Investigating Unpaid Medicaid Claims

Overview

Even with the best process, errors can happen. If your Medicaid claim has gone unpaid, the following check list will help you rule out any issues on your end before you reach out to Support.

Checklist

Check Authorizations

If you are billing any form of Medicaid, check to make sure you haven't billed without an authorization, and that your authorization information is up to date. If you requested to turn off authorization notifications, you may wish to turn them back on.

Check Visit Types & Payer Descriptors

Check to make sure your visit types and payer descriptors (for those that use payer descriptors) are correct. A more detailed walkthrough on identifying and correcting these issues is available here.

Check for Data Delivery

Make sure your data was actually uploaded to the clearinghouse, aggregator, or state portal. The following can affect your data delivery:

• Unbilled visits
  • Make sure visits in the past are closed or canceled
  • Make sure the Visit Approval Dashboard is cleared out
  • Make sure you have calculated billing
  • Make sure the billing report is completed
• Missing key data required by your state
  • wrong or missing clients or caregivers
  • wrong or missing data elements from client/caregiver profiles, such as primary diagnosis codes (see your state guide for further details on client/caregiver requirements)
  • wrong or missing data elements from the authorizations, such as missing admission ID (in most states)
• Incorrect company data
  • If you provide Ankota wrong or incomplete data, this can result in misbilling. For exapmle, if you have more than one NPI, it is important to provide that information and what category/ies each NPI applies to; this is the same for EINs, provider Medicaid IDs, taxonomy codes, etc.
• Wrong data upload location
  • Make sure the right data was sent to the right location; for example, if you are billing Aetna via Availity with an EDI file, do not upload the Aetna EDI file to Waystar
• No data upload location
  • If you have a new clearinghouse, aggregator, or state portal, you probably lack the configuration necessary to export. Reach out to Ankota Support to request to be configured for a new clearinghouse, aggregator, or state portal

Check Responses

If you have errors returned by the clearinghouse, review them. These will likely you point you in the direction of what needs correcting, such as a wrong primary diagnosis code, a wrong DOB, wrong Medicaid ID, or misspelled name. Error codes are usually provided in response files such as the Tellus response files, in claim confirmation files directly from the state (such as EMOMED's claim confirmation file), and in 835 response files (see the Exceptions report for a list of the error codes after you have uploaded the 835). It's critical to include these errors when you reach out to Support.

Reaching out to Support

If you cannot find any issues on your end, it is time to reach out for Support help. If your claims were already accepted into a clearinghouse, you will normally want to speak to the clearinghouse first and ensure you have as much error information as possible before reaching out to Ankota Support. 

For the fastest response, you will want to provide Support key details, as in the following examples:

Example 1:

Hi, Support!

I have a claim rejection I need help with. Here is the information:

• Company & State: Always Better Care (ABC), MO
• Payer: Medicaid (no MCO)
• State: MO
• Clearinghouse/Upload location: EMOMED
• Visit #: 123456789-abcd
• Caregiver: John Doe
• Date & Time: 11/1/2021 5pm-7pm
• Visit Type: T1019 Personal Care
• Error: the generic "16" error, which didn't help: Claim/service lacks information or has submission/billing error(s).

I went through your suggested checklist and can't find any errors. Can you help me dig into this further?

Thanks!

Jim Doe, ABC Billing Department

Example 2:

Hi, Support!

I have a claim rejection I need help with. Here is the information:

• Company & State: Definitely Exceptional Caregivers (DEC), VA
• Payer: MCO, Aetna Better Health
• State: VA
• Clearinghouse/Upload location: Availity
• Visit #: 987654321-abcd
• Caregiver: Jane Doe
• Date & Time: 11/1/2021 5pm-7pm
• Visit Type: T1019 Personal Care
• Error: R2, I don't know what this means. 

I got a specific response, but I'm not sure what it means. Help?

Thanks!

Maria Doe, DEC Billing Department