Frequently Asked Questions


Bookmark and Share

 

Frequently Asked Questions

 

Category Search>>



All categories

Page:  1  2  3  4  5  6  7  8  9  10  ...  31  (Next)
ALL

ADJUSTMENTS

Can you use the Web Tool for adjustments, if you filed through a clearinghouse?

Yes, you may submit an adjustment through the Web Tool, even if the original claim was filed using a clearinghouse – as long as it is within 15-18 months. However, UB-04 (Institutional) billers must file adjustments in the same medium as the original claim.

How far back can you file a void?

15 - 18 months

How long does it take to process an adjustment?

It takes approximately 30-45 days to process an adjustment - the same as a normal claim in process.

If doing a void/replace adjustment, does the Form 130 go along with the CMS-1500 claim form?

Yes, the replacement claim will be attached to the Form 130.

If you have a multiline claim and only one line needs recouping, you still complete an adjustment?

Yes, claims are 100% adjusted, all lines will be replaced.

Is an adjustment only done when you have been paid?

Yes, only paid claims can receive an overpayment or underpayment.

What happens if someone in your office initiates a refund with the 205 and an adjustment, how do you get it back?

The program area would have to research the adjustment to return funds.

What happens if you void the wrong claim?

If it is voided, you can submit a new claim in.

When a claim is in a denied status, can you do an adjustment?

You must wait for the rejection, and then do a correction. An adjustment can only be made to a paid claim.

When would you use a void?

You would use a void if you bill for something by mistake; accidental claim submission, for example.

Will the system distinguish that a company has multiple provider numbers?

Yes, make sure all their information is correct when completing the claim form.

Will voids show up on the remit?

Yes

CREDIT BALANCE REPORTING

Do I still submit the UB-04 adjustment if I've submitted the credit balance report?

The MIVS credit balance reporting format is not eliminating or replacing a provider’s necessity to submit a UB-04 for claim adjustment(s).

How do I know that my credit balance report was received?

Providers may send an e-mail request for Medicaid credit balance receipt confirmation to creditbalancemivs@bcbssc.com.

For questions call 1-888-289-0709 option 5, option 1.

Is the credit balance report replacing other credit balance reivews I receive from other agencies?

The Medicaid Credit Balance Report is not replacing the current credit balance reviews performed by other reviewing agencies. Providers are not to report other agencies’ identified claims on the Medicaid Credit Balance Report - this may cause possible duplication of claim recoupment. Providers impacted by such reviews need to continue their current procedure in responding to any correspondence received from other agencies’ credit balance reviews.

What is a credit balance?

A credit balance is a positive amount that remains in a patient’s account which may have resulted from multiple reimbursements from several payers, adjustments to previously paid claims of a provider, duplicate payment, or subrogation events due to accidents and other injury cases. When another third party payer reimburses a provider for claims that Medicaid paid, either in part or in full, a refund is due to the Medicaid Program.

When is the credit balance report due?

Reports are due by the 30th day of the following month after the respective quarter end. If the report has not been submitted by the due date, a late notification letter will be sent to the provider.

Where can I find the Medicaid Credit Balance Report forms?

The Medicaid Credit Balance Report Certification Page and Claim Detail forms can be found under the For Providers menu option at SCDHHS.gov – see Credit Balance Forms.

Where do I send in my credit balance report?

The reports and checks may be mailed regular or certified mail to MIVS, Attn: Benefit Recovery – Credit Balance Reporting, P.O. Box 8355, Columbia, SC 29202-8355 or may be sent by facsimile to MIVS, Attn: Benefit Recovery – Credit Balance Reporting, 803-462-2582.

Why was my credit balance report rejected?

Providers that submit inaccurate or incomplete information will be notified of the rejected credit balance report. The provider will be instructed to re-submit another report for the applicable quarter.

EDIT CODES

Edit 150

Edit 953

Edit 989

Edit 990

ENROLLMENT: CLAIMS

Why are our claims denying for dates of service prior to the individual provider leaving the practice?

Prior to requesting the removal of an Individual provider from your group practice ensure that the pending claims are adjudicated. However, if the provider has already been removed from the group prior to the claim(s) being adjudicated and needs to be added back to the group,  submit the request on the business letterhead with the provider’s or an authorized signature via Fax: (803) 870-9022 or Mail: Medicaid Provider Enrollment, PO Box 8809, Columbia, SC 29202-8809. Updates will be processed within ten (10) days of receipt. 

Will my claims from two weeks ago process if I just enrolled today?

Upon approval of enrollment (the provider has met all necessary requirements); the enrollment date of the provider’s effective date will retroactively begin 90 days prior to the date of receipt of the application. However, depending on the provider’s type/ specialty, if the provider is required to sign a contractual agreement in addition to the provider enrollment agreement, the enrollment date is the effective date of the contract. Note: Medicaid will not pay for claims prior to an enrollment effective date or before the provider’s licensure/certification date.

ENROLLMENT: LINK PROVIDER TO GROUP

How do I enroll a new provider who has joined our group?

Individuals can be added anytime to a group without having to pay an application fee. If an individual wants to be added to a group that is not currently enrolled, the group will have to pay an application fee and enroll. Once the group is enrolled, the individual must then request to be added to the group. If the individual provider is already enrolled in South Carolina Medicaid, submit in writing an update request to have the provider affiliated with the group. The request must be on the business letterhead to include the Group’s Medicaid Legacy ID number and the provider’s NPI number with the provider’s or an authorized signature via Fax: (803) 870-9022 or Mail: Medicaid Provider Enrollment, PO Box 8809 Columbia, SC 29202-8809. Updates will be processed within ten (10) days of receipt.   If the individual provider is currently in the process of enrolling, the provider can indicate on the online application group affiliation.

Where do I list the individuals affiliated with our group on the enrollment application?

During the online enrollment process, organizations cannot affiliate individuals to their group. It is the responsibility of the individual provider to affiliate with a group. The request must be on the business letterhead to include the Group’s Medicaid Legacy ID number and the provider’s NPI number with the provider’s or an authorized signature via Fax: (803) 870-9022 or Mail: Medicaid Provider Enrollment, PO Box 8809 Columbia, SC 29202-8809. Updates will be processed within ten (10) days of receipt.

Why is the group enrollment effective date before the date our individual provider joined the group?

When an Individual provider is affiliated with a group, the original group enrollment date remains the same regardless of when the individual provider was affiliated. The individual provider does not receive a new enrollment date when affiliated with the group.

ENROLLMENT: STATUS

How can we get an enrollment status update?

Contact the Provider Service Center (PSC) (888) 289-0709, option 4 for Provider Enrollment.  Please have your Reference ID number available.

How long does the enrollment process take?

Enrollment applications will be processed within thirty (30) business days from the date of receipt. The thirty (30) business day timeframe may be exceeded for enrollment applications that require: additional information, a site visit, a contractual agreement, or are submitted with sanction information.

Why did my enrollment application get rejected after I made the corrections I was told to?

A provider is notified about rejections via the Enrollment Rejection Letter. The rejection letter indicates the reason(s) for the rejection. For further assistance, contact the Provider Service Center at 1 (888) 289-0709, option 4.

ENROLLMENT: UPDATE PROFILE

How do I update the individual provider’s name?

SCDHHS requires the individual provider to send in a completed/signed W9 form with the individual’s name, SSN, address and signature. Providers are also required to complete the Disclosure of Ownership and Control Interest Statement Form.

Why can’t we update our enrollment profile over the phone?

SCDHHS requires updates to a provider’s file to be submitted in writing on business letterhead with the provider’s or an authorized signature. Submit any updated changes via Fax: (803) 870-9022 or Mail: Medicaid Provider Enrollment, PO Box 8809, Columbia, SC 29202-8809. Updates will be processed within ten (10) days of receipt.

MANAGED CARE ORGANIZATION (MCO)

How are MCO plans chosen for a beneficiary if they are auto-enrolled?

The plan is chosen based on the beneficiary’s needs, service area, and any needed specialists.

If a plan doesn’t cover family planning, do we bill to Medicaid and send the EOB?

Certain services are “carved out”, not covered, by the MCOs and MHNs. Those services can be billed directly to SC Medicaid. You do not need to bill to the managed care plan for a denial.

If the beneficiary doesn’t have an ID number for the MCO, how do we obtain it?

Contact the MCO.

Is the EFT form used for MCOs as well?

No, they have their own forms and billing systems.

What do you do if you contact a Primary Care Provider and they have no record of a patient?

If this were to happen, you would need to contact the Managed Care Organization directly.

Will MCO info be available via the Web Tool?

A provider can verify Managed Care Organization enrollment on the eligibility section of the Web Tool under the “Beneficiary Special Program Data” section.

MED BASICS

Are program representatives organized by demographics?

Yes they are, depending on service area.

Can I handwrite on the claim forms?

Yes you can, or you use a printing service.

Does the Medicaid card have all the information needed?

No, you should further investigate eligibility using eligibility resources and the information provided on the card.

For ambulatory care, are children under 19 exempt from copay?

Children under 19 are exempt from all copays.

How are MCO plans chosen for a beneficiary if they are auto-enrolled?

The plan is chosen based on the beneficiary’s needs, service area, and any needed specialists.

How can you get copies of enrollment letters?

To receive a copy of a beneficiary’s enrollment letter, they may contact Healthy Connections Choices or the beneficiary’s plan (that they were enrolled into).

How do patients learn updated information?

Patients learn of updates at their enrollment anniversary dates, or you may share information with them.

How does Medicaid know what the provider is receiving from another carrier/third party payer?

There are spaces/sections on the claim form that identify what you receive from the other carrier.

How often are provider manuals updated?

Provider manuals are usually updated monthly based on program area.

If a beneficiary doesn’t have their copay, can you refuse them?

No, as a Medicaid provider you cannot refuse a beneficiary if they do not have their copay.

If the beneficiary doesn’t have an ID number for the MCO, how do we obtain it?

Contact the MCO.

What do you do if a beneficiary is out of visit counts?

When checking eligibility, you will see what visit counts they have left. You can request more from your representative or treat them as a self pay.

What do you do if you contact a Primary Care Provider and they have no record of a patient?

If this were to happen, you would need to contact the Managed Care Organization directly.

What is the payment cycle?

The payment cycle is: Wed-Mon, payments are processed on Tuesday, and payment is received as early as Friday.

What should I do if one line does not pay on your claim?

Correct and refile that one line.

When would you use a void?

You would use a void if you bill for something by mistake; accidental claim submission, for example.

Where are your procedure codes located?

Procedure codes are located in Section 4 of your manual and the DHHS website.

Where can carrier codes be located?

Carrier Codes can be located in Appendix 2 of the Provider Manual.

Where can you find an out of state referral form?

That form can be found on SCDHHS.gov.

Where do you get the bulletins?

You can sign up for e-bulletin on the SCDHHS.gov page.

Where is the Provider Service Center located?

It is housed at MCCS.

Who updates the website for manuals?

MCCS sends the updates and changes once received from DHHS.

NURSING HOME

Can I add a beneficiary to the TAD if documentation is not approved?

You must have authorized signed documentation in order to add a beneficiary to your TAD. You should not add a beneficiary before the DHHS 181 is forwarded to DHHS Medicaid Eligibility for approval. Contact your Eligibility office if additional information is needed.

Can you add beneficiaries or other information to the TAD for me?

No, MCCS staff cannot add any information to the TAD. You can only make changes via DHHS Form 181, CRCF 01 and IPC change forms.

Can you assist with Medicaid/bed hold billing procedures?

An authorized SNF 181 along with a separate Medicare-to-Medicaid bed hold billing 181 is required.

Can you correct the 181/CRCF-01 form?

No. MCCS staff cannot make corrections to the DHHS Form 181 or CRCF 01 form.

Does the Nursing Facility (NF), Intermediate Care Facility (ICF) / Mental Retardation (MR) or Swing Bed facility have to wait for a denial from DHHS before submitting an invoice to the hospice agency?

Yes. The denial must be attached.

I did not receive my TAD. Can you fax/mail a copy?

MCCS can send a copy of the TAD when requested.

Is an eligibility signature required for termination? (Nursing Home)

No signature is required for terminations.

Is the date of discharge for Nursing Facilities or Intermediate Care Facility (ICF) / Mental Retardation (MR) room and board Medicaid reimbursable?

Nursing Facilities and ICFs/MR are not reimbursed for the date of discharge.

Nursing Facilities and ICFs/MR should not invoice hospice agencies for the date of discharge. The date of hospice discharge for a reason other than death or transfer to another facility is billed to Medicaid.

For example: If the person was in an NF or ICF/MR facility from Feb. 1 to Feb. 23, 2013, and was enrolled in hospice from Feb. 1 to Feb. 14, 2013, the hospice would pay NF or ICF/MR the room and board for Feb. 1 to Feb. 13, 2013. Medicaid would pay the NF or ICF/MR for dates of service from Feb. 14 to Feb. 22, 2013. 

Should claims returned on Form 017 or 017CI without processing be re-filed?

Yes. Once corrections are made, Medicaid claims should be re-billed using the CRCF-01 form for OSS and the DHHS 181 for NFs. Coinsurance claims can be submitted at any time of the month once corrections are made.

What happens if my DHHS Form 181, CRCF 01 or IPC form is not received on time or is not received at all?

No changes will be made regarding beneficiaries’ income, IPC/CRCF status, etc., for the current billing month if change forms are not received by MCCS. However, changes can be made during the next month’s billing process.

What happens if the NF or ICF/MR* accepts a hospice resident while Medicaid eligibility is pending and it is later determined that the resident is not eligible? Who is responsible for room and board payment to the NF or ICF/MR?

The hospice is responsible for the room and board amount.

It is imperative that the hospice social worker continues to pursue eligibility for the resident to decrease the financial risk in the event the resident is ultimately not eligible for nursing facility benefits. 

*Nursing Facility (NF) or Intermediate Care Facility (ICF) / Mental Retardation (MR)

What happens if the Nursing Facility (NF) or Intermediate Care Facility (ICF) / Mental Retardation (MR) is paid in error for hospice dates of service?

The nursing facility must submit a request for an adjustment. The adjustment process must be completed before the hospice can be paid for room and board dates of service.

What is the physical address to over-night a TAD?

The PO boxes and physical address are included in the Provider manual as well as on the mailing envelope.

For regular mail:
Medicaid Claims Receipt – NF Claims Section
Nursing Homes
P.O. Box 100122
Columbia, SC 29202-3122
 
Medicaid Claims Receipt – NF Claims Section
OSS/IPC/Hospice:
P.O. Box 67
Columbia, SC 29202
 
For UPS, FedEx, etc.
Medicaid Claims Receipt – NF Claims Section or CRCF Claims Section
8901 Farrow Road
Columbia, SC 29203

NOTE: Late change forms should be sent overnight or faxed, with all attachments, to (803) 870-9020. Forms should not be faxed unless they are sent past the deadline. Faxed corrections should be received no later than the third working day of each month for Nursing Home providers and the 17th day of the month for OSS providers.

When are TADs available for providers to view on the Web Tool?

TADs are not yet available on the Web Tool. Medicaid will continue to send copies of the TADs to providers until the TADs are available on the Web Tool.

When are the DHHS Form 181, CRCF 01 and IPC forms due back to MCCS?

Nursing Home change forms are due to MCCS on the first working day of each month. OSS change forms are due no later than the 17th of each month. These dates are subject to change based on holidays, etc.

Who is responsible for pharmaceutical costs as it relates to the terminal illness?

The hospice agency is responsible for pharmaceutical costs related to pain management and symptom control of the terminal illness.

Why would a Nursing Facility provider receive a 951 rejection if the beneficiary had always been eligible for NF Medicaid since entering the facility?

A 951 Edit Code means the beneficiary was not eligible for Medicaid on the date of service. The beneficiary and/or responsible party for the beneficiary might not have completed the annual Medicaid eligibility review. Inform the nursing facility caller to contact the beneficiary’s eligibility caseworker.                                                                                                                                                                                

Will every Nursing Facility or Intermediate Care Facility (ICF) / Mental Retardation (MR) have the same rate?

No.

Will the hospice agency receive a copy of the DHHS Form 181 when the recurring income changes?

Yes, they will receive a copy of the 181 to verify the income change. It is recommended that the NF or ICF/MR attach a copy of the most current 181 when invoicing the hospice. Recurring income is noted in Section III of DHHS Form 181. Medicaid Eligibility is responsible for determining recurring income.

REVALIDATION

Can a customer service advocate tell me if another provider has started and saved a provider revalidation application?

No. The only information that the provider service center has is if a provider revalidation application has been completed and submitted. The provider service center cannot see if a provider has started the application process but not completed it. If you have the revalidation reference number, NPI and Medicaid ID of the provider in question, you can access the application to see if there is any work in progress. Revalidation FAQs PDF

Can I check on the status of my provider revalidation application?

Yes. You can check on the status of your provider revalidation application by calling the Provider Service Center at (888) 289-0709, option 4. You will need your revalidation reference number in order to check on the status of your provider revalidation application. Revalidation FAQs PDF

Can I request an extension?

Extensions will not be granted due to the stringent timelines mandated by Federal Regulation 455.104 (b), (c), and 455450 (e). Revalidation FAQs PDF

Can I save my provider revalidation application and return to it later?

Yes. There are certain points that are clearly defined in the provider revalidation application process where you can save your work and exit the application. An incomplete application will be deleted and unable to be recovered 30 days from the day the application was created. Revalidation FAQs PDF

Do all providers need to go through the provider revalidation process?

All South Carolina Healthy Connections Medicaid providers will go through the provider revalidation process. The current process, however, is for all South Carolina Healthy Connections Medicaid providers who have an enrollment date 90 days prior to or on 12/03/2012. These providers are required to go through the provider revalidation process. Revalidation FAQs PDF

Do all providers need to pay the provider revalidation application fee?

If you are an institutional provider as determined by CMS, you will need to pay a provider revalidation fee of $553.00 if you revalidate in 2015. The 2016 fee will be determined by CMS and will be published after it is established by CMS. If you are a provider with multiple NPIs associated with your Medicaid ID, you will need to complete a new enrollment for each non-primary NPI. You are responsible for the new enrollment fee/s. Revalidation FAQs PDF

Do I need to contact South Carolina Healthy Connections Medicaid to schedule a site visit?

No. If a site visit is needed, a Provider Relations Representative will contact you. Revalidation FAQs PDF

Do I need to pay a provider revalidation application fee?

If you are an institutional provider as determined by CMS, you will need to pay a provider revalidation fee of $553.00 if you revalidate in 2015. The 2016 fee will be determined by CMS and will be published after it is established by CMS. If you are a provider with multiple NPIs associated with your Medicaid ID, you will need to complete a new enrollment for each non-primary NPI. You are responsible for the new enrollment fees. Revalidation FAQs PDF

Do other states have provider revalidation?

Yes, all 50 states have been mandated to perform provider revalidation. Revalidation FAQs PDF

How can I attach supporting documentation to the provider revalidation application?

There is no need to upload documentation. The provider will enter the required information and complete an attestation form verifying that all of the information is correct. Revalidation FAQs PDF

How can I find my enrollment date?

You can find your enrollment date by calling the Provider Service Center at (888) 289-0709, option 4. Revalidation FAQs PDF

How can I find my provider type?

Visit the Provider Type/ Specialty listing document found here, go to www.scdhhs.gov/provider and select the link titled “Provider Type and Specialty Listing” in the Provider Lists subsection, or please visit this link to view all provider manuals. Look in the “Billing Procedures” section of the manual or manuals that you think apply to your provider type to determine which procedures you bill for. This information will help you find your provider type. Revalidation FAQs PDF

How can I pay my fee?

The fee can only be paid at https://ssl.sc.gov/Checkout/DHHS. The fee will be collected prior to the provider revalidation process. Revalidation FAQs PDF

How do I complete the provider revalidation process for all other NPIS associated with my Medicaid ID?

You will need to complete a new enrollment for every NPI associated with your Medicaid ID except for the primary NPI that is identified on the revalidation notification letter. All new enrollments need to be completed within 30 days from the date on the revalidation notification letter. To access the online provider enrollment application, copy and paste https://providerservices.scdhhs.gov/ProviderEnrollmentWeb/ into your browser. Revalidation FAQs PDF

How do I complete the provider revalidation process?

The provider revalidation application is available exclusively online. When it is time to revalidate your enrollment as a provider, you will receive a revalidation notification letter. You have 30 days from the date on the revalidation notification letter to complete and submit the provider revalidation application in its entirety with all current information. Revalidation FAQs PDF

How do I know if I am a moderate or high risk provider?

Refer to the Provider Type/ Specialty listing document. Go to www.scdhhs.gov/provider and select the link titled “Provider Type and Specialty Listing” in the Provider Lists subsection. Revalidation FAQs PDF

How do I make sure that my address and other information are correct?

Contact the South Carolina Healthy Connections Medicaid Provider Service Center at 888-289-0709, option 4. It is your responsibility to ensure that your contact information is current. Customer Service Advocates cannot update your address information over the phone.

To update your address, please fax or mail a letter requesting an address change to MCCS Provider Enrollment on company letterhead. The Provider Enrollment fax number is (803) 870-9022. The address is Medicaid Provider Enrollment, P.O. Box 8809, Columbia, SC 29202-8809. The letter should include the provider’s legacy and NPI numbers, as well as the new address, along with the provider’s or an authorized person’s signature and a contact person’s name and telephone number in case there are any questions. Once the address information is updated and the revalidation notification letter is re-sent, the provider will still have 30 days from the date on the original revalidation notification letter to fully complete the provider revalidation process.

Revalidation FAQs PDF

How long do I have to complete the provider revalidation process?

You have 30 days from the date on the revalidation notification letter to complete and submit your provider revalidation application in its entirety with all current information. Revalidation FAQs PDF

How long will it take me to complete the provider revalidation application?

Each provider type is different. Your provider type and your preparation before beginning the application will factor into the time it takes you to complete the provider revalidation application. The process will take a minimum of 30 minutes, but it may take several hours. Revalidation FAQs PDF

How will I know that I need to begin the provider revalidation process?

When it is time to revalidate your enrollment as a South Carolina Healthy Connections Medicaid provider, you will receive a revalidation notification letter in the mail. The revalidation letter will contain detailed instructions for the revalidation process and a revalidation reference number that is specific to each provider. You will use this information to access the provider revalidation application online. You will need to complete and submit the provider revalidation application in its entirety with all current information. Revalidation FAQs PDF

How will I know that my provider revalidation has been approved?

Once the provider revalidation application is approved, provider revalidation approval notification will be emailed to the email address entered on the provider revalidation application. Revalidation FAQs PDF

I am a group provider with multiple NPIs associated with my Medicaid ID. How do I complete the provider revalidation process?

Your revalidation notification letter will list all of the NPIs associated with your Medicaid ID. The revalidation notification letter will identify one NPI as being the primary NPI associated with your Medicaid ID.  Complete the provider revalidation application for the primary NPI following the standard procedure. Within 30 days from the date on the revalidation notification letter, all other NPIs attached to your Medicaid ID will need to complete an online provider enrollment application. To access the online provider enrollment application, copy and paste https://providerservices.scdhhs.gov/ProviderEnrollmentWeb/ into your browser. This ensures that the billing process continues uninterrupted. Revalidation FAQs PDF

I am a medical clinic and I see that other medical clinics are revalidating in June and July 2015. I haven’t received my revalidation notification letter yet. What should I do?

All medical clinics will revalidate within June, July or August 2015. If your clinic’s address information has changed recently and needs to be updated, please fax or mail a letter requesting an address change to MCCS Provider Enrollment on company letterhead. The Provider Enrollment fax number is (803) 870-9022. The address is Medicaid Provider Enrollment, P.O. Box 8809, Columbia, SC 29202-8809. The letter should include the provider’s legacy and NPI numbers, as well as the new address, along with the provider’s or an authorized person’s signature and a contact person’s name and telephone number in case there are any questions. Once the address information is updated and the revalidation notification letter is re-sent, the provider will still have 30 days from the date on the original revalidation notification letter to fully complete the provider revalidation process. If your clinic’s address information has not changed recently or has changed recently but the address change procedure was followed correctly, your revalidation notification letter will be mailed later in summer 2015. Revalidation FAQs PDF

I am a Medicare provider who has revalidated with Medicare. Do I need to revalidate with South Carolina Healthy Connections Medicaid?

Yes, if you want to maintain your enrollment with South Carolina Healthy Connections Medicaid. Revalidation FAQs PDF

I am a provider in a stand-alone dental office. Do I need to revalidate with South Carolina Healthy Connections Medicaid?

I am a provider with multiple NPIs attached to my Medicaid ID. I completed the provider revalidation application for my primary NPI. Why are my claims being rejected?

Within 30 days from the date on the revalidation notification letter, all other NPIs attached to your Medicaid ID will need to complete an electronic provider enrollment application. To access the online provider enrollment application, copy and paste https://providerservices.scdhhs.gov/ProviderEnrollmentWeb/ into your browser. If you did not complete an electronic provider enrollment application for all non-primary NPIs associated with your Medicaid ID and you wish to continue billing with those NPIs, claims for those NPIs will be rejected. You may resubmit claims once you have received confirmation that the electronic provider enrollment application is complete. Revalidation FAQs PDF

I am also a Medicare provider and I have paid the provider revalidation fee to Medicare. Do I need to pay the South Carolina Healthy Connections Medicaid provider revalidation fee?

No, not if you have paid your Medicare fee in the last 12 months. Revalidation FAQs PDF

I am an individual provider who is affiliated with or linked to multiple organizations. Do I need to revalidate for all of the organizations where I am affiliated or linked?

 

The provider revalidation application allows you to list multiple organizations that you may be affiliated with or linked to. You will need to include every group you are associated with currently. You do not need to complete a provider revalidation application for each group. The group provider is responsible for provider revalidation. Revalidation FAQs PDF

I am an out of state South Carolina Healthy Connections Medicaid provider who has paid the provider revalidation fee for the state where I practice. Do I need to pay the South Carolina Healthy Connections Medicaid provider revalidation fee?

No, not if you have paid your Medicare fee in the last 12 months. Revalidation FAQs PDF

I am an out of state South Carolina Healthy Connections Medicaid provider, and I have already revalidated with my state. Do I need to revalidate with South Carolina Healthy Connections Medicaid?

Yes, if you want to maintain your enrollment with South Carolina Healthy Connections Medicaid. Revalidation FAQs PDF

I am currently under review by Program Integrity. Do I need to complete the provider revalidation application?

I am under review by Program Integrity and I am required to have a site visit for the Program Integrity Process. Am I required to have a separate site visit for provider revalidation?

I enrolled after 12/03/2012. Am I required to go through the provider revalidation process?

You are not required to go through this current provider revalidation process. You will be notified of the next provider revalidation process when it begins. Revalidation FAQs PDF

I’m concerned about entering my payment information on the website. Is the website secure?

Yes, the website is secure. South Carolina Healthy Connections Medicaid uses the national standard in website security software to ensure that the information entered onto the site is secure. Revalidation FAQs PDF

I’m concerned about entering my social security number or other identifying information on the provider revalidation website. Is the website secure?

Yes, the website is secure. South Carolina Healthy Connections Medicaid uses the national standard in website security software to ensure that the information entered onto the site is secure. Revalidation FAQs PDF

If I do not receive the revalidation notification letter, what can I do?

Have you recently changed your mailing address? Was the proper procedure followed to inform SCDHHS of the change? To update your address, please fax or mail a letter requesting an address change to MCCS Provider Enrollment on company letterhead. The Provider Enrollment fax number is (803) 870-9022. The address is Medicaid Provider Enrollment, P.O. Box 8809, Columbia, SC 29202-8809. The letter should include the provider’s legacy and NPI numbers, as well as the new address, along with the provider’s or an authorized person’s signature and a contact person’s name and telephone number in case there are any questions. Once the address information is updated and the revalidation notification letter is remailed, the provider will still have 30 days from the date on the original revalidation notification letter to fully complete the provider revalidation process.

If you have not recently changed your mailing address, please remember that South Carolina Healthy Connections Medicaid provider revalidation will occur in phases beginning in June 2015 and ending in March 2016. Providers should not take any steps to revalidate until they receive their revalidation notification letters. If you have not received a revalidation notification letter and your contact information is current with SCDHHS that is a strong indication that your provider revalidation phase has not begun.

Revalidation FAQs PDF

If I think my revalidation notification letter is lost in the mail, can I call the Provider Service Center and have someone give me my revalidation reference number over the phone?

No. The only way to access your revalidation reference number is to have your revalidation notification letter remailed to you. Revalidation FAQs PDF

Is revalidating as a provider the same thing as recertifying or updating my provider credentials?

In South Carolina, no, provider revalidation is not the same thing as recertification. However, some states use terms such as “revalidating,” “recertifying” or “recredentialing” interchangeably.  South Carolina Healthy Connections Medicaid provider revalidation could possibly be different from other states’ recertification process and certification updates required for specific provider types. For example, a certified nurse practitioner who is also a Medicaid provider needs to ensure that they have completed the provider revalidation process with South Carolina Healthy Connections Medicaid and that they have been recertified by the American Academy of Nurse Practitioners. The two processes are separate. Revalidation FAQs PDF

Is this the same thing as the Durable Medical Equipment (DME) revalidation process?

The provider revalidation process for South Carolina Healthy Connections Medicaid providers and South Carolina Healthy Connections Medicaid DME suppliers is the same. The timeline is different. DME suppliers need to revalidate every three years. Revalidation FAQs PDF

On a hospital claim, if the pay-to provider has revalidated, but the line provider fails to revalidate, will the claim deny?

If MMIS validates the NPI of the rendering physician, then the claim will deny if the individual has not revalidated. Revalidation FAQs PDF

The bulletin references March 2016 as being the due date/last day for provider revalidation.

Is that the last day that I can submit my provider revalidation application? Is that the day I will receive provider revalidation confirmation from South Carolina Healthy Connections Medicaid?

South Carolina Healthy Connections Medicaid mailed revalidation notification letters for phase 1 of provider revalidation on June 4th, 2015. South Carolina Healthy Connections Medicaid provider revalidation will occur in phases from June 2015 to March 2016. When it is time to revalidate your enrollment as a South Carolina Healthy Connections Medicaid provider, you will receive a revalidation notification letter in the mail. Revalidation FAQs PDF

To which address will the provider revalidation notification letter be mailed?

The provider revalidation notification letter will be mailed to the primary practice location address. Revalidation FAQs PDF

What do I need to do to prepare for a site visit?

You will receive a site visit form with this information after your site visit has been scheduled. Revalidation FAQs PDF

What do I need to do to prepare for revalidation?

It is highly recommended that you make sure your primary practice location address and provider type are current with South Carolina Healthy Connections Medicaid. It is your responsibility to ensure that your information is current.

To update your address, please fax or mail a letter requesting an address change to MCCS Provider Enrollment on company letterhead. The Provider Enrollment fax number is (803) 870-9022. The address is Medicaid Provider Enrollment, P.O. Box 8809, Columbia, SC 29202-8809. The letter should include the provider’s legacy and NPI numbers, as well as the new address, along with the provider’s or an authorized person’s signature and a contact person’s name and telephone number in case there are any questions. To update info other than an address, please go to www.scdhhs.gov/Provider and select “FAQ Guide” for instructions on how to update information in your profile.

Revalidation FAQs PDF

What if I do not complete my provider revalidation within 30 days?

If you do not fully complete the provider revalidation process within 30 days from the date on the notification letter, it is considered voluntary termination from South Carolina Healthy Connections Medicaid. You will need to enroll as a new provider. Revalidation FAQs PDF

What if my address is correct, but other information needs to be updated?

If any information that you used for your provider enrollment has changed and you have not informed SCDHHS of the change, you will need to follow the standard procedure to update your information. Please go to www.scdhhs.gov/Provider and select “FAQ Guide” for instructions on how to update information in your profile. Revalidation FAQs PDF

What if my revalidation notification letter is returned due to an incorrect address?

If the revalidation notification letter is returned to South Carolina Healthy Connections Medicaid as undeliverable mail, we will call you using the phone number on file in order to update your address. You will need to follow the standard procedure to update your address. To update your address, please fax or mail a letter requesting an address change to MCCS Provider Enrollment on company letterhead. The Provider Enrollment fax number is (803) 870-9022. The address is Medicaid Provider Enrollment, P.O. Box 8809, Columbia, SC 29202-8809. The letter should include the provider’s legacy and NPI numbers, as well as the new address, along with the provider’s or an authorized person’s signature and a contact person’s name and telephone number in case there are any questions. Once the address information is updated and the revalidation notification letter is re-sent, the provider will still have 30 days from the date on the original revalidation notification letter to fully complete the provider revalidation process.

If you are unable to be reached using the phone number on file, your inability to complete the provider revalidation process means that you have voluntarily terminated as a South Carolina Healthy Connections Medicaid provider and will need to enroll as a new provider.

Revalidation FAQs PDF

What if my revalidation reference number does not work on the website?

If your revalidation reference number does not work on the website, ensure that the computer you are using meets the web application system requirements for the provider revalidation application. Please visit https://www.scdhhs.gov/ProviderRequirements and scroll to the section labeled “Web Application System Requirements” for more information.

If you are still unable to use your revalidation reference number, please contact the Provider Service Center at (888) 289-0709, option 4.

Revalidation FAQs PDF

What if there are NPIs associated with my Medicaid ID that I do not want to revalidate?

If there are NPIs associated with your Medicaid ID that you do not want to revalidate, do not complete an enrollment application for them. No action is needed on your part. Revalidation FAQs PDF

What information will the provider revalidation process require?

A checklist of the documentation that you will need for the provider revalidation process can be found by copying and pasting this link you’re your browser https://www.scdhhs.gov/sites/default/files/Online%20Enrollment%20Application%20Visual%20Guide.pdf or by visiting https://www.scdhhs.gov/Provider and selecting “Online Application Visual Guide” from the “Provider Enrollment Information” section. This is currently a link to the Provider Online Enrollment Application Visual Guide. The information needed for enrollment is very similar to the information needed for revalidation. Revalidation FAQs PDF

What is provider revalidation?

All enrolled South Carolina Healthy Connections Medicaid providers who are not Durable Medical Equipment (DME) suppliers must revalidate their enrollment criteria every five years in accordance with the Affordable Care Act. DME suppliers must revalidate every three years. Revalidation FAQs PDF

When does provider revalidation begin?

South Carolina Healthy Connections Medicaid mailed revalidation notification letters for phase 1 of provider revalidation on June 4th, 2015. Providers should not take any steps to revalidate until they receive their revalidation notification letters. It is important that providers keep their address information up to date to ensure that they receive the revalidation notification letter.

South Carolina Healthy Connections Medicaid provider revalidation will occur in phases beginning in June 2015 and ending in March 2016. Providers should not take any steps to revalidate until they receive their revalidation notification letters. It is important that providers keep their address information up to date to ensure that they receive the revalidation notification letter.

Revalidation FAQs PDF

When should I expect to receive my provider revalidation approval?

Once the provider revalidation process is complete and error free, provider revalidation approval will be emailed to the email address entered during the provider revalidation process within 30 days. Revalidation FAQs PDF

Where can I find additional information about the South Carolina Healthy Connections Medicaid provider revalidation process?

For additional information about the South Carolina Healthy Connections Medicaid provider revalidation process, please visit www.scdhhs.gov/revalidation or medicaidelearning.remote-learner.net. Revalidation FAQs PDF

Who is mandating the provider revalidation process?

This implementation is in response to directives in the standards established by Section 6401(a) of the Affordable Care Act (ACA) in which CMS requires all state Medicaid agencies to implement the provider enrollment, screening, and revalidation provisions of the Affordable Care Act. These regulations were published in the Federal Register, Vol. 76, February 2, 2011, and were effective March 25, 2011. Revalidation FAQs PDF

Will I need a site visit?

All moderate and high risk providers will need a site visit. The site visit must occur within 30 days from the date on the revalidation notification letter. Revalidation FAQs PDF

Will there be training available for the South Carolina Healthy Connections Medicaid provider revalidation process?

There will be webinars, e-learning opportunities, and classroom training sessions available. For information about dates, times and registration, please visit medicaidelearning.remote-learner.net. Revalidation FAQs PDF

SCREENING REQUIREMENTS

Can a billing provider be an ordering or referring provider as well?

Yes, as long as the provider is not designated as an ordering/referring provider exclusively. Future edits will prevent claims payment if an ordering/referring-only provider submits their NPI as a billing provider.

Can a provider be moved from one risk category to another?

Yes, providers can be reassigned from the “limited” or “moderate” categories due to:

  • Imposition of a payment suspension within the previous 10 years
  • A provider or supplier has been terminated or is otherwise precluded from billing Medicaid
  • Exclusion by the OIG
  • A provider or supplier has been excluded from any federal health care program
  • A provider or supplier has had billing privileges revoked by a Medicaid contractor within the previous 10 years
  • A provider or supplier has been subjected to a final adverse action (as defined in 42 CFR 424.502) within the past 10 years
  • Instances in which CMS lifts a temporary moratorium for a particular provider or supplier type and a provider or supplier that was prevented from enrolling based on the moratorium, applies for enrollment as a Medicaid provider or supplier at any time within 6 months from the date the moratorium was lifted.

Explain the Medicaid application fee and how much is it?

For 2015, SCDHHS must collect a $553 application fee from business organizations and entities that are enrolling in South Carolina Medicaid with an Employee Identification Number (EIN). [Note: $542 for 2014.] The fee is to be used to cover the cost of program integrity efforts including the cost of screening associated with provider enrollment processes. This fee can vary from year to year based on adjustments made pursuant to the Consumer Price Index for Urban Areas (CIP-U). The application fee will be imposed on business organizations and entities that are enrolling in South Carolina Medicaid that are: (1) initially enrolling, (2) adding a practice location and (3) revalidating enrollment information at least every five years (with the exception of DME providers, who must revalidate every three years). Providers that are EXEMPT from the application fee are: individual physicians or non-physician practitioners.

How are providers categorized by risk categories?

Three levels of screening (limited, moderate and high) are recognized for those provider types that are also recognized provider or supplier types under Medicare.  For those provider types that are not recognized under Medicare, SCDHHS has assessed the risk of fraud, waste and abuse using similar criteria to those used in Medicare.  See the list below for SCDHHS risk categories:

Limited Risk:

(State-regulated and State-licensed would generally be categorized as limited risk)

  • Physician or non-physician practitioners and medical groups or clinics (excluding Physical Therapists and Physical Therapists Groups)
  • Nursing Homes, Hospitals, Public and Private Community Mental Health Centers, Audiologists, Certified Nurse Midwife/Licensed Midwife, Certified Registered  Nurse Anesthetists, Anesthetist Assistants, CMS Parts A & B, Managed Care Organizations,  Licensed Marriage and Family Therapists, Licensed Professional Counselors, Licensed Independent Social Workers –Clinical Practice, Psychologists, Speech Therapists, Nurse Practitioners, Physician’s Assistants, Occupational Therapists, Physicians, Speech and Hearing Clinics, End Stage Renal Disease Clinics, DHEC Clinics, Federally Qualified Health Clinics, Federally Funded Health Clinics and Rural Health Centers, Ambulatory Surgical Centers, Diabetes Education Clinics, School Districts, Developmental Rehabilitation Clinics, Infusion Centers, Pediatric Aids Clinics, Maternal and Child Health Clinics, Dentists, Opticians, Optometrists, Podiatrist, Chiropractors, Pharmacy, Pharmacy Part D, Individual Transportation Providers, Contractual Transportation Providers , Transportation Broker,  X-Ray (not portable)

Moderate Risk:

(Highly dependent on Medicare, Medicaid and CHIP to pay salaries and other operating expenses and which are not subject to additional governmental or professional oversight and would be considered moderate risk)

  • Rehabilitative Behavioral Health Services,  Physical Therapists , Comprehensive Outpatient Rehabilitation Facilities (CORFs),  Hospice Providers, Community Long Term Care (individuals and groups), Independent Laboratories, X-Ray (portable), Ambulance and Helicopter Providers
  • Currently enrolled (revalidating Home Health Agencies)
  • Currently enrolled (revalidating DMEPOS)

 High Risk:

(Identified by the State as being especially vulnerable to improper payments and would be considered as high risk)

  • Proposed (newly enrolling) Home Health Agencies (HHAs), Suppliers of Durable Medical Equipment, Prosthetics, Orthothics and Supplies (DMEPOS)

How can a provider check to see if the ordering/referring physician is enrolled with Medicaid?

 

 

On the SCDHHS website SCDHHS.gov, there is a searchable listing of Enrolled Providers under the For Providers tab. If the provider is not listed, then the provider is not currently enrolled with Medicaid. You may also contact the Provider Service Center at 1 (888) 289-0709, option 4 to verify the provider’s enrollment. 

 

How can I obtain more information regarding the new provider screening and other enrollment requirements?

A link to the Federal Register, Vol 76, No. 22, dated February 2, 2011, can be found on the SCDHHS website at SCDHHS.gov.

If I am currently enrolled in Medicare or with Medicaid in another state, will I have to go through the entire enrollment and screening process and pay another application fee to enroll in South Carolina Medicaid?

For 2015, SCDHHS must collect a $553 application fee prior to executing a provider agreement whether upon an initial enrollment, reactivation, revalidation or an enrollment to add a new practice location. [Note: $542 for 2014.] The provider enrollment application fee is applicable to providers that the Centers for Medicare & Medicaid Services (CMS) has identified as institutional providers.  South Carolina Healthy Connections Medicaid recognizes and enrolls the following institutional providers:  Ambulatory Surgery Centers, Community Mental Health Centers; Comprehensive Outpatient Rehabilitation Facilities; Durable Medical Equipment, End Stage Renal Disease Facilities; Federally Qualified Health Centers; Home Health Agencies; Hospices; Hospitals, Acute Inpatient Facilities, Inpatient Psychiatric Facilities, Inpatient Rehabilitation Facilities, Independent Clinical Laboratories; Skilled Nursing Facilities and Rural Health Clinics.

The fee is to be used to cover the cost of program integrity efforts including the cost of screening associated with provider enrollment processes. This fee can vary from year to year based on adjustments made pursuant to the Consumer Price Index for Urban Areas (CIP-U). A provider will be exempt from the fee if they have submitted and received approval for a Hardship Waiver request or they can demonstrate they are enrolled or have paid the application fee to Medicare and/or another state’s Medicaid or CHIP for the same enrollment location jurisdiction.  A different enrollment jurisdiction means “a new enrollment with an address different from a currently enrolled location.”  Individual physicians (sole proprietors enrolling with an EIN and Social Security Number (SSN) are considered individuals), non-physician practitioners and non-physician practitioner organizations are exempted from paying the enrollment application fee.

What are some of the new provider screening and enrollment guidelines?

  • Enhanced provider screening and enrollment based on risk categories (limited, moderate and high) for fraud, waste and abuse for each provider type as assigned by CMS and the SCDHHS.
  • Background checks and unannounced pre and post enrollment site visits.  Fingerprint-based criminal history records checks.   At the present time, the criminal background checks and fingerprinting are not required. 
  • Updated Disclosure of Ownership and Controlling Interest Statements
  • Enrollment of ordering/referring providers 
  • Suspension of provider Medicaid payments in cases of credible allegations of fraud
  • Denial of enrollment and/or termination of a provider from the Medicaid program “for cause”.  This is defined as the revocation of Medicaid billing privileges for specific reasons such as denial/termination from the Medicare program, denial/termination from other state Medicaid and Children’s Health Insurance Programs, or other reasons based on credible allegations of fraud, integrity or quality.
  • Institution of application enrollment fees for business organizations and entities that are enrolling with South Carolina Medicaid with an Employee Identification Number (EIN).
  • Implementation of a temporary moratorium on new provider enrollments, when instructed by CMS, to protect against high risk of fraud and abuse
  • Revalidation of enrolled providers at least every five years, with the exception of DME providers, who need to revalidate every three years.

What is a Temporary Moratorium?

A temporary moratorium is the imposition of a hold or freeze on the enrollment of new or initial Medicaid providers and suppliers of a particular provider type or the establishment of new practice locations of a particular provider type in a specific geographic area for a period of six months.  CMS may extend a temporary moratorium in six month increments.  The announcement of a moratorium will be reported in the Federal Register.

When will the new screening and enrollment guidelines be implemented?

Although indicated in a May 9, 2012 Medicaid Bulletin and letter to State Agencies this would be implemented by August 1, 2012, due to delays a new implementation date will be targeted and communicated to providers in future bulletins. Prior to implementation, provider outreach activities will focus on communication of the new policies and other related information. New screening and enrollment information will be distributed through Medicaid bulletins, SCDHHS website messages and alerts, training and orientation activities for certain programs and updates to Program Manuals.

Who initiated these new screening and enrollment guidelines?

The Centers for Medicare and Medicaid Services (CMS), under standards established by the Affordable Care Act (ACA), with a focus on strengthening requirements for Medicaid provider screening and other enrollment requirements. 

Will a provider be notified if they are terminated “for cause” and do they have appeal rights?

Yes, a provider will be notified via certified mail when terminated for cause. The provider does have appeal rights.

Will the entities in each screening category stay the same?

CMS will continuously evaluate whether they need to change the assignment of categories of providers and suppliers to various risk categories.  If they assign certain groups of providers and/or suppliers to a different category, this change will be proposed in the Federal Register.

THIRD PARTY LIABILITY (TPL)

Can MIVS track down where other payer’s money goes if you are not paid?

No, but they can contact other payers to obtain payment information.

Can the HIIRF form be faxed?

The HIIRF can be faxed to Medicaid Insurance Verification Services at (803) 252-0870.

Can you accept a beneficiary as just a private pay patient even if they have Medicaid?

Yes, you just have to let them know before they receive any services.

Do we need to send an EOB?

An Explanation of Benefits from a third party payer should be kept on file in the provider’s office, especially if the payer didn’t submit payment.

Do we send an EOB with claims?

You do not send an EOB with claims, unless it is requested.

Do you have to ask MIVS to research TPL non-payment?

No, they do this on their own to ensure payment.

Does the Medicaid card have all the information needed?

No, you should further investigate eligibility using eligibility resources and the information provided on the card.

For HIPP referral, who should you contact?

For HIPP referral, providers should contact the Medicaid Insurance Verification Services at 1-888-289-0709 option 5, option 4. The HIPP Fax is 803-462-2580.

How do patients learn updated information?

Patients learn of updates at their enrollment anniversary dates, or you may share information with them.

How long do you have to request a hearing for an appeal?

You have 30 days to request a hearing.

If a Health Insurance Information Referral Form (HIIRF) is completed with no documentation, will the beneficiary's TPL record be updated?

No, MIVS will further investigate and draft a letterhead showing steps taken.

If a plan doesn’t cover family planning, do we bill to Medicaid and send the EOB?

Certain services are “carved out”, not covered, by the MCOs and MHNs. Those services can be billed directly to SC Medicaid. You do not need to bill to the managed care plan for a denial.

If I have a difficult payer, do I need to complete a reasonable effort document?

Yes you can. It is to show efforts made to obtain other payments from other insurers.

If I send a HIIRF, will I see anything saying it was received?

No, just wait a few days and check eligibility again.

If my third party has several addresses, which one do I choose?

You would contact the company to find out which address is for your service area.

If the beneficiary had Champus or Tri-Care and it paid 100%, why would I need to file to Medicaid?

You would need to file to Medicaid for reporting purposes and for seeing the claim through from beginning to end. 

If you know a service isn’t covered, do you still file to the other carrier?

Yes, you still file to the other carrier to obtain a valid denial. Three denials should be kept on file each year.

What do you do if monies are sent to the patient?

Change them to self pay after or before service completion.

What happens when Medicaid recoups for retro-health recovery and it is outside of the timely filing window?

Professional billers do not receive retro health letters. Medicaid contacts or solicits billing payments from the private health plan.

What if a claim is created, but the beneficiary says that he/she no longer has the insurance on file?

If a beneficiary no longer has the insurance policy that is seen on the Web Tool, the provider can refer the beneficiary to their eligibility counselor/worker, or complete the Health Insurance Information Referral Form (HIIRF) to update the beneficiary’s third party payer information. Making a change to a policy that already exists in the Medicaid Management Information System (MMIS) takes five days. The HIIRF Form can be faxed to 803-252-0870.

Where are the specifics for pay and chase?

The specifics for pay and chase are found in Section 2 (polices) and section 3 (billing) of your provider manual.

WEB TOOL

Are Web Tool lists separated by login?

No, your lists are sharable.

Can batches be deleted after they are sent?

No. Batches cannot be deleted at this time.

Can claims be lost via the Web Tool?

Generally, they don’t get lost using the web.

Can I check claim status on the Web Tool?

Yes. Key in the NPI or provider ID number and the recipient ID number and press submit.

Can I do a span date on the Web Tool?

Yes, by entering in information in the to and from fields.

Can we find edit codes on the Web Tool?

No, however the edit code listing is found in Appendix 1 of your provider manual.

Can Web Tool Lists be sorted by provider?

Not at this time. The Lists can be sorted by who created them. 

Can Web Tool users in the same organization see each other’s claim information?

Users in the same organization based on the provider’s NPI number will be able to see claim information entered by other users.

Can you copy a Web Tool batch and then later delete an individual claim?

Yes, you can copy batches and delete selected claims.

Can you correct a Web Tool claim online?

Yes; this can be done by submitting a new claim. 

Can you export data from Web Tool?

Not at this time, however you can print screen and save it as a file.

Can you file Medicaid as secondary on Web Tool?

Yes, providers must file to all other payers and then input that information (received money) on the claim form on the Web Tool. There is a place to identify the hierarchy.

Can you print the batch ID?

Yes you can, by doing a file>print from the browser bar.

Can you resubmit a denied claim once correct on Web Tool?

Yes. Copy the claim, correct it, and submit it.

Can you resubmit the same claim via the Web Tool?

Yes, if you submit a new claim, you will get a new CCN.

Can you send me a copy of the Remittance Advice (RA)?

Copies of Remittance Advice statements can be retrieved online via the Web Tool.

If the remittance advice date is not available, complete a Duplicate Remittance Advice Request Form in the Forms Section of all provider manuals. There is a processing fee of $20 plus 20 cents per page copied. The charges will be deducted from a future Remittance Advice, appearing as a debit adjustment. The duplicate RA policy was enacted in December 2010.

Can you use the Web Tool for adjustments, if you filed through a clearinghouse?

Yes, you may submit an adjustment through the Web Tool, even if the original claim was filed using a clearinghouse – as long as it is within 15-18 months. However, UB-04 (Institutional) billers must file adjustments in the same medium as the original claim.

Do I have to request another Login and Password if more than one person wants to use the Web Tool?

Yes, all users must have their own individual login ID and Password to access the Web Tool.  If more than one user tries to login under the same login ID and Password, they will receive a denial message.

Do you have to put in diagnosis codes?

If the service you are providing requires the use of a diagnosis code, then you must enter the diagnosis code with your claim information. 

Do you have to put the last 4 digits of the zip code for Claims Entry?

Yes; you can find zip codes on the US Postal Services website: www.usps.com.  Click on Look Up a Zip Code

Do you have to submit claims through Web Tool?

No, you may use other options like hard copy or vendor/clearing house.

Does Suspended mean processing?

No; Suspended means that the claim is in review. 

Does the Web Tool’s Lists feature allow you to save a beneficiary’s prior authorization in a field?

No, prior authorization may not be necessary for all services. There is a field for prior authorization.

Does Web Tool’s Status show whether it is approved to be paid?

Yes

How can I verify that my claims on the Web Tool have been submitted successfully?

If you received a batch number for the submission, then the submission reached MCCS. Go to Reports and click on the type of report that was sent (i.e.: CMS-1500, etc.). If a batch number is shown for the day and number of claims in the batch sent, the submission went through.

How can you find out MHN info for a beneficiary?

A provider can verify Medical Homes Network enrollment on the eligibility section of the Web Tool under the “Beneficiary Special Program Data” section.

How do I file a replacement claim for a paid claim that is partly incorrect?

Go to the Web Tool submission page. Log in; go to claims entry/history; click on the correct batch number; click on the correct claim number; copy; click the claim type on the left; click on batch, claim; edit; scroll down to claim submission reason code; select replacement. To complete this task, you must have the original Claim Control Number (CCN).

How do I know the charge?

You can find the charge for the service in your provider manual.

How far back can you bill?

Within 12 months

How far back can you file a void?

15 - 18 months

How long will a Web Tool claim stay out as a draft?

Three months.

How soon does information show up in Web Tool’s Status?

After payments process

I cannot enter all of the characters in a procedure code or a diagnosis code. Can you help me?

Remove decimal points from the code. To start afresh, backspace to the beginning of the field or highlight the characters in the code and press delete.

If a beneficiary isn’t eligible, will the Web Tool show ineligible?

Yes, information is listed in red.

If I delete a person from the Web Tool list and the person returns, do I have to re-enter all of the information?

Yes. Once an entry is deleted, it is lost. You can choose to make the entry inactive, so you won’t see it.

If I have two separate claims for one beneficiary, do I have to enter the claim information twice on Web Tool?

Yes, you would have to submit two different claims. You can go to your submitted claim bucket and copy the claim with additional edits and changes and then resubmit it instead of rekeying two claims.

If I submit a claim through a vendor, will I be able to view it under Web Tool’s History?

No

If providers aren’t getting remits, who can they contact?

Provider Service Center/EDI

If the beneficiary had Champus or Tri-Care and it paid 100%, why would I need to file to Medicaid?

You would need to file to Medicaid for reporting purposes and for seeing the claim through from beginning to end. 

If the Web Tool says they have 2 visits but the beneficiary goes somewhere else, how do we know if they have anymore visits?

Web Tool is updated nightly; you should always check and if they are out of visits, let them know before providing services.

If you are checking a new person’s eligibility, can you add them to your recipient list from that screen?

Yes, there is a button to do that.

If you are missing information, will the Web Tool process the claim anyway?

Yes and no; there are basic required fields that are denoted by asterisks, however if you forget modifiers, the Web Tool won’t recognize that.

If you copy an entire Web Tool batch over, can you choose which claims to submit?

Yes

If you have primary diagnosis codes, do you have to add additional codes?

No, you just need the primary code.

If you make an error and you submit the claim on the Web Tool, is there a way to cancel or make a correction that same day?

Once a claim is submitted via the Web Tool, there is no way to cancel or make a correction to the submitted claim that same day.  Once the claim has gone through the payment cycle, you will be able to see if the claim has been rejected, paid, or suspended.  You will then be able to make corrections to the claim before resubmitting as a new claim.

In the Web Tool's status section, do claims purge based on batch ID?

They purge based on the check date.

Is the EFT form used for MCOs as well?

No, they have their own forms and billing systems.

Is the Web Tool claim ID number automatically entered?

Yes.

Is the Web Tool updated daily?

Yes, the Web Tool is updated every night.

Is there a limit to the number of claims in a Web Tool batch?

There is not a limit to the number of claims in a batch.

Is there a way to find a claim in History if you had not submitted it through the Web Tool?

No; you can only view that claim’s status.

Under the Web Tool's status option, can I check the status of a claim I submit hard copy?

Yes, it doesn’t matter the submission method.

What form needs to be completed for access to the Web Tool?

The trading partner agreement form needs to be completed.

What if a claim is created, but the beneficiary says that he/she no longer has the insurance on file?

If a beneficiary no longer has the insurance policy that is seen on the Web Tool, the provider can refer the beneficiary to their eligibility counselor/worker, or complete the Health Insurance Information Referral Form (HIIRF) to update the beneficiary’s third party payer information. Making a change to a policy that already exists in the Medicaid Management Information System (MMIS) takes five days. The HIIRF Form can be faxed to 803-252-0870.

What is an MHN referral number?

If your service requires a referral, the MHN gives you an authorization number.

What is the payment cycle?

The payment cycle is: Wed-Mon, payments are processed on Tuesday, and payment is received as early as Friday.

What is the Web Tool’s Non-Contractual box?

The Non-Contractual box is to be selected/entered when the provider is not contracted with the beneficiary’s third party payer.

When a claim is in a denied status, can you do an adjustment?

You must wait for the rejection, and then do a correction. An adjustment can only be made to a paid claim.

When I try to change my Web Tool password, it keeps saying I haven’t met the criteria. What should I do?

The system recognizes when your password does not meet the password requirements.  However, if you have reviewed your selected password and it does meet the password requirements, contact the EDI Support Center at 1-888-289-0709, and choose Option “1”. 

When should eligibility be checked?

You should check before providing services.

When would you use a void?

You would use a void if you bill for something by mistake; accidental claim submission, for example.

Where are the carrier codes listed?

Appendix 2 of your SCDHHS Provider Manual.

Where can I attach documentation to my Web Tool claim?

On the Claim Entry screen, go to the Document tab to attach your documentation. (Effective August 17, 2015) Claims Attachments – Web Tool Reference Guide.

Why are Web Tool claims suspending?

Contact the PSC, option “2” for claims issues. 

Will MCO info be available via the Web Tool?

A provider can verify Managed Care Organization enrollment on the eligibility section of the Web Tool under the “Beneficiary Special Program Data” section.

Will systems recognize a duplicate claim if it is denied?

No, because it did not process. 

Will voids show up on the remit?

Yes

Will Web Tool list information auto-update for you as changes are made?

No, it is not tied to another system. Updates are your responsibility.

Would you ever get locked out of the Web Tool if you put your password in wrong?

No, there is no limit on password attempts. 

WEB TOOL: CHECK ELIGIBILITY

How can you find out MHN info for a beneficiary?

A provider can verify Medical Homes Network enrollment on the eligibility section of the Web Tool under the “Beneficiary Special Program Data” section.

If a beneficiary isn’t eligible, will the Web Tool show ineligible?

Yes, information is listed in red.

If the Web Tool says they have 2 visits but the beneficiary goes somewhere else, how do we know if they have anymore visits?

Web Tool is updated nightly; you should always check and if they are out of visits, let them know before providing services.

If you are checking a new person’s eligibility, can you add them to your recipient list from that screen?

Yes, there is a button to do that.

Is the Web Tool updated daily?

Yes, the Web Tool is updated every night.

What if a claim is created, but the beneficiary says that he/she no longer has the insurance on file?

If a beneficiary no longer has the insurance policy that is seen on the Web Tool, the provider can refer the beneficiary to their eligibility counselor/worker, or complete the Health Insurance Information Referral Form (HIIRF) to update the beneficiary’s third party payer information. Making a change to a policy that already exists in the Medicaid Management Information System (MMIS) takes five days. The HIIRF Form can be faxed to 803-252-0870.

What is an MHN referral number?

If your service requires a referral, the MHN gives you an authorization number.

When should eligibility be checked?

You should check before providing services.

Will MCO info be available via the Web Tool?

A provider can verify Managed Care Organization enrollment on the eligibility section of the Web Tool under the “Beneficiary Special Program Data” section.

WEB TOOL: GETTING ACCESS

Can Web Tool users in the same organization see each other’s claim information?

Users in the same organization based on the provider’s NPI number will be able to see claim information entered by other users.

Do I have to request another Login and Password if more than one person wants to use the Web Tool?

Yes, all users must have their own individual login ID and Password to access the Web Tool.  If more than one user tries to login under the same login ID and Password, they will receive a denial message.

What form needs to be completed for access to the Web Tool?

The trading partner agreement form needs to be completed.

When I try to change my Web Tool password, it keeps saying I haven’t met the criteria. What should I do?

The system recognizes when your password does not meet the password requirements.  However, if you have reviewed your selected password and it does meet the password requirements, contact the EDI Support Center at 1-888-289-0709, and choose Option “1”. 

Would you ever get locked out of the Web Tool if you put your password in wrong?

No, there is no limit on password attempts. 

WEB TOOL: LISTS FEATURE

Are Web Tool lists separated by login?

No, your lists are sharable.

Can Web Tool Lists be sorted by provider?

Not at this time. The Lists can be sorted by who created them. 

Does the Web Tool’s Lists feature allow you to save a beneficiary’s prior authorization in a field?

No, prior authorization may not be necessary for all services. There is a field for prior authorization.

WEB TOOL: REMIT & STATUS

Can batches be deleted after they are sent?

No. Batches cannot be deleted at this time.

Can I check claim status on the Web Tool?

Yes. Key in the NPI or provider ID number and the recipient ID number and press submit.

Can you send me a copy of the Remittance Advice (RA)?

Copies of Remittance Advice statements can be retrieved online via the Web Tool.

If the remittance advice date is not available, complete a Duplicate Remittance Advice Request Form in the Forms Section of all provider manuals. There is a processing fee of $20 plus 20 cents per page copied. The charges will be deducted from a future Remittance Advice, appearing as a debit adjustment. The duplicate RA policy was enacted in December 2010.

Does Suspended mean processing?

No; Suspended means that the claim is in review. 

Does Web Tool’s Status show whether it is approved to be paid?

Yes

How can I verify that my claims on the Web Tool have been submitted successfully?

If you received a batch number for the submission, then the submission reached MCCS. Go to Reports and click on the type of report that was sent (i.e.: CMS-1500, etc.). If a batch number is shown for the day and number of claims in the batch sent, the submission went through.

How soon does information show up in Web Tool’s Status?

After payments process

If I delete a person from the Web Tool list and the person returns, do I have to re-enter all of the information?

Yes. Once an entry is deleted, it is lost. You can choose to make the entry inactive, so you won’t see it.

If I submit a claim through a vendor, will I be able to view it under Web Tool’s History?

No

If providers aren’t getting remits, who can they contact?

Provider Service Center/EDI

In the Web Tool's status section, do claims purge based on batch ID?

They purge based on the check date.

Is there a way to find a claim in History if you had not submitted it through the Web Tool?

No; you can only view that claim’s status.

Why are Web Tool claims suspending?

Contact the PSC, option “2” for claims issues. 

Will voids show up on the remit?

Yes

Will Web Tool list information auto-update for you as changes are made?

No, it is not tied to another system. Updates are your responsibility.

WEB TOOL: SUBMIT A CLAIM

Can batches be deleted after they are sent?

No. Batches cannot be deleted at this time.

Can you copy a Web Tool batch and then later delete an individual claim?

Yes, you can copy batches and delete selected claims.

Can you correct a Web Tool claim online?

Yes; this can be done by submitting a new claim. 

Can you file Medicaid as secondary on Web Tool?

Yes, providers must file to all other payers and then input that information (received money) on the claim form on the Web Tool. There is a place to identify the hierarchy.

Can you resubmit a denied claim once correct on Web Tool?

Yes. Copy the claim, correct it, and submit it.

Can you resubmit the same claim via the Web Tool?

Yes, if you submit a new claim, you will get a new CCN.

Can you use the Web Tool for adjustments, if you filed through a clearinghouse?

Yes, you may submit an adjustment through the Web Tool, even if the original claim was filed using a clearinghouse – as long as it is within 15-18 months. However, UB-04 (Institutional) billers must file adjustments in the same medium as the original claim.

Do you have to put in diagnosis codes?

If the service you are providing requires the use of a diagnosis code, then you must enter the diagnosis code with your claim information. 

Do you have to put the last 4 digits of the zip code for Claims Entry?

Yes; you can find zip codes on the US Postal Services website: www.usps.com.  Click on Look Up a Zip Code

Do you have to submit claims through Web Tool?

No, you may use other options like hard copy or vendor/clearing house.

How do I file a replacement claim for a paid claim that is partly incorrect?

Go to the Web Tool submission page. Log in; go to claims entry/history; click on the correct batch number; click on the correct claim number; copy; click the claim type on the left; click on batch, claim; edit; scroll down to claim submission reason code; select replacement. To complete this task, you must have the original Claim Control Number (CCN).

How do I know the charge?

You can find the charge for the service in your provider manual.

How far back can you bill?

Within 12 months

How far back can you file a void?

15 - 18 months

How long will a Web Tool claim stay out as a draft?

Three months.

I cannot enter all of the characters in a procedure code or a diagnosis code. Can you help me?

Remove decimal points from the code. To start afresh, backspace to the beginning of the field or highlight the characters in the code and press delete.

If I have two separate claims for one beneficiary, do I have to enter the claim information twice on Web Tool?

Yes, you would have to submit two different claims. You can go to your submitted claim bucket and copy the claim with additional edits and changes and then resubmit it instead of rekeying two claims.

If you are missing information, will the Web Tool process the claim anyway?

Yes and no; there are basic required fields that are denoted by asterisks, however if you forget modifiers, the Web Tool won’t recognize that.

If you copy an entire Web Tool batch over, can you choose which claims to submit?

Yes

If you have primary diagnosis codes, do you have to add additional codes?

No, you just need the primary code.

If you make an error and you submit the claim on the Web Tool, is there a way to cancel or make a correction that same day?

Once a claim is submitted via the Web Tool, there is no way to cancel or make a correction to the submitted claim that same day.  Once the claim has gone through the payment cycle, you will be able to see if the claim has been rejected, paid, or suspended.  You will then be able to make corrections to the claim before resubmitting as a new claim.

Is the Web Tool claim ID number automatically entered?

Yes.

Is there a limit to the number of claims in a Web Tool batch?

There is not a limit to the number of claims in a batch.

Under the Web Tool's status option, can I check the status of a claim I submit hard copy?

Yes, it doesn’t matter the submission method.

What is the payment cycle?

The payment cycle is: Wed-Mon, payments are processed on Tuesday, and payment is received as early as Friday.

What is the Web Tool’s Non-Contractual box?

The Non-Contractual box is to be selected/entered when the provider is not contracted with the beneficiary’s third party payer.

When a claim is in a denied status, can you do an adjustment?

You must wait for the rejection, and then do a correction. An adjustment can only be made to a paid claim.

When would you use a void?

You would use a void if you bill for something by mistake; accidental claim submission, for example.

Where are the carrier codes listed?

Appendix 2 of your SCDHHS Provider Manual.

Will systems recognize a duplicate claim if it is denied?

No, because it did not process. 


Page:  1  2  3  4  5  6  7  8  9  10  ...  31  (Next)
ALL