Errors That Result In Denied Claims;
This information is presented for you to review your internal procedures and identify areas where the number of denied claims could be reduced. Denied claims result in delay of payment. Please note HIPAA claim adjustment reason and remit remark codes as provided on the remittance advice.
Claim Errors (Remittance Advice Remarks)
• The rendering provider is not eligible to perform the service billed (185) or claim/service lacks information which is needed for adjudication. (16/MA30)
o Service code not covered to the provider type or specialty
Note: If a procedure code is not covered, the provider will need to submit documentation for review to Molina per the following:
• The request must submitted in writing
• The request must be supported with documentation
o documentation should include any claim examples or indicate why the code should be payable
• If there is no supporting documentation, the request will not be considered.
• Missing/incomplete/invalid HCPCS Code (A1/M20)
o Validate code keyed correctly
o Validate code is current for Date of Service (DOS)
• Missing/incomplete/invalid/deactivated/withdrawn National Drug Code (NDC) (16/M119)
o For resolution to these denials, please refer to www.dhhr.wv.gov/bms
----Select Drug Code/NDC Drug Information.
o NDC, unit of measure and units should be submitted on Medicare primary claims (even though not required by Medicare) so the information will cross over to Medicaid, eliminating the need to submit Medicaid secondary -claims on paper.
• Incomplete/invalid plan information for other insurance (Invalid Medicare Action Code) (16/N245)
o Claims denied by Medicare and submitted electronically must include a Medicare Action Code (MAC)
• This service/equipment/drug is not covered under the patient’s current benefit plan (204)
o Non-covered WV Medicaid Service
• This case may be covered by another payer per coordination of benefits/secondary payment cannot be considered without the identity of or payment information from the primary payer. The information was either not reported or was illegible. (22/MA04)
o Payer information is not submitted on electronic claim
o Explanation of Benefit (EOB) is not submitted with paper claim
• Charges are covered under a capitation agreement/managed care plan (24)
o For members enrolled in Medicaid MCO - MCO is responsible for the service
o For Members who have a PAAS provider, PAAS approval is required
–View member’s Medicaid Card to verify MCO or PAAS information
–Utilize AVRS to verify MCO or PAAS information
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