Tuesday, May 10, 2016

Provider missing / Recipient eligibility not established


This section provides information about the most common billing errors encountered when providers submit claims to the Medical Assistance Program. Preventing errors on the claim is the most efficient way to ensure that your claims are paid in a timely manner.
Each rejected claim will be listed on your remittance advice along with an Explanation of Benefits (EOB) code that provides the precise reason a specific claim was denied. EOB codes are very specific to individual claims and provide you with detailed information about the claim. The information provided below is intended to supplement those descriptions and provide you with a summary description of reasons your claim may have been denied. Claims commonly reject for the following reasons:

1. The appropriate provider and/or recipient identification is missing or inaccurate.'

?? Verify that your NPI and 9-digit Medical Assistance provider numbers are entered in Blocks #33a/b. The ID Qualifier 1D must precede the 9-digit Medial Assistance provider number. Do not use your PIN or tax identification number.

?? Verify that a valid NPI and 9-digit Medical Assistance provider number for the requesting, referring or attending provider are entered in the Blocks #17a/b and each provider is correctly identified. The ID Qualifier 1D must precede the 9- digit Medical Assistance provider number in block 17a.

?? Verify that the NPI and 9-digit rendering Medical Assistance provider number you entered in Block #24j. is in fact, a rendering provider. The ID Qualifier 1D must precede the 9-digit Medial Assistance provider number. If you enter a group NPI and provider number in the block for the rendering provider, the claim will deny because group provider numbers cannot be used as rendering provider

?? Verify that the recipient’s 11-digit Medical Assistance identification number is entered in the Block #9a.

?? Verify that the recipient’s name is entered in Block #2, last name first.

2. Provider and/or recipient eligibility was not established on the dates of services covered by the claim.

?? Verify that you did not bill for services provided prior to or after your provider enrollment dates.

?? Verify that you entered the correct dates of service in the Block #24a of the claim form. You must call EVS on the day you render service to determine if the recipient is eligible on that date. If you have done this and your claim is denied because the recipient is ineligible, double-check that you entered the correct dates of service.

?? Verify that the recipient is not part of the Medical Assistance HealthChoice Program. If you determine that the recipient is in HealthChoice, contact the appropriate Managed Care Organization (MCO).

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