• If this is your first visit, be sure to check out the FAQ & read the forum rules. To view all forums, post or create a new thread, you must be an AAPC Member. If you are a member and have already registered for member area and forum access, you can log in by clicking here. If you've forgotten your username or password use our password reminder tool. To start viewing messages, select the forum that you want to visit from the selection below.
  • We're introducing new features and a new look to make the forums easier to use and more valuable to you. See what's new and let us know what you think!

Billing Medicaid for claims denied by medicaid managed care plans.

JesseL

Expert
Messages
378
Best answers
0
We have a claim denied for being out of network by a medicaid managed care plan. I'm trying to bill straight medicaid for it through epaces but keep getting the denial as below:

"(F2 ) - Finalized/Denial-The claim/line has been denied. (97 ) - Patient eligibility not found with entity. Note: This code requires use of an Entity Code. (PR ) - Payer"

Any ideas? I figured straight medicaid is payor of last resort so trying to get this paid.
 

mitchellde

True Blue
Messages
13,303
Location
Columbia, MO
Best answers
0
Traditional Medicaid will not pay this claim because patient has a managed care plan.
It is a good denial with no appeal posdible. When a patient signs up for Medicaid they are placed on a specific plan according to many factors. So straight Medicaid is not a payer of last resort, it is the payer some patients are assigned to and some are not according to their needs. If you knew the patient was a Medicaid HMO patient, and you are not a provider for that payer, then the patient should have been immediately referred to the appropriate provider by the front desk staff, unless this was an emergency.
 

KN

Networker
Local Chapter Officer
Messages
99
Location
Upper Saddle River, NJ
Best answers
0
You will need to do an eligibility check through Epaces and it will tell the status of the straight Medicaid coverage. If the patient is not eligible you will can appeal to the Medicaid Managed Care Plan for reimbursement. Even though you provider is out of network the member may have out of network coverage of some kind. Did you verify eligibility with the Medicaid Managed Care Plan prior to the services? If so, you may want to base your appeal on what you were advised. If all fails you will have to bill the member. Good Luck
 

JesseL

Expert
Messages
378
Best answers
0
It is a good denial with no appeal posdible. When a patient signs up for Medicaid they are placed on a specific plan according to many factors. So straight Medicaid is not a payer of last resort, it is the payer some patients are assigned to and some are not according to their needs. If you knew the patient was a Medicaid HMO patient, and you are not a provider for that payer, then the patient should have been immediately referred to the appropriate provider by the front desk staff, unless this was an emergency.
Yeaa what happen was she was in-network but I think she had to recertify or recredential with the payer and they issued no warning to the provider that she had to do this. SOme rep from that payor assigned all her patients to another PCP (who probably paid/bribed him to do this), at least that's what the provider thinks.. So the end result is we saw a lot of patients with that plan and didnt get paid for it due to the payer considered the provider to be out of network for not doing the re credentialing.

Was hoping to get straight medicaid to pay for these :(
 
Last edited:
Top