New NCHC Claim Edit for Non-Covered Diagnosis Codes

Beginning November 1, 2015, claims for N.C. Health Choice (NCHC), also known as SCHIP, billed with non-covered diagnosis codes (ICD-9 or ICD-10), will deny as result of a new edit. Edit/EOB 01814 - CLAIM DENIED FOR NON COVERED DIAGNOSIS FOR NCHC RECIPIENT will affect NCHC original and adjustment claims when any non-covered diagnosis code is billed. When a claim is billed with a combination of covered and non-covered diagnosis codes, it will deny regardless of the diagnosis pointers at the detail line.

This new edit is being implemented based on date of processing, not date of service. Claims with a date of service prior to November 1, 2015, processed on or after November 1, 2015, are subject to the edit. Claims with non-covered diagnosis codes that paid prior to November 1, 2015, and are adjusted on or after November 1, 2015, are subject to the new edit, which will cause the adjustment to deny.

This update reflects N.C. Session Law 2011-145. There is no reprocessing scheduled due to this new edit. The new edit is not applicable to encounter claims.