Restrictive Coverage Information on Recipient Eligibility Inquiry

Starting January 5, 2015, when a recipient has a Living Arrangement Code of 18 (Special Assistance/Institution for Mental Disease), a special message of restricted coverage will be sent in the eligibility verification response for the AVRS, the Provider Portal, and the 271 X12 transaction. The specific eligibility verification message/response for each inquiry channel is listed below:

AVRS and Provider Portal Restrictive Coverage Message: This is a restrictive coverage category. The recipient is not eligible for Medicaid claims payment.
271 Health Care Eligibility Benefit Response: A number of segments in the 271 Health Care Eligibility Benefit Response, Loop 2110C, will be used to report Living Arrangement Code ‘18’:
·         the EB01 segment will have “F” for “Limitations,”
·         the EB03 segment will have “32” for “Plan Waiting Period,” and
·         the MSG01 segment will have the message “Not eligible for Medicaid claims payment.” 
Since the restrictive coverage may not apply for an entire month, the specific day(s) of restrictive coverage will be provided, along with the message/response.
Trading Partners should refer to the 270/271 Health Care Eligibility Benefit Inquiry and Response Companion Guide on the Trading Partner Information page of the NCTracks Provider Portal for additional information.
Note: Claims submitted for these recipients will be denied if the dates of service on the claims are on or within the days of restrictive coverage and the Living Arrangement Code is 18. Denied claims will fail with Edit 00099 (RECIP IN MENT INST AT DOS) and post EOB 01799 - RECIPIENT IS NOT ELIGIBLE FOR MEDICAID CLAIMS PAYMENT DUE TO CURRENT LIVING ARRANGMENT.