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
- Verify the provider utilized for the Billing section of the claims has settings that match their settings in Medicaid. This includes:
- 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.