Edit Name: Exact Duplicate

IndianaAIM Resolutions Manual ESC 1047

EDIT NAME: CERTIFICATION CODE MISSING – CARE SELECT MEMBER

CLAIM TYPE: H, I, M, O HEADER/DETAIL: Detail

LOCATION: 00 OVERRIDEABLE: Yes

PROGRAMS: All ALLOW DENIAL: Yes

RECYCLE DAY: 0

DISPOSITION: H/I/M/O 00 All Regions Suspend 10 Paper w/o attach Suspend 11 Paper w/attach Suspend 20 ECS w/o attach Deny 21 ECS w/attach Deny 22 Shadow Inactive 50 Voids/Replacement non-check related Suspend 51 Voids/Replacement check related Suspend 52 Shadow Replacement Inactive 54 Mass Adj. Void Transaction Deny 55 Mass Replacement NH Deny 56 Mass Replacement FIN Deny 57 Mass Replacement Reprocess SE Deny 58 Replacement Processed by EDS SE Deny 61 Elec. Replacement w/attach or claim note Suspend 62 Elec. Replacement w/o attach or claim note Suspend 64 Spenddown EOM auto-initiated Mass Replacement Deny 67 Shadow Mass Replacement Inactive 72 Payer Elec. Replacement Deny 80 Claims Reprocessed by EDS SE Deny 90 Special Batch Suspend

EDIT DESCRIPTION: Fail this edit if the rendering provider is not the recipient’s PMP, based on the “from” date of service, and the Certification Code is missing.

SPECIAL BATCH This edit may only be forced when approval and supporting documentation is obtained from OMPP.

New 4/27/07 IndianaAIM Resolutions Manual ESC 1047

EDIT CRITERIA: If the rendering provider is not the recipient’s PMP, based on the “from” date of service, and the Certification Code is missing, fail this edit with EOB 1047.

Exceptions:  Bypass HCFA 1500 claim type for Billing Provider Type 12, Specialty 120 - School Corp) or 212 (CSHCS).  This edit will bypass for the following rendering specialties:  280 (Lab),  281 (Mobile Lab),  290 (Free Standing Radiology),  291 (Mobile Xray),  311 (anesthesiologist),  333 (pathologist)  341 (radiologist).  Podiatry, Chiropractic, Vision provider Services, Dental  Emergency services  Family Planning Services  Mental Health (including MRO)  Bypass this edit when the procedure code billed is listed as “Not Covered” for the Care Select program in the Program to HCPC Procedure Restriction Maintenance window.  Transportation

MRT/PASSR/First Steps are inactive for this edit.

EOB CODE: 1047 - The Certification Code is Missing-Medicaid Select. Please verify and resubmit.

ARC CODE: 16-Claim/Service lacks information which is needed for adjudication. Additional information is supplied using remittance advice remark codes, whenever appropriate.

REMARK CODE: M58- Missing/incomplete/invalid claim information. Resubmit claim after corrections.

Paper Replacements:  Void/replacement claims suspend in data corrections, the analyst will go back to the original (Mother) claim to see if the certification code is present. If so, the analyst will key the certification code information onto the adjusted (Daughter) claim.

Void/Replacements:  When the void or replacement claim suspends in data correction, the analyst will go back to the original (Mother) claim to see if the certification code is preset. If so, the analyst will key the certification code information onto the adjusted (Daughter) claim.

New 4/27/07 IndianaAIM Resolutions Manual ESC 1047

 Go to the Inquiry Screen  Type in the ICN you are working on  Once the claim is retrieved  Click on Option  Click on void/replacement  The window will display the original ICN  Click on the original ICN  Look at the certification code (cert code) that is on the original claim  Put the certification code (cert code) on the suspended claim

New 4/27/07