Suggestions To Eliminate/Correct Top Medicaid Denials
Each of the Medicaid plans have reported very similar top denial reasons for professional claims (CMS-1500). The following list contains the most frequently encountered denials with the method of correction. Due to variances in the specific frequency for each payer, these items are not necessarily in highest volume order.
Patient covered by primary insurer – please bill insurer first
Always verify eligibility!! If the member is covered by one of the Risk-Based Managed Care Organizations (MCOs), the other insurance data on Web interChange may not be the most up-to-date information. If your MCO claim is denied, contact the MCO to request information about the other insurance. Anthem and MHS have on-line eligibility systems to provide information about other insurance. If the member’s plan (Traditional, Care Select, or MCO) states that other insurance is available you must submit a claim to that insurer and provide proof of denial before the plan will pay your claim. If the other insurer denies the claim for “no coverage in effect” provide the denial to the plan to have the other insurance end-dated. Submitting the denial with the claim will allow your claim to process but will not trigger a review of the other insurance listed. For Traditional and Care Select members, send a copy of the denial to the TPL Department. For MCO members, submit a copy of the denial as an Appeal or to your Field Representative.
Coverage not in effect on date of service/patient covered by Medicaid Risk Based Managed Care entity
Always verify eligibility before rendering care! Just because they were Traditional Medicaid or MHS the last time you saw them does not mean they have not changed plans. Be sure your staff understand the different plans and update the financial class information as appropriate.
Service not covered for Package B member
Always verify eligibility! If the member is enrolled in Package B they do not have full Medicaid benefit. They have coverage for only pregnancy-related care, complications, family planning, transportation, and pharmacy services. If the services fall within the definition of coverage, a pregnancy diagnosis MUST be utilized as the primary diagnosis code, even if you are treating a complication such as diabetes. Flagging the charge ticket as Package B will help communicate to the claims entry staff to review the diagnosis before the claim is submitted.
Limit for timely filing has expired
The filing limit for Traditional Medicaid and Care Select is 365 days from the date of service. Any claim with a date of service greater than 1 year must have documentation to support a waiver of the filing limit. Claims staff will not research any claim. It is the provider’s responsibility to submit the data with a paper claim or using the Attachment Cover Page following the submission of an electronic claim. It should be noted that the MCOs do not permit a 1 year filing limit for contract providers. Each MCO has varying filing limits and the time limit generally applies to the initial claim submission. Once the claim has been submitted, the provider then has 60 days from the date of the EOB/EOP to file a corrected claim or submit an appeal. Failure to submit the initial claim within the specified time limit or file the correction/appeal within the 60 day limit will result in a denial. The plan then has complete discretion as to whether or not they will waive the limit, most will not.
Authorization not on file/no authorization for service
Providers may search by CPT code for Traditional Medicaid and Care Select members to determine if prior authorization is necessary. This feature is available on the Medicaid website using the Fee Schedule. Currently, the MCOs do not have an on-line search engine to determine authorization requirements. When in doubt, call! All out-of-network providers (except self-referral services) require authorization before providing care. Most inpatient admissions require authorization, If authorization for the inpatient stay is not obtained none of the providers furnishing care during the confinement will be paid. Don’t assume the hospital obtained the authorization; always call to verify that authorization has been obtained. If authorization is not obtained prior to rendering the service, the plan has total discretion whether or not to provide a retro-authorization, regardless of medical necessity. Most plans will not retro-authorize care.
Duplicate of a previously processed claim
Claims submitted/processed by Traditional Medicaid and Care Select will only hit as an exact duplicate if a previous claim for the same member, same provider, same code, and same date of service show as previously paid. This includes claims that paid $0. Generally, if the claim shows on a paid page of the Medicaid RA, it cannot be resubmitted; an adjustment will be required. This is true for claims containing surgical procedures. If you have received this denial message, Medicaid is trying to tell you that you cannot just rebill the denied claim or denied detail. Rather, an adjustment (void/replacement) is necessary to correct the claim. For all MCOs, a claim will hit as a duplicate if another claim for the same member, same provider, same code(s), same date of service have been processed, regardless of whether they paid or denied. If a claim has been denied, a corrected claim must be submitted. When submitting a correction, be sure to mark the claim as “Corrected Claim” to prevent the duplicate denial.
Patient covered by Medicare, bill Medicare first or QMB recipient bill Medicare first
This denial is often caused by claims being mailed to the wrong address, mis-routed by Medicaid, or because of a benefit limitation.
- If the member has Medicare and Medicare has paid the claim and you are billing to obtain the allowable Medicare coinsurance and/or deductible be sure the claim is submitted as a Medical Crossover to the correct PO Box. Also, be sure you have completed the crossover information in Item 22 of the claim form (or electronic field).
- If Medicare has denied the service it is not considered a crossover and is mailed to the Medicaid Medical Claims PO Box and a copy of the Medicare Remit is required. No information should be entered in Item 22.
- If the member is covered by a Medicare HMO/Replacement Plan, do not complete Item 22 of the claim; enter the amount paid by the HMO in Item 29; always submit a copy of the HMO EOB/EOP; and mail the claim to the Medicaid Medical Claims PO Box, these claims are not considered crossovers.
- If the denial states the member is QMB please bill Medicare first, review the Medicare Remit. If Medicare has covered the service it should be filed to the Medical Crossover PO Box with Item 22 completed with the crossover data. If Medicare denied the service, review the Medicaid eligibility.
- If the member is listed as QMB only there is no secondary payment available. For QMB only members Medicaid only covers the applicable portion of the Medicare coinsurance and/or deductible. If the member was notified in advance that Medicare and Medicaid do not cover the service, the member may be billed.
