Florida Medicaid new Exclusion edits for electronic claims

For clients submitting claims electronically to Florida Medicaid you may receive the following exclusions:

Edit 06 0001C:INVALID EPSDT (early and periodic screening, diagnosis and treatment) REFERRAL COND CODE - IN LOOP 2300, IF CRC01 = ZZ AND CRC02 = Y; CRC03 MUST BE AV, S2, OR ST
Fix: Add the correct Condition Code

• AV: Patient refused referral (Available, Not Used)
• NU: Patient Not Referred (Not Used)
• S2: Under Treatment (for referred diagnostic or corrective health problem)
• ST: New Services requested (patient referred to another provider for diagnostic or corrective treatments or scheduled for another appointment with check up provider for diagnostic or corrective treatment for at least one health problem identified during a Child Health Check-up, not including dental referrals

Edit 14 0007D:DTL PAID/ADJUST OUT OF BALANCE - THE SUM OF ALL 2430-SVD02 (DTL PRIMARY PAYOR PAID AMT) + (PLUS) CAS03 + CAS06 + CAS09 + CAS12 + CAS15 + CAS18 (ALL ADJUSTMENT AMTS) MUST EQUAL 2400-SV102 (CHARGE AMOUNT) (PROFESSIONAL)
Fix: on HCFA 1500 or CMS-1500 claims the Charge amount must equal the Paid Amount + Adjustment Amounts.

Edit 14 0008C:CLM PAID/ADJUST OUT OF BALANCE - IF LOOP 2320-AMT01 = D (PRIMARY PAID AMT) IS PRESENT, THE SUM OF AMT02 (WHEN AMT01 = D) (PRIMARY PAID AMT) + (PLUS) LOOP 2320 CAS03 + CAS06 + CAS09 + CAS12 + CAS15 + CAS18 (CLM ADJUSTMENT AMTS) + LOOP 2430 CAS03 + CAS06 + CAS09 + CAS12 + CAS15 + CAS18 (DTL ADJUSTMENT AMTS) MUST EQUAL 2300 CLM02 (TOTAL CHARGES)
Fix: on HCFA 1500 or CMS-1500 claims the Charge amount must equal the Paid Amount + Adjustment Amounts.

Edit 14 0015C:MISSING INFO FOR OTHER INSURANCE - IF LOOP 2330B IS SENT, THEN EITHER LOOP 2430 OR 2330B-DTP SEGMENT MUST BE SENT
Fix: Make sure the "other" insurance carriers information is being submitted on the claim.

Edit 35 0001C:MISSING REFERRING PROVIDER NBR - IN LOOP 2310A REFERRING PROVIDER, EITHER NM109 OR REF SEGMENT MUST BE SENT
Fix: Add the referring provider number

Confused by Electronic Medical Claim billing then read these articles on Billing Health Insurance medical claims

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