO) and payer codes MA (Medicare Part A) and/or MB (Medicare Part B) on the same claim.

Solution:
If your claim contains payer code ‘16’ in field SBR09 (Claim Filing Indicator Code), Loop 2320, SBR segment, then you are indicating that there was Medicare HMO involvement for this client. Please check to see if you entered another iteration of Loop 2320, SBR segment, with field SBR09 containing values ‘MA’ or ‘MB’ indicating Medicare Part A or B. (If the client was in a Medicare HMO, there can be no Medicare Part A or Medicare Part B coverage. However, please note that if a client has Medicare HMO coverage on one date and Medicare Part A or B on another date, then please bill as two separate claims, except for Hospital Inpatient. Hospital Inpatient may submit one claim if the coverage changes after the admission date.) Using the loop and segment below, please re-submit the claim with the correct fields populated.

(NOTE: You may also wish to use MEVS or contact your Local Department of Social Services to verify/determine the coverage of the client.)