NYS Department of Health Revised emedny edits - Reason Codes and Remark Codes. Old Reason Code BILLING DATE INVALID MA52 MA31

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1 Revised edits - s and s Definition BILLING DATE MA52 MA EMERGENCY CODE MUST INDICATE Y OR N SERVICE PROVIDER ID NUMBER REFERRING PROVIDER ID NUMBER RECIPIENT INELIGIBLE ON SERVICE DATE PROVIDER INELIGIBLE SERVICE ON DATE PERFORMED SERVICE PROVIDER ID NUMBER NOT ON NYS MASTER FILE M58 MA N N B7 38 N UNITS GREATER THAN MAXIMUM PROCEDURE CODE INCONSISTENT WITH FAMILY PLANNING CODE PRIMARY DIAGNOSIS INDICATES ABORTION/ABORT CODE SECONDARY DIAGNOSIS INDICATES ABORTION/ABORTION CODE PRESCRIPTION / ORDER NUMBER IS MISSING MISSING OR QUANTITY DISPENSED B NEW / REFILL NUMBER AUTHORIZED REFILLS NUMBER DISPENSE AS WRITTEN CODE PROFESSION CODE B NYS Medicaid Fiscal Agent 1

2 Revised edits - s and s Definition REFILL EXCEEDS MAXIMUM NUMBER AUTHORIZED PLAN LIMITATIONS EXCEEDED REFILL NUMBER EXCEEDS MAXIMUM PRESCRIBING PROVIDER PROFESSION CODE FOR ISSUING PRESCRIPTION CATEGORY OF SERVICE FOR NDC CODE ADMIT NUMBER MISSING M58 N FAMILY PLANNING INDICATOR FOR BILLING PROVIDER INAPROPRIATE SECOND SERVICE - SAME DAY PROCEDURE/FORMULARY CODE EXCEEDS SERVICE LIMITS M63 M PROC EXCEEDS SERVICE LIMITS DIAGNOSIS CODE BLANK A FULL ICD-9 CM CODE REQUIRED MA ICD-9-CM DIAGNOSIS CODE ON PHYSICIAN CLAIM NOT ON FILE ICD-9-CM DIAGNOSIS CODE ON PHYSICIAN CLAIM NOT ON FILE DOS FOR WEEKLY RATE NOT ON A SUNDAY MA06 M ONLY UPSTATE CONTRACTOR ALLOWED TO BILL FOR SERVICE PATIENT BORN IN HOSPITAL/YEAR OF BIRTH DIFFERS FROM ADMIT YEAR MA38 N TYPE FOR SERVICE NYS Medicaid Fiscal Agent 2

3 Revised edits - s and s Definition PRESCRIBING PROVIDER ID NOT ON MMIS PROVIDER FILE/PRESCRIBER TYPE BLANK PRESCRIBING PROVIDER CATEGORY OF SERVICE FOR PHARMACY CATEGORY OF SVC INVALD FOR DME ORDERING OR REFERRING PROVIDER ID OR LICENSE NUMBER NOT ON CLAIM N CLINIC SPECIALTY CODE NOT ON NEW YORK STATE MASTER FILE EXCLUDED PRIOR TO SERVICE/ORDER DATE SERVICE PROVIDER EXCLUDED PRIOR TO SERV/ORDER DATE DECEASED ON SERVICE/ORDER DATE SERVICE PROVIDER DECEASED ON SERVICE/ORDER DATE REFERRING PROVIDER PROFESSION CODE REFERRAL DATA INCONSISTENT N SPECIALTY CODE FOR LONG TERM HHC CATEGORY OF SERVICE DOES NOT ALLOW EMERGENCY RECIPIENT LESS THAN 21/PRESCRIBER NOT PHC NURSE PRACTITIONER/MIDWIFE NOT QUALIFIED TO PRESCRIBE LEGEND DRUGS NYS Medicaid Fiscal Agent 3

4 Revised edits - s and s Definition PART A DEDUCTIBLE PREVIOUSLY PAID FOR THIS SPELL OF ILLNESS N17 N ENHANCED FEE PROCEDURE CODE USED FOR NON-QUALIFIED RECIPIENT OR PROVIDER FOR SERVICE - RECIPIENT NOT QUALIFIED MEDICARE BENEFICIARY - MEDICARE APPROVED AMOUNT NOT GREATER THAN ZERO REFERRAL FOR SERVICE DESIGNATED MENTAL ILLNESS DIAGNOSIS REQUIRED DAY TREATMENT RATE FOR PRINCIPLE PROVIDER CODE B REFERRING ID BLANK - OMH REHABILITATION SERVICE LICENSE NOT ON NYS LICENSE FILE M33 N287 N MANAGE CARE COORDINATION PROGRAM INPATIENT SERVICE NOT PROVIDED/ORDERED/REFERRED BY PRIMARY PROVIDER PROVIDER NOT ALLOWED TO BILL FOR PORTABLE XRAY SERVICES CLAIM PROVIDER NOT EQUAL RESTRICTION RECIPIENT FILE PROVIDER NYS Medicaid Fiscal Agent 4

5 Revised edits - s and s Definition P.T.CLINIC RATE BILLED/PROVIDER P.T. CLINIC NUMBER MISSING N PROVIDER ID AND SERVICE ID IDENTICAL M57 N NO COVERAGE: PENDING FAMILY HEALTH PLUS MA85 N OPTOMETRIST INDICATED NOT QUALIFIED TO PRESCRIBE RECIPIENT INELIGIBLE, EXCESS INCOME/SPENDDOWN MISSING OR ELIGIBILITY OVERRIDE CODE N PIN N DRUG-PREGNANCY INFERRED PRECAUTION MAJOR PROGRAM - SERVICE CONFLICT N130 NYS Medicaid Fiscal Agent 5