Frequently Asked Questions

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Frequently Asked Questions


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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.

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


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 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 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.

Will recertification dates be listed on Web Tool?

No, it would violate HIPPA.

Will systems recognize a duplicate claim if it is denied?

No, because it did not process. 

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.

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