EDI claims billing to Medicaid is largely the same as billing commercial claims, but there are a few areas where claims billed to Medicaid are more likely to be rejected. Typically, troubleshooting occurs if the Medicaid portal data does not match CentralReach’s data. Please verify all information sent on these claims prior to submitting the claim, so that the billing information being submitted matches the information in the Medicaid portal.

The following items can be audited to ensure successful claim submissions to Medicaid:

• Using a generic user account for the Facility information of the claim.
  • A common rejection for organizations is having the same account used in both the Billing and Facility areas of a claim. To circumvent this, a Generic user account needs to be created to pull another office location to a claim and to be utilized as the Facility when generating claims. The generic user should have the same Claims Settings as the organization account.
• Matching the Billing Provider in box 33 with what Medicaid has stored for the provider.
  • Verify the provider utilized for the Billing section of the claims has settings that match their settings in Medicaid. This includes:
    • Correct NPI, as it is stored within Medicaid’s system
    • 9 digit zip code
    • Address
    • Business name 
      • If recently changed, update with Medicaid
    • Taxonomy code
• Inputting the correct codes for the Provider/Supplier and Rendering Provider, in boxes 31 and 24J respectively
  • It is important that the user being utilized as the Provider/Supplier for generated claims has the correct information, specifically the NPI as recognized by Medicaid and taxonomy code. 
• Inputting the Medicaid Provider ID as the G2 identifier
  • The 1D identifier, or Medicaid Provider ID, is antiquated for EDI claims and is now submitted under the G2 identifier. Within CentralReach, while the 1D identifier is retained as an option within a user’s Claims Settings, it is not pulled when generating claims. It needs to be stored under the G2 identifier in the user’s Claims Settings. Check with your specific Medicaid payor to verify if this needs to be set when submitting EDI claims.

If users are experiencing issues when converting an appointment, check to see if they have the following Billing permissions:

1. Access: basic access to the Billing module.
2. (Timesheets > Access): access to the Timesheets screen in the Billing module.
3. (Timesheets > Allow Conversion Modifications): optional, but allows assigned users to make changes to a timesheet during conversion.
4. (Timesheets > Manage Timesheets): optional, but necessary for schedulers who seek to convert appointments on behalf of other employees.

If the user has enabled these permissions, but is still unable to successfully convert, consider the following questions:

1. Is there a validation alert on my appointment?
   • If there is an issue with the authorized code in the appointment the user is trying to convert, then the timesheet will not save. This alert will display when viewing the calendar, if “Show Authorization Warnings on Calendar” in the Scheduling module’s Additional Settings is enabled for the organization. Otherwise, this error message can be viewed within the appointment by enabling the Validation toggle in the appointment.
2. Are the principals on the appointment connected?
   • If the user is listed under “Additional Participants” in the appointment being converted, the user must be connected to the user in the “Appointment with*” field.
3. Is the appointment between two employees?
   • Appointments with an employee in the “Appointment with” field cannot be converted.
4. Is there a lock date set?
   • In the Scheduling module’s Additional Settings, “Schedule Lock Date” gives an administrator the ability to set a date when employees will no longer have the ability to edit, add, or convert appointments. If the appointment is set to occur past this lock date, employees will not see the option to convert the appointment.

There are quite a few reasons why your organization is encountering missing ERA’s:

1. The payor did not send the ERA due to the organization not being registered.
2. The ERA was sent to a clearinghouse in an incompatible format.
3. In the rare instance, the ERA never made it to the clearinghouse and a request must be made to the payor to send that ERA again.

These are the troubleshooting steps to follow, to ensure your resend request to the payor is handled accordingly:

1. The very first important step is, call the payor:
   • As ERA registration rules vary per payor, many require you to call & confirm registration after submitting the forms.
   • ERA registrations also expire for certain payors, so it is very important to first confirm that the payor is sending this information.
2. What to ask the payor:
   • Am I registered to receive ERA’s?
   • Was the ERA sent to my clearinghouse?
   • Can you provide the full file name of the 835 file sent to the clearinghouse?
     • Example: 123456789_ERA_STATUS_4010_2018010203.zip
       • As this file is in an incompatible format, request that your clearinghouse convert these to 5010 by default.
         • • They can reprocess older 4010 files that they have upon request.
       • Please note, zip files are not currently supported for the Waystar (Zirmed) gateway.

If the clearinghouse indicates that they have the ERA in proper format and it still is not in the ERA list, create a support ticket and provide as much of the following information to CR Support, as possible, such as the claims ID, check #, etc.

If you have a fee schedule set with modifiers and are not seeing the modifiers auto-populate in your timesheets during appointment conversion or timesheet creation, there are a few things to check:

1. Is the fee schedule I set up with these modifiers properly linked to the payor?

• Navigate to the Billing module and select Fee Schedules
• Click on the By Payor tab and on this screen, the name of the fee schedule set on the service code should be linked to the correct payor and plan here

Click here to learn how to link fee schedules to payors’ insurance plans.

2. Is there a custom rate set for the client on this timesheet?

Fee schedules operate as a default rate for the service code and payor. If there is a custom client rate set for the service code on an appointment/timesheet, this will take priority over all fee schedules set for that code for this client.

The timesheet does not pull in the fee schedule when a custom client rate is set, and therefore would not have the modifiers set either. You can verify whether this is the case by:

• Navigating to the Billing module and selecting Service Codes
• Click on Custom Rates and search for the client to populate any custom rates they have for all available service codes

Click here to learn more.

3. Is the Procedure Info field under this service code’s properties set to Optional?

The Procedure Info options within a service code’s properties govern whether or not the actual modifier fields will be available when generating a timesheet with that code. Make sure this is set to Optional, if set to Not Needed, these fields will NOT be available on the timesheet, and therefore will not import to a claim.

Please note, there are modifier fields that can be set under the service code properties. Modifiers do not auto-populate when set in these fields. The modifier settings within a service code’s properties operate as suggested modifiers for that code. They are only utilized when clicking the Use suggested modifiers link on a timesheet.