Frequently Denied Edits
Frequently Denied Edits That Are Posting on Remittance Advices and Helpful Hints to Correct
New FAQs added in response to February 23, 2023, workshop
1.Please share info on Remittance Advice, Payment Date.
Provider Payment/EFT/RA Information: Gainwell Technologies run a financial cycle each week. Claims received via EDI by noon on Friday and web portal claims by 7 p.m. should appear on the following week’s Remittance Advice Statement. Remittance Advice Statements are available each Monday morning. Payments to providers via EFT are available by Thursday morning, and paper checks are mailed each Wednesday evening.
2. If Medicare is the primary insurance and Medicaid is secondary, and we are mailing the secondary 1500 claim to Medicaid, Box 1 should have Medicare checked?
Yes. In FL 1 (Figure 1), enter X in the box labeled “Medicare” when submitting a crossover claim and enter X in the box labeled “Medicaid” for non-crossover claims. This information is available via the Paper Claims Billing Manual: https://medicaid.ms.gov/wp-content/uploads/2022/10/Section-4.pdf.
3. What about if Medicare Advanced is primary to Medicaid, will Box 1 be checked as Medicare or should Medicaid be checked?
This directive is applicable for any Medicare primary claims.
4. How can I access job aids? Can they be printed?
Go to medicaid.ms.gov > Portal for Providers > MESA Tips. The most recent Job Aid will be at the top of the list. Job Aids are in PDF format and are printable.
5. We bill CPT 2 codes to report quality services that are 0.00 charges that will show on the EOB from Medicare and Medicare Advantage. Do we have to enter all these 0.00 charges on the portal for secondary or just the ones that have a dollar amount?
Typically, providers will omit the 0.00 charges from the claim and mark through those items on the EOMB.
6. TPL electronically submitted via clearinghouse, does it require primary EOB?
Yes, any claims with TPL does require attachment to be submitted with it.
7. So, is this going to be for the TPL electronic submitted claims also, not just the paper claims?
Any claims with TPL does require an attachment to be submitted with it, including the EDI 37 claims.
8. Please clarify when we need to enter other insurance reason code, Paid verses Non-Payment.
Claims submitted through the portal must be submitted with attachments.
9. We have never required the primary EOB for TPL, when is this going into effect?
This is not a new standard. TPL claims have required EOB for several years. Please review Late Breaking News for updates.
10. Is it correct that Medicaid is NO LONGER paying claims if Medicaid is the secondary? I have received information that if a patient has a primary insurance such as Cigna,and Medicaid is secondary, Medicaid will no longer pay for services?
No, this is not accurate information. If you have claims that you believe to be denied for this reason, please contact your field representative for assistance.
11. What about timely filing for claims that we are not going to have a TCN for because they were not keyed due to Gainwell not accepting them during the time frame they were due?
This is currently under review by Gainwell and the Mississippi Division of Medicaid. Please continue to monitor Late Breaking News as well and attend future webinars.
12. Do we need to send claims that deny for timely that are legacy claims to Admin review?
Timely filing as a whole is being reviewed by Gainwell and the Mississippi Division of Medicaid (DOM), and the more information will be coming soon regarding this. We are asking providers to keep track of those claims for when a process is put into place.
13. Can you go over the how to submit for administrative review, please?
Timely filing rules may be found on the Division of Medicaid website at https://medicaid.ms.gov/providers/administrative-code/. (Administrative Code Part 200; Chapter 1; Rules 1.6, 1.7 and 1.8). Providers may submit an Administrative Review of a Claim when: 1) A beneficiary’s retroactive eligibility prevents the provider from filing the claim timely and the provider submits the claim within ninety (90) days of the system’s add date of the beneficiary’s eligibility determination, 2) the Mississippi Division of Medicaid adjusts claims after timely filing and timely processing deadlines have expired, or 3) the provider has submitted a Medicare crossover claim within one-hundred and eighty (180) days of the Medicare paid date and the provider is dissatisfied with the disposition of the claim. The request should include a new day claim, supporting documentation, and a cover letter containing specific details of why the claim denied and actions taken to file timely. Requests for Administrative Reviews must be submitted to the Office of Appeals at the Mississippi Division of Medicaid and must include: 1) Documentation of timely filing or documentation that the provider was unable to file the claim timely due to the beneficiary’s retroactive eligibility, 2) documentation supporting the reason for the Administrative Review, and 3) other documentation as required or requested by the Division of Medicaid.
Submit Administrative Reviews to:
Division of Medicaid
Attention: Office of Appeals
550 High Street, Suite 1000
Phone: 601-359-6050
Fax: 601-359-9153
https://medicaid.ms.gov/providers/administrative-code/\
14. I have issues with printing Medicaid secondary claims. When I print the form from my clearinghouse Box 1 had Medicaid checked, and not Medicare. Box 1A is pulling in the patient’s primary insurance ID number, and not the Medicaid ID number. Box 9 (A-D) and Box 11 (A-C) are pulling in the wrong information. I had a call with my clearinghouse yesterday, and she tried to help figure out a way to manually change some of the incorrect information. We could not get Box 1 to change to Medicare and keep Medicaid and Medicaid address listed at the very top of the claim. I hope this makes sense. Our clearinghouse is SSI, and I’m not sure what to try next to get the claim forms correct, so that I can continue printing the claims that I need to print to mail to Medicaid.
Your clearinghouse will likely have to make a programming change to the software to ensure that the appropriate information is captured when you must print claims from your software. I would advise that they utilize the billing manuals on the DOM’s website (http://medicaid.ms.gov) when making those changes. Reach out to your provider representative regarding this.
15. If we have legacy claims that need to be corrected, do we just need to hold them for now or send via paper?
The issue is voiding and adjusting. So, even if you attempt to adjust via paper or on the portal, you still run the risk of having the same issue of not avoiding or adjusting correctly. So, until this is completely fixed, please keep track of those claims. If you are going to fall into any kind of timely filing, we suggest making the attempt and see if it goes through. If you do get an error message, capture it with a screen shot so you have supporting documentation.
16. We have Part C claims that were submitted on the portal with the EOMB uploaded, and they denied with the only adjudication error being “2408 – EOMB INFORMATION IS UNDER REVIEW”. Should there be another error, or is this saying there is an issue with the EOMB that we uploaded?
Send those ICNs to your field representative, so we can look at those. If it is a clerical error, then we can review it and work with staff to prevent such errors in the future.
17. We’re seeing the 2408 denials, but also seeing duplicate denials when it should not be a duplicate. We just sent an email this morning with examples, but is anyone else seeing this?
Please send examples to your field representative, so they can take a look at these.
18. In the past when we have checked eligibility for patients, if has shown when a child changes insurance through the Medicaid programs such as Medicaid to MS-CAN and vice versa; however, the portal is not showing this information so we are unable to actually enter correct dates for initial and termination of insurance, resulting in several claims being denied for insurance change status of which we are unaware of at the time.
This is one of the enhancements that we are looking into for the MESA portal. We are not sure when this will be implemented, and we do not have a timeline. It is being worked on currently.
29. Dup error is 5001 for Part C claims. I’m not having an issue with rendering provider. We’re seeing the 2408 denials, but also seeing duplicate denials when it should not be a duplicate. We just sent an email this morning with examples, but is anyone else seeing this?
We have been experiencing issues with dups, and we are looking into these areas. Please send examples to your provider representatives to address these issues.
20. We are having several inpatient claims denying due to ungroupable DRG, which seems to be maternity IP claims. Our HIM department has reviewed and determined correct coding. How would we find out what is causing the denial?
The ungroupable DRG edits has been identified, and it is currently being worked on. More information will be provided at a later date.
21. What is the purpose of calling the call center because every time we call them, they can’t give us any answers. They tell us to call our field representative?
It is based on what they know as everyone, including our call center, is in a learning period. The Call Center is very knowledgeable. If they are asking you to reach out to your provider representative, then that is so a deeper investigation can be done into your specific issue.
22. Any idea of a time frame for the suspension of EOBs for EDI crossover claims? Or is it possible that could be made permanent?
DOM decided to relax the EOMB for electronically submitted crossover claims at this time. We do not know if this will be permanent.
23. Are Bilateral Modifiers and Therapy Overlaps denials still outstanding?
These fall into the arena of duplicates, and we are looking into these as well.
24. Will you clarify for the claims process through Gainwell, if lines are paid and the claim needs to be corrected? We still must void the claim first and then submit the claim with the corrections. The line paid and some denied.
You should be able to simply bill the claims that denied. You do not have to void the entire claim. However, this depends on the claim type. If it is an institutional, inpatient, or long-term care, then that would have to be on the same claim. It is important to be careful with the policy, and the type of claim you are submitting. If the claim paid for some details and denied for some details, then the best thing to do is an adjustment and correct it so that it is all on one claim in case there are any other policies that say all of these services need to be billed on the same claim.
25. What could be the problem when it is saying: “RENDERING PROVIDER IS NOT ENROLLED UNDER BILLING GROUP NUMBER FOR DATES OF SERVICE”.
This usually means that the provider is not linked to the group. It could be that more than one MESA ID is under that NPI, or it could be that one MESA ID is linked to your group but not to the other MESA ID. It is suggested that you send your provider representative the ICN so they can investigate this further.
26. Do the field representatives come out and visit offices/facilities?
This depends on the situation. Please reach out to your field representative to discuss further.
New FAQs added in response to February 9, 2023, workshop
1.Can you show the UB paper claim session for the form that has to be included with the UB and EOB?
The interactive fee schedule is accessible by the administrator of the portal account only. However, the updated, comprehensive fee schedule, which is more detailed is now available via this link: Fee Schedules and Rates – Mississippi Division of Medicaid (ms.gov)
2. Can you show the UB paper claim session for the form that has to be included with the UB and EOB?
Please follow this website link: https://medicaid.ms.gov/providers/billing-manual/
3. Why is there more than one denial or description codes on EOB that contradict each other? For example: one will be EOMB is under review and the other code will be non-covered charges. What denial or description code do we use?
Recently, the Mississippi Division of Medicaid (DOM) relaxed the edit on EDI 837 submitted crossover claims; however, currently the portal and paper submitted claims will still suspend for review to ensure the information matches what is found on the EOMB. Gainwell is working with the DOM to provide additional explanation of benefits on the remittance advice explaining why it was denied. That will expedite the process of correction and resubmission.
4. Does the EOB information need to be on the detail portion only for professional and crossover professional claims?
Yes, that’s correct.
5. Is there supposed to be an amount paid on paper claims that are Medicare and Medicaid, Medicare Advantage and Medicaid claims (in block 29 on HCFA 1500 claim form)?
Block 29 is for Medicare payments, portions actually paid by Medicare. If applicable, it must be filled.
6. If a claim denies for timely filing, and we want to do reconsideration, do we copy claim on portal and attach the documentation to prove timely filing, or is there another way we are supposed to do reconsiderations?
Reconsiderations were done in the older legacy system. Now you will have to follow the administrative review process that’s listed on the policy.
7. Where can I locate the Consent to Sterilization form?
Click here to find the form: https://medicaid.ms.gov/wp-content/uploads/2022/09/Sterilization-Consent-Form_English-PDF.pdf.
8. For the crossover claims that I have denied as duplicate of a legacy claim, do I need to do an administrative review for those? Or wait for whatever solution MESA is working on?
We are reviewing these denials one by one to determine if it is a true duplicate denial or if additional review/research is needed. Additionally, you will need to attach a copy of the claim and EOMB (if applicable) showing that the Medicare paid date was within the timely filing period, because once it is reviewed, if it meets the criteria, the claim will be specially handled to be overridden for the timely filing.
9. Is there a solution being investigated for crossover claims that were originally submitted in Envision and denied during the transition, but are not being denied for timely?
That is something that DOM is currently reviewing, as well as all timely filing for both Medicaid and Medicare crossovers.
10. Will an add-date be added to the eligibility screen for retro Medicaid?
That is something that is being explored as a future enhancement. Please check the “Late Breaking News” for updates.
11. In relation to reconsideration for timely filing denials: I have been told to do this on portal by copying a claim and attaching a letter for reconsideration with documentation to prove TF; however, when I do that, the claim says, “finalized denied as duplicate”. Will this claim still be reviewed, or do I need to skip this step and go to “Administrative Review for reconsiderations”?
You will need to copy the claim and attach a letter for reconsideration following the administrative code. Then you would need to do an adjustment on that claim that was previously paid. If you are following the administrative procedures and sending it for review, at that point your documentation will be reviewed by DOM. Once approved, it will be sent to Gainwell so that the timely filing can be overridden.
12. Do we do that by copying the claim on portal or editing the claim on portal?
Once you’ve received your denial for timely filing, then your next step is (if you meet the criteria) is to make a copy of the claim and the attachment. Complete the steps that it tells you for administrative review and send it to the address for review.
New FAQs added in response to February 2, 2023, workshop
1.Any update on voids for legacy claims?
We are still working on this. If you are trying to void a claim that was submitted to Gainwell and paid by Gainwell, then that fuctionality is working. We are still working on the process of voiding claims that were paid in Legacy. There will be more information forthcoming.
2. In the “Late Breaking News January 25, 2023” – in regard to it, please expand on the following information this Late Breaking News states: “Temporary Discontinuance of EOMB Attachments on Secondary Medicare Claims, Effective immediately, the Mississippi Division of Medicaid (DOM) has temporarily discontinued the requirement that an explanation of Medicare benefits (EOMB) be attached for all secondary Medicare claims submitted via EDI to include Medicare Part C (Medicare Advantage). Please note, an EOMB will continue to be required for all claims submitted via portal or paper submission. DOM will provide advanced notice to providers before reinstating this requirement for EDI submitted claims.”
This is strictly for EDI electronic claims. In the past, when you submitted crossover claims electronically, we asked that you submit the EOMB and the ATN form in a hard copy mailed to us. With the release of this “Late Breaking News”, this has been temporarily discontinued, and it is no longer needed for secondary claims. You just need to bill your Medicare information electronically within your EDI software. However, web portal and hardcopy claims are still requiring the Medicare EOMB.
3. We are having issues seeing our remittance. We have a clearinghouse that we file through. Do we have to have the trading partner ID attached before we can see the remittance reports? We are trying to see the PDF versions of the remittances ourselves.
Please ensure that you are logged in under the provider ID that payment is being made under. If you have verified this, please reach out to your provider field representative for additional assistance.
4. We are trying to see the PDF files ourselves.
Please ensure that you are logged in under the provider ID that the payment is being made under. If you have verified this, please reach out to your provider field representative for additional assistance.
5. If our clearinghouse sends EOB w/claims, could you all just ignore them as not needed? I don’t think we can stop them from sending with secondary. We are sending secondary hardcopy presently but would like to send electronic, if possible.
Yes, it is possible to send these electronically. For electronic submission claims, go to DOM website>Provider Portal>EDI Claims Companion Guides (found under the MESA Provider Portal FAQs in red font)>DOM Companion Guides section. Share these companion guides with your clearinghouse, which will show them how to submit their claims electronically.
6. Are there any updates on the overlap denials for OP therapy claims that must be split by type of therapy?
This is something that has been identified and is being researched, so there will be more information forthcoming.
New FAQs added in response to January 26, 2023, workshop
1.Does the discontinuance of EOMB attachments on secondary Medicare claims found within the Late Breaking News from January 25, 2023, apply to both Medicare and Medicare Part C?
Yes, it applies to anything that is submitted electronically via EDI, which includes Part A EDI, Part B EDI, or Part C EDI. However, anything submitted through the portal or paper still requires an EOMB.
2. Late Breaking News Temporary Discontinuance of EOMB Attachments on Secondary Medicare Claims – is this only traditional primary or MCR Replacement primary as well?
This is for Medicare Part A, B, and C submitted via the 837 X12N batch file.
3. Can traditional Medicare primary claims with a payment also be submitted electronically without an EOB attachment?
Yes, it can be submitted electronically, just as the Part C claims.
New FAQs added in response to January 24, 2023, workshop
1.The visits renew in July, not January?
The benefits start on the fiscal year, which is July.
2. Can we find frame eligibility on the website yet?
You may check the history of whether the member has received the frames by going under ‘Eligibility’ and then ‘Treatment History’.
3. Do you have to put all diagnosis codes, or will one do?
It will pay with only one diagnosis code, so you can enter one or many.
4. How do you enter more than one diagnosis code on a claim?
Go to the ‘Diagnosis Codes’ section and select the next number (1, 2, 3, etc.) within the table. Enter the ‘Diagnosis Type’ and ‘Diagnosis Code’. Then, click ‘Add’. You can add as many as needed within this step.
5. Regarding the eligibility, that is not really feasible long-term…it would be ok for frames (V2020), but there are too many lens V codes to have to search through to be sure there’s a benefit left.
We realize that vision benefits and service limits has been an issue for vision providers on the portal. This is currently being investigated. Please stay tuned to the “Late Breaking News” for an update.
6. When will the recording be up on the website regarding Provider Recredentialing from January 12, 2023?
The recording is now available. It is located here: https://medicaid.ms.gov/mesa-provider-workshop-webinars/
7. Do you have to copy a claim to resubmit, or can you revise the original claim that was denied?
The copy function will copy the entire claim. You have multiple options when copying. You can copy the Member Information, Service Information, Member and Service Information, or the Entire Claim. This allows you to not have to re-enter all the information. Once you select what you want to copy, you can go back into the claim and edit the areas that need to be changed.
8. You stated that you can copy and edit the claim for revisions, but what if the claim has already been submitted. Do we have to cancel it first?
If you submitted your claim and the claim has denied, you do not have to cancel the claim. You have the option to copy that information within the claim and revise. Even if the claim has paid, you still have the option to go in and copy the information to revise without cancelling the claim.
9. If my resident has a stay at another facility and is still a resident at my facility, could that be a reason for duplicate?
That is a possibility if those dates that you are billing for overlap.
10. When is Mississippi Division of Medicaid (DOM) going to resolve the over payment issue Skilled Nursing Facility providers have encountered with Part A crossover and duplicate payments on Part B?
This is currently being worked on and addressed. Please stay tuned to the “Late Breaking News” for an update.
11. If you have more than one denial on a claim, will one denial appear at a time, or will all denials appear so that we will not have to continue to correct and submit?
All of your regular, fee-for-service claim denials should provide you with all of your denial codes at one time. The only time that you may not see a straight denial is when you submit a crossover as this will go into a pending status.
12. Why would Part B coinsurance claims appear on remit as a denial stating that the EOB is under review?
With the crossover claims, that EOB code shows as a zero in our system and this pertains to the whole claim. It is not an actual denial, but an edit that hits the claim stating that the EOB is under review. After the EOB has been reviewed regardless of if the claim is paid or denied, the edit code stays on the claim. So, when you see a status like this, it is not an actual denial code. It is a status code stating that the claim is in this status. Once it comes out of this status, you will be paid, or you get a denied status.
13. After my claim processes, if you look the claim ID up on the MESA portal, it states “Finalized denied, Code 4502”. OA133 is the only code on the EOB. Can someone explain?
If you have no other denial error codes, then that means the claim is denied because something is not correct with the EOB submitted and the claim. This depends on the type of claim submitted. For example, it could be that the detail line does not match the EOB or for inpatient claims, the header information does not match the submitted EOB.
14. What if the claim is a secondary? Do we have to attach the EOB?
The EOB is required when submitting secondary claims.
15. Where do you attach the EOB?
Under ‘Step 2’, at the very bottom there is a section titled ‘Attachments’. Click on the plus sign to upload attachments.
16. Will you do a presentation on crossover claims again soon?
We are not sure at this moment. There are two recorded webinars on DOM’s website with demonstrations on crossover claims. To find these webinars, follow these instructions: Go to the Division of Medicaid’s website (www.medicaid.ms.gov). Select ‘Provider Portal Webinars’. Scroll down to find the ‘Submitting Crossover Claims’ webinar. Then, click the ‘Webinar Video Recording’ hyperlink next to the webinar listing.
17. Can the provider and/or benefit information be corrected within the claim through the edit option in MESA?
Yes, the provider and benefit information within the claim can be edited while the claim is in a paid status. You can update your provider information only.
18. How do we determine our field representative?
The Provider Bulletin will be posted within the next few weeks, which has a complete list of all provider field representatives by county.
19. How do we void an older claim from legacy?
This is currently being worked on, and we will inform the provider community when this issue has been resolved. Please look for the “Late Breaking News” with an update on this matter.
20. I just submitted a claim, and there was an error. Do we copy and enter all the information and enter the correction as a new claim? Do we void the first claim?
If you submit a claim and the claim has paid, you do have the option to click the edit button to make changes and resubmit. If the claim has denied, you have the option to copy that claim, edit as needed, and resubmit.
21. While we are waiting for the credentialing issue to be resolved, will we get extra time if it takes a while to resolve?
If it gets to the point that more time is needed, then we will address this at that time and make concessions as needed. However, we are aiming for this not to become an issue.
22. When submitting a crossover claim from Medicare, should we check Medicare in Block 1?
If you are submitting a crossover claim on paper (1500 form), you should select Medicare in Block 1. There are billing instructions on the DOM website for paper claim submissions. Go to the DOM website (www.medicaid.ms.gov). Under ‘Resources’, select the ‘Paper Claims Billing Manual’ hyperlink. On the next page, click the ‘Paper Claims Billing Manual’ hyperlink for the entire document. This gives you a breakdown of all the fields on the paper claim forms.
23. How are refunds from legacy being handled for payments that the provider owes back to Medicaid?
Those payments would have to be discussed with our financial team. We would need to review the provider’s remits to see if those payments have been recouped. Please contact your provider representative.
24. To add an attachment, is there an “EOB” listed for the attachment type within the drop-down list?
There is an EOMB option within the attachment drop-down list.
25. How do we file an appeal? I can’t seem to find any information on the website anywhere.
Effective October 3, 2022, the Claim Reconsideration Form will no longer be available for providers to submit to the new fiscal agent, Gainwell Technologies. Providers are encouraged to submit electronic claims to reduce the potential for error. Resources are available to providers to assist with learning more about how to use the new Medicaid Enterprise System Assistance (MESA) portal (Resource Information – MESA Portal for Providers). Providers who submit electronic claims should adjust claims electronically, which allows for attachments for medical review. Additionally, providers who submit paper claims should refer to their return to provider (RTP) letter and follow instructions in the letter. Appeal claim reconsideration options are reserved for instances when a claim is denied based on medical necessity. Should an appeal be necessary, please follow the requirements in the Administrative Code, Title 23, Part 300: Appeals. More information can be found on the “Late Breaking News” posted October 21, 2022, at the following link: https://medicaid.ms.gov/late-breaking-news/.
26. For appeals, what if it’s a legacy claim?
Providers are encouraged to submit electronic claims to reduce the potential for error. Resources are available to providers to assist with learning more about how to use the new Medicaid Enterprise System Assistance (MESA) portal (Resource Information – MESA Portal for Providers). Providers who submit electronic claims should adjust claims electronically, which allows for attachments for medical review. Additionally, providers who submit paper claims should refer to their return to provider (RTP) letter and follow instructions in the letter. Appeal claim reconsideration options are reserved for instances when a claim is denied based on medical necessity. Should an appeal be necessary, please follow the requirements in the Administrative Code, Title 23, Part 300: Appeals. More information can be found on the Late Breaking News posted October 21, 2022, at the following link: https://medicaid.ms.gov/late-breaking-news/.
New FAQs added in response to January 19, 2023, workshop
1.Can timely filing claims be filed through the portal? If so, where, and how is that indicated?
No, currently, timely filing cannot be filed through the portal. Updates to this process will be forthcoming. Timely filing rules may be found on the Mississippi Division of Medicaid website at https://medicaid.ms.gov/providers/administrative-code/ .
(Administrative Code Part 200; Chapter 1; Rules 1.6, 1.7 and 1.8)
2. I just want to verify: do all doctors need to be recredentialed under MESA, even if they were not technically due to be credentialed?
If they are due for recredentialing, they will receive a recredentialing notice. If they have not received notification, they do not presently need to recredential.
3. I work in credentialing; when my administrator signed me up, it’s showing I am a provider delegate. Do I need to be just a provider or delegate?
Currently, delegates do not have credentialing authorization, only administrators have such rights. So, if you are trying to credential, you would need to be re-enrolled as an administrator.
4. What happens when you have two taxonomies that are in the same classification and grouped in the same category, yet the enrollment types are listed with different application categories? Is it a requirement to enroll separately?
If you have two taxonomy, that means you have two locations. If they are under different application categories, then they need to enroll separately. You can apply for multiple taxonomies and multiple locations on the same application. However, when you are enrolled, you will be assigned a separate Medicaid ID for each of the taxonomies and each of the locations.
5. Are there any updates on the IP facility denials for no DRG grouper?
This update is forthcoming. Please continue to monitor “Late Breaking News” for further communications.
6. Are there any updates on bilateral denials?
This update is forthcoming. Please continue to monitor “Late Breaking News” for further communications.
7. When the mailing address is out of state, how do you fix the error message regarding the county?
For the county, you need to select “out of state”. At the bottom, there is an option to make this selection. That will take care of the county.
8. Is there a training video for a patient that has primary commercial insurance and Medicaid as secondary? Everyone I enter on MESA denies for other primary insurance. I am putting in the primary insurance and the information from the primary payer.
Yes, this subject has been covered in a previous presentation. Please check the Mississippi Division of Medicaid (DOM) website at https://medicaid.ms.gov for previously recorded webinars.
New FAQs added in response to January 12, 2023, workshop
1.Some of our providers do not have a recredentialing app in their MESA portal. Should *all* providers have a recredentialing app in their profile to complete?
Only the master administrator, which is the administrator who set up the account, has access to the recredentialing. As the revalidation due date nears, a letter will be mailed to the provider, and the option will be made available via the provider’s portal account. The link will become available six months before the next recredentialing due date.
2. I received letters for provider numbers that I do not recognize. They are legacy ID numbers. How do I find out what these numbers are for? I am referring to what is shown on your letter in the first line after your redaction.
This is the new Medicaid ID within the new Gainwell system, MESA. You need to register online within the MESA portal with this new Medicaid ID to get into your account. Then, you can go to the Mississippi Division of Medicaid website at https://medicaid.ms.gov, and click on the ‘Provider Portal >Taxonomy Lookup’. Enter the legacy ID or NPI number and select ‘Search’. This will bring up information about the taxonomy, and all the MESA IDs that are linked to that particular NPI. Also, this will provide you with some insight about those provider numbers.
3. Should I be asked to pay a fee? When I got to the end of my recredentialing app I was asked to enter payment type. We are a CMCH.
Then, yes, it applies to your provider type. Some providers, based on the provider type, will be asked to pay the fee for recredentialing, which will appear on the application for recredentialing.
4. Can the admin delegate the re-evaluations to a delegate portal, or does the admin have to complete the re-evaluation themselves?
Currently, only the administrator has privileges to complete the re-evaluation process. We know that providers have asked for delegates to have this privilege, so we are currently working on implementing this feature. We will let providers know when this is available.
5. When you change locations or set up a new office, do you automatically go into a recredentialing process?
When you change locations, a new enrollment application must be submitted.
6. Our office never received a letter to update our state license. We have always received a letter every year before the Gainwell transition. Do you know why?
We do not know why you have not received a letter. If it is time to update your state license, then you can do that through the secure portal by logging into the portal and send under the secure email. This will send it to the appropriate entities for licensing updates.
7. If you are with a large health system, does the admin still have to complete all the recredentials?
Yes, the admin has to complete all of the recredentials.
8. I’ve been trying to recredential a provider that came on board, but it’s not letting me change the credentialing team address. How do I make the changes in the provider address?
This will be shown in the live demonstration today.
9. What if we are just adding a location and not changing addresses?
For each new location, you must submit a new application.
10. Our office does not have a Medicare number, yet while I am trying to do the recredentialing on the portal a Medicare number is showing up. How can I delete this info?
This will be shown in the live demonstration today.
11. Are you saying providers have a new Medicaid ID?
Yes, coming from the legacy system, which was Conduent. You either had a zero added or another number added depending on whether it was a new provider. If it was an existing number from Conduent, then a zero was added. If it is an entirely new MESA ID, then a one (1) was added.
12. When we try to register two of our providers on the MESA portal, we receive an error message stating: “PIN does not correlate with MESA ID”. The PIN is the last 4 of social security number (SSN), which is what we are trying to use, but the portal states it is incorrect. We are trying to set up in the portal.
When you set up the initial portal account, a PIN should have been given to you at that time. It is usually the last 4 of your tax ID or last 4 of your SSN, depending on if you are a facility or individual. If you are working as an individual and are a sole proprietor and have a separate FEIN, then the FEIN is your tax ID and the last 4 of the FEIN will be your PIN. If you are a facility, then you have a separate tax ID and the PIN will be the last four of the tax ID.
13. Some of our providers have a link for recredentialing, but some of them do not have the link for recredentialing. Do the providers that do not have the link have to be recredentialed?
The link should be out there six months before the recredentialing due date. More than likely, the link has not been sent yet. For those who have received the link and/or letter, please go ahead and start the recredentialing process.
14. How do we change the administrator on our clinics? We have had a role change within our facility since we enrolled.
If someone set up the portal, then they are the administrator, and everyone is designated as a delegate. The registered administrator can go in and assign delegates the role of administrator, which will give them access to all the tabs, but they will not be the actual administrator. The link for recredentialing is not available for delegates, only the administrator.
15. Can there be more than one administrator for the MESA account?
No. There can only be one administrator per MESA ID account.
16. We have started receiving notifications to recredential/revalidate some of our providers. Will this entail creating the provider an account and then being able to select the ‘recredential your provider enrollment’ link under upcoming actions? I do not see the link as a delegate or an administrator.
When the provider logs into the portal, only the administrator will see the recredentialing/revalidation link. Delegates will not get to see this link at this time. This has been brought up by several providers. The Mississippi Division of Medicaid (DOM) and Gainwell are looking into it but the current functionality only allows administrators to see this link and submit the application. Also, the link is only available six months before the recredentialing is due.
17. How do you add an additional service location through the MESA provider portal? I still fax in the request, but am wondering how it can be done through the provider portal?
If this is for a different location, then a new application must be submitted through the public portal where you submit it as a regular enrollment application for the additional service location that is not currently registered in MESA.
18. The provider that I’m recredentialing already had information in the “credentialing team” place under “provider address”. I’m not able to change that address.
For the recredentialing process, we do not allow changes to the address because that is a key element within the system. However, there is a characteristic link available on the secure portal which will allow you to submit any address changes. Once submitted through this process, it will be evaluated and then the changes will be applied. However, even with the characteristics, we can never change the servicing address for an application. You would have to submit a special request to DOM regarding this matter.
19. Is the provider role the same as administrator?
Yes.
20. Just for clarification, you said recredentialing for one location will apply to all locations even if we received a separate letter with a different ID number and different due date?
This is for facility recredentialing and not individuals. Recredentialing for one location for an individual provider will suffice for all other locations for an individual provider but not a facility provider.
21. Where you are entering the taxonomy on the location add Gainwell changed our taxonomy from multi-specialty to single specialty. I would still enter the multi-specialty because that is what we are, but what is the correct taxonomy to enter?
You would enter the taxonomy that is assigned to you within the system.
22. Who do we contact if we have issues while submitting our application?
You should contact your representative.
23. When submitting a new provider application, what is the turnaround time to have that 100 percent completed?
This depends on whether a clean application was submitted with no corrections to be made or additional information needed. If you ever need an update on your application, you can reach out to your representative or enter the application tracking number for a status.
24. We have always been multi-specialty, yet Gainwell changed us to single specialty. We are multi-specialty, so do I need to enter single specialty since that is what Gainwell deemed us as?
Yes, you will need to put the taxonomy that you have been assigned by Gainwell.
25. How do I complete recredentialing for the other IDs we have?
If you have received a recredentialing notice for each of those IDs, you will have to log into your secure portal account and click on that recredentialing link in order to submit the recredentialing application, which was shown during the January 12, 2023, workshop.
26. Do all servicing addresses under our group need to be individually enrolled, and will they have individual logins? Do providers then need to be linked to each individual address now?
Yes, if you have multiple services and locations linked to that NPI or facility, then you must register each one of those on the portal. All individual providers that are providing services will have to be enrolled into the MESA system. When the group is enrolling, they will have to identify which individuals are part of that group, so they will have to do an affiliation. They can do this affiliation at the time of application submission or if they want to maintain the data, we have the flexibility available where the affiliated providers can log into their own secure portal and click the link for affiliated providers. When you click on the link, it will show you if there are any existing providers that are associated to you. This will allow you to maintain the information for them or add new ones as needed.
27. Is there a current list of field reps assigned to each individual county? I understand these were switched around in the transition to MESA.
Yes, this is housed on the Mississippi Division of Medicaid’s website at http://medicaid.ms.gov.
28. I am the administrator and when I log into the account, I do not see the upcoming actions section on the home page. Will it not show up until we have a provider that is needing to be recredentialed?
That is correct. However, also ensure that you are under the correct MESA account for the specific provider.
29. Some of our providers have a link for recredentialing but some do not. Do the providers that do not have the link have to be recredentialed?
You will not see the recredentialing link until it’s time for you to recredentialing and you receive a letter.
30. Do facilities have to show proof of liability insurance?
Yes, facilities also must provide proof of liability insurance.
31. Where do I go to check on the submitted application with the tracking ID?
That information is located on the letter. So, to access your status of your application, you’ll select a provider enrollment access link. Then you’ll select the enrollment status link under the online provider enrollment section on the left-hand side of the provider enrollment page and enter your application tracking number.
32. Is there a place in MESA system where we can verify that credentialing letters have been sent to the facility or providers?
No, we do not have a place on portal that shows the letters mailed out to the providers.
33. Once an application is suspended and a tracking number is assigned, will that tracking number be continually used?
Yes, it will be continually used for the applicable application.
34. In the section requesting the information on Medicare and Medicaid beds, what effective date and end date is being requested?
It is recommended to add a default date. Gainwell and DOM are working on updating this panel to not require this information.
35. If a provider is receiving letters with ID numbers that we don’t recognize, how do we look up the numbers verify the identity?
http://dom-azure-app.medicaid.ms.gov/
36. Where can I obtain a pin number for our providers to create an account for them?
It would be last four digits of the providers SSN/TAX ID.
37. We have received letters of credentialing due soon, but they are not showing up on our portals. What do we need to do?
There was a data update applied later based on the information received from CCOs requiring the credentialing dates to be updated for some providers. That’s why they may no longer need to go through recredentialing at this time. A new recredentialing notice letter will be sent six months prior to their new recredentialing due date. However, please send us your email ID so we can reach out to you and work with to see if your providers fall into this situation.
38. How can someone other than the administrator submit recredential applications?
At this time, only administrator can submit the recredentialing applications.
A39. re the steps the same to enroll a new facility?
Yes, it will be the same steps. Please make sure you are submitting the enrollment application for your new facility through the highlighted link on the public MESA portal page.
40. How can I update a provider’s servicing address?
To update a provider’s servicing address, you must send in a change of address of form. This can be submitted via secure correspondence functionality available on the secure portal (requires log-in), providers can also mail in or fax or email this form.
41. Is there a list of required documents for the application process?
Yes, a list should be provided before the application is started. If you have already started an application, you will need to suspend the application and sign out in order to view the list.
New FAQs added in response to January 10, 2023, workshop
1.Our secondary professional crossovers being keyed online are paying at $0 saying that claim totals do not balance, and this is due to the sequestration amount not being entered. There isn’t a field for the sequestration. The sequestration is a payment adjustment (not a payment). When the available fields are entered, the allowed amount is not being calculated properly. Could you direct me to the guidelines for entering sequestration? Sequestration is not mentioned in any of the billing instructions/guidelines.
This is something that is currently being explored, so more information is forthcoming.
2. What is the status of items not covered by Medicare but are covered by Medicaid being denied without the Medicare explanation of benefits? With Conduent, the EOB was not required, same as diapers. Codes E0245 and S8490 are examples. You said on a previous webinar this was being worked on.
This is an issue that is still being reviewed and explored. More information should be forthcoming.
3. Are you going to address the issue we are experiencing with our SNF Part A crossover claims? We have received payments when we should not have. Last week I provided my email address and have not heard from anyone.
This issue has been fixed. Going forward, the SNF Part A crossover claims are processing and pricing correctly. However, for the claims that have overpaid, Gainwell is working with the Mississippi Division of Medicaid to do the recoupments because we need to make sure that we do not do any jeopardy to recouping monies back in excess. This is still being worked out. so please watch the “Late Breaking News” for any updates.
4. If the billing provider is the same as the rendering provider, do you have to fill in both?
If you are billing under the group, then you must have a rendering provider. If you are billing as an individual, then you do not and you should be fine.
5. Is the web portal system ready for us to do Medicaid secondary crossovers claims where the primary does not crossover, and we can enter them in the system for therapist?
This is still considered a crossover claim. Assuming you are stating that the COBA file did not automatically crossover from Novitas, and you were having to enter the crossover claim in our system, that would still be a crossover claim. You would enter that as you normally would any other crossover claim via EDI, web portal or send in paper.
6. On step 1, do we need to put an individual provider ID when we are billing for multiple providers? We are billing as an individual.
No, you do not need to put an individual provider ID in step 1.
7. I know you all are working on the commercial insurance denials for incontinence supplies. Is there a timeline for this?
There is not a timeline at this moment, yet we are working on this. Please continue to monitor the “Late Breaking News”.
8. Will the system be modified so we can enter claims in the portal with the TCN (for timeliness purposes) from the previous system instead of having to mail in paper claims?
Currently, that is not an option. There may be a future enhancement but for now you must follow what is established and what is currently in place.
9. I am an ambulance provider. We transport patients to and from dialysis, and these are crossover claims. One leg of the trip is being denied as duplicate, and these claims have different modifiers. Is this a known issue that is being worked on?
Yes, these are being worked on at this time. Ambulance providers are being looked at, especially anything with duplicates that has modifiers distinguishing one trip from another.
10. We have received this “TPL-payment” denial several times and have not been able to get clarification on what this means or how to correct it. Can someone please assist?
Please refer to the “Late Breaking News” article posted on December 19, 2022. titled, “Claim denials related to TPL amount is less than % specified“. It states that the Mississippi Division of Medicaid (DOM) advises providers to resubmit previously denied claims with TPL attachments when the claim was denied for Edit 798 – TPL Amount Less than % Specified. Effective December 15, 2022, any claim with a TPL payment greater than zero and a TPL attachment will process without denying for this edit. Claims submitted with TPL attachments will still receive Edit 798; however, the claims will process.
11. When submitting a claim for Blue Cross Blue Shield of Mississippi, what do we use as the claim filing indicator for these claims?
CI is the claim filing indicator.
12. Do we file an appeal for the claim to be looked at with the EOB, because the claim states it denied not pending review?
No appeal is needed. You just need to resubmit that claim.
13. Don’t you have to put the other insurance info on each line detail if you have more than one line of codes?
If you have more than one procedure code on the claim, then you are going to enter each detail line for those procedure codes. Then, the EOB should accommodate that with the corresponding codes that you submitted. When you are entering the other insurance, you want to enter that by beneficiary and TPL information along with the corresponding details.
14. Just to clarify, do the CPT codes have to be entered twice: once for the TPL information, and then on the service line for Medicaid?
Yes, this is correct.
15. Does MESA accept Medicare crossover claims, or do we only file them on MESA web?
MESA is the web portal system for filing claims. Crossover claims can be submitted electronically, on hard copy paper, or through the portal. There are instructions and guides on how to submit claims for each, which can be found within the Provider Portal.
16. If we enter the claim in the portal, I saw where the EOB had to be uploaded. On some earlier webinars, it was indicated if the TPL paid, and we mailed a paper claim we didn’t have to mail a EOB if paid. So, if we mail paper on a paid TPL, do we need to mail an EOB?
For TPL, the EOB is only required if the insurance carrier did not pay, and that member has TPL insurance on file. Then, there is an editing policy in place that would suspend the claim, and the Gainwell staff will review to see why the insurance did not pay. If it was due to provider billing error, then the claim would get denied. If it was for a valid reason, then that claim would be reviewed, processed, and paid. Also, to clarify, if the member has Part A, Part B, and Part C, then you always must send the EOB,but if it is regular third-party liability unrelated to Part C, then you do not need to have an EOB.
17. For Managed Medicare UHC where they paid an amount, does the EOB need to be uploaded?
If you are billing a Medicare crossover claim, the Medicare EOMB will always need to be submitted for purposes of looking and verifying the Medicare paid date, regardless of how it is being submitted (paper, EDI, or web portal).
18. Where do I find the contact info for the specific county field reps? The FAQs say look in December bulletin but for my county that says TBA and contact Justin. Is that still correct? My billing county is Clay County.
The December 2022 bulletin is now the January 2023 bulletin. It will be out hopefully this week.
19. Where are the recorded webinars that we can go back to reference?
Go to the DOM website (https://medicaid.ms.gov). Select the blue box to the left marked “Provider Portal Webinar”.
New FAQs added in response to December 20 workshop
1.It is very time consuming to enter a claim via portal line by line at the detail. Is this something that can be investigated to make the process easier? I have hundreds of claims that I must manually enter.
This is something that was brought up before in a previous webinar that could be a future enhancement. For now, that detailed information is needed on crossover because we are looking at the detail level for professional and outpatient claims.
2. Are authorizations for Medicaid secondary required for physical therapy services?
Information regarding PA for therapy services can be found in the Administration Code. Reference rule 1.6 Administrative Code on the Mississippi Division of Medicaid website
3. My question is in regard to denies for consent – we attach the consent, and it still denies. What do we need to do?
There is a process where you can send the supporting documentation. For all the consent claims that are submitted for with consent forms. Those are reviewed by Gainwell clinical staff and by the Mississippi Division of Medicaid clinical staff, but when the Gainwell staff reviews them, there is specific criteria that consent form needs in order to be completed accurately. One of the things we see quite often that gets denied are signature dates that are not valid from either when the member signs versus when the provider signs. I would strongly recommend revalidating the consent form and checking all the required data that is included to ensure it has no errors. Then, if you feel everything is correct, submit an appeal.
4. I sent an email to my field representative yesterday. What is the typical turnaround time for a response?
Turnaround time is typically 24 to 48 hours.
5. Have ER claims deny for needs authorization? ER claims don’t need an authorization, do they?
The answer to this question should be answered based on the services billed.
6. TPO and Medicare Advantage? Explain, please.
For TPL, if you were billing (for example, Blue Cross Blue Shield), and they don’t have a PA requirement, but Medicaid does, once you billed it to Blue Cross Blue Shield, the PA that doesn’t override or supersede the PA requirements for Medicaid. So, they have a TPL and even though that PA is not required for TPL, if it’s required for Medicaid services, you are required that prior authorization information. And of course, Alliant is the utilization review organization that handles that, and you can reach out to them for whatever criteria they need.
New FAQs added in response to December 15 workshop
1. How do you enter a claim on the new Medicaid website?
Go to the DOM website. Click on “Provider Portal.” On the “MESA Portal for Providers” page, Click on the blue Provider Login. Register on the left side within the blue Login box or if already registered, enter your User ID within the box and select login. Enter answer to your challenge question. Enter your password. Select Claims tab at the top. Select which type of claim. Select Claim Type within the drop down and enter the claim information within the sections as applicable to the claim. Select continue at the bottom and proceed through all the steps as applicable.
2. What is the best option to correct a denied claim? The copy or edit function?
If your claim denied, you must copy, correct the invalid information and resubmit. If the claim was in a paid status and you want to correct or add additional information, then use the edit to complete an adjustment.
3. If I receive a denial for an EOMB that requires review, what is the timeframe the claim will be reprocessed? Will it show on a new remit? I’m not sure why it would deny instead of pending. It is a crossover claim that was submitted via paper.
The review of the crossover claims suspending for manual review take some time, the staff are trying to review as quickly as possible and working the oldest to newest.
4. When you submit a paper claim, why does it send an error message that the signature is not on the claim? The doctor’s signature is on file when credentialing is completed. Is it not?
Signatures are required on the claim. You can use a stamp of the physician or sign the form. It cannot be typed.
5. The value code you mentioned earlier, you said it denied with 4.00, so it should be entered as 4 without the decimal?
We are talking about the value code where you are putting your cover days, so the 80 or 81. If you are billing it on paper, just put a 4 (a whole number) to the left of the implied decimal or the dotted line; no zeros. The scanners will pick it up and you will not have any issues. If you are going on the portal, even though you see the zeros in web portal, web portal has the ability to strip that out and it is sending just the 4 to the claims engine and the claim is processing. We are not seeing any issues with claims sent through the portal or EDI claims. It is just with paper claims and it is because of the scanners when they scan that field.
6. My inpatient claim is denying stating “PA not found,” but I’m entering the number that was given from Alliant Health and it begins with an “A.”
If you are entering what looks to be a completely valid PA from Alliant and it is not in our system, you need to contact Alliant and validate that the PA number is in their system and it is correct. The two PA numbers that have been brought to our attention as denying were not in the Alliant system. There was some problem with the PA number that the provider had versus what Alliant had for that stay. If you validate and the PA number is correct, then contact your Provider Representative within Gainwell, so we can check our system and troubleshoot.
7. Why would you not fix the scanning versus making payers change the way they submit a paper claim?
We are working on this behind the scenes. We are working on how we are interpreting the covered days with our scanners and with the system. The guidance given now is a way to get around how the scanners are picking it up to get your paper claims paid quickly.
8. Is there a timeframe we need to wait to submit a claim once Alliant approves an authorization?
We are not sure how often Gainwell processes Alliant files but it should not be a huge delay at all. We suggest you check after about 24 hours. The Gainwell team will follow up on this question and give you an exact time frame of how many times we are bringing in those PA’s.
9. Why does eligibility show benefits for medical but not for dental for MS Medicaid pediatric patients?
We have not published the various different eligibility benefit plans and what they mean yet. When you are doing an eligibility verification, it will come up and if the member is in regular fee for service (or traditional) Medicaid benefit plan, that covers the vision, DME, inpatient, outpatient, dental, home health, pharmacy, Hospice, etc. If they have an additional benefit plan, then you might see QMB, SLMB, and pharmacy. If they have a QMB or SLMB in addition to the traditional Medicaid, then our system runs through the benefits plan and will determine what can be paid and where. There is a hierarchy of how those plans align. We had a request to break down the member benefit plans and post. That is forthcoming, so stay tuned. It will either be in the FAQs or a link will be on the DOM homepage.
10. All crossover claims I am manually entering on the MESA Portal are getting denied for “Reason Code 133: The disposition of this service line is pending further review.” The portal states the EOB is under review. Also, how do we enter the negative Medicare primary payment on the portal so that it auto populates the correct allowed amount?
Crossover claims that are entered via paper, Web Portal or batch EDI require the EOMB to be attached. The claim will suspend for a clerk to review the EOMB to ensure it matches the information on the claim.
11. Why is Gainwell denying claims with CARC code CO-16 with RARC MA92 for patients over the age of 65? Providers are experiencing this issue statewide and was not seeing it with the prior fiscal agent.
This is a MS State Medicaid policy stating that a member over the age of 65 will need to have Medicare Coverage and that will need to be billed first before billing Medicaid.
12. I need to understand why the provider is dealing with the issues with Alliant Health and Gainwell’s system. Please respond so I can let DOM know your response.
In the two examples I had, the provider had a PA from Alliant that they had documented in their system. That is what they put in on their claim. We did not have that PA number in our system. When they contacted Alliant, they said they had the wrong PA number. Either something was transposed or they were missing a number. If Alliant says the provider has the correct number, then the provider needs to reach out to Gainwell. Gainwell will see if it is in our system. If it is not in our system, then we have to investigate why. If it is in our system, then there is something else going on and it is probably not about the PA number at all. I am not suggesting that Gainwell is out of the picture. It starts with Alliant. Alliant creates the PAs, they send the PAs to Gainwell, and we load the PAs within the system. So, step 1 is to verify with Alliant. Step 2 would be to contact Gainwell, if the PA is verified as correct with Alliant.
13. We have a few patients that do not have Medicare coverage, but have QMB/SLIMB benefits. Is there any information on how we can process these claims?
QMB/SLIMB are only for members that do have Medicare. They will not qualify for either of these eligibilities without having proven that they have Medicare.
14. So does Medicaid need to be filed for a denial? I have also received information that the patient may no longer qualify for Medicare coverage, but cannot cancel MCDMS coverage due to the pandemic.
If you have a denial from Medicare, then yes, you can file to Medicaid with the denial attached.
15. Can you do it for Dental?
We have covered dental in the past, and will cover again in the future. However, if you want to review a previous webinar, all recordings are on the DOM home page.
16. Which denial code or reason will be on the portal to let us know Gainwell will reprocess claims that were in keying error on Gainwell’s end?
The denial code that we are seeing the most is that the ICD prop code is missing or invalid. If you see this denial and you know it is a paper claim, then that is your trigger to know that it is a keying error and it needs to be reprocessed. If you are unsure, you can contact the Call Center and have them look up the claim. The Call Center can validate if it is a keying error and start the process to get the claims pulled and rebatched.
17. How will we know which legacy EOMB is correct? Our facility only receives one type of EOMB from Medicare.
As long as the EOB shows Medicare on the face of the document, that is a valid Medicare EOMB.
18. Do you still have one year to submit/file claims?
Per the TPL rules, all claims have one year from the date of service to be filed. If it is a Medicare crossover, then you have 180 days from the Medicare paid date.
19. When I copy the claim all the information does not flow over. For example, the NDC information does not flow over and neither does the Medicare information for the service line items.
We have not heard of any issues with copying over the claim information. Except, if you have an attachment that was on your original claim and you copy it to resubmit, then you may need to include the attachment again for that claim that you are resubmitting. Also, if this was a Part C claim, then you would do everything the same except in the claim filing indicator, you would choose 16.
20. If a provider enters the wrong Medicare payment in the crossover claim, is there a way to adjust that amount after the claim has been submitted?
If the claim was denied because of a provider entry error compared to what the EOB said, then that would result in a denied claim. So, in answer to your question, yes, you would need to correct what was entered in error on the claim, attach the EOMB, and resubmit the claim for processing and payment.
21. Is timely filing for crossovers 60 or 180 days?
180 days .
22. What does the “claim type cannot be assigned” denial mean?
That usually means that on a UB claim the provider has entered a type of bill that is invalid or is not in our system to be associated with a claim type. Contact your provider representative and work with them to confirm that you are using a type of bill that is within the Mississippi Medicaid system.
23. If you have multiple line items but the PR is only for one line, do you have to enter information under every service line item? I only have a PR for one line.
If you have a multiple line claim and the patient responsibility is only applicable to one detail, then that is the detail you put it on. You do not put it on every detail. If it was only applied by Medicare to the first detail and that was the only detail Medicare allowed, then you only put it on that detail.
24. Will there be a training session on swing bed claims?
Yes, swing bed claims are on our radar, and this will be covered in January 2023.
25. For outpatient Part C portal entry claims, can the provider payment information be reported at claim level instead of line-item detail?
No, it must be at the detail level.
26. Are there going to be any more enhancements to make the crossovers more “user friendly”? Adding the line-item detail is very time consuming! This wasn’t required with the legacy system.
At this point the MESA system does require outpatient crossovers and professional crossovers to have the Medicare or Part C information at the detail level. This is how Medicaid would like it reported, so it is unlikely to change.
27. Part C crossovers, line-item details are not equaling the header info due to sequestration rate online item. No place to add the sequestration on the line-item detail.
The sequestration rate was ended quite a while ago. I’m confused as to why we would still be getting sequestration rates, but you can enter the paid amount that Medicare paid without sequestration amount if you would like, so that the amounts match. We don’t pay off the paid the amount we pay off the coinsurance and deductible. So that’s what we would be looking for.
28. Do outpatient claims with a commercial insurance as primary need to be entered with line level details also? What if the primary did not pay line level on an outpatient claim?
Detail level is only needed on Medicare info, not on commercial insurance.
29. Can you explain the reporting for sequestration rate again?
The sequestration amount can be added in the claim line information as a contractual reason code.
30. Can you verify that the admit date/hour and admit source codes are required? There isn’t a red asterisk, but she entered it on all examples, so it’s confusing.
If there’s not a red dot/asterisk saying it’s required, then it would not be required.
31. So, if it denies and still has that 4502 denial for EOMB requires review, it officially denies?
The 4502 EOB I believe, says that the claim was denied, that the EOMB was invalid. If viewing on the portal, please be sure to review the description of the EOMB.
32. The claims that are mailed certified USPS are still not on file from early November. Are you backlogged, and how long?
We will verify with operations and confirm, but we were recently told that they are up to date.
33, Can you speak to the system issues with submitting secondary claims for patients with TPL insurance? As of yesterday, the EOB info does not take after entering it. After I click “continue”, I get the error that EOB info is missing. If I go back to Step 1 and then continue again to Step 2, save the TPL EOB info again, it will finally take and allow me to continue to the next step.
This question is addressed via a demonstration. The time stamp for the question and demo begins at 2:24:25.
34. Are taxonomy codes required for each physician on the inpatient claims?
It is for the attending, and it would be for any of the other ones that are required. So, if we need a surgical, it would require a taxonomy. If you’re only putting it on there for informational purposes, then we still want the taxonomy. If you can, the NPI is the least.
35. Why wasn’t an EOB attached on this claim type?
It’s because it’s an outpatient claim with primary insurance that made a payment.
36. So, if they do not pay anything, is that considered a TPL denial like it was before?
If the Members primary insurance (not Medicare Part A, B, or C0, a commercial plan (Aetna, Anthem, etc.), and they make a payment all that goes to the patient deductible. So, the payment is all going towards deductible, or they make a payment that’s greater than zero. Those claims do not need any an EOB. We need the EOB when the primary insurance denies the claim, they completely deny that claim for a variety of reasons. You then do submit the EOB with that type of claim. Then when you do that, we will look at that EOB and evaluate why the claim was denied.
37. If the claim is finalized/ denied when submitted, can we copy then and submit right then? Do we have to wait until we have an RA date to prevent a duplicate denial?
If you’re working and submitting your claim via the portal, you can go ahead and copy it, make your correction to whatever error you were getting denied immediately.
38. What about denial 798 payment from primary less than 75 percent?
That is still under review and awaiting direction from the Mississippi Division of Medicaid.
39. Can we send paper claims for secondary along with the EOB from the primary payer?
Yes.
40. I only put Medicare EOB information at the header level step one. I never put EOB at the line level, and my claims are still paying.
That would only be for inpatient claims because all other claims are required at the detail level.
New FAQs added in response to December 13 workshop
1.Do we need to mail in a paper EOB as well as uploading it electronically?
No. If you upload it electronically, then that is all that is needed.
2. When should Medicare Part A be used, and Medicare Part B be used?
Medicare Part A is for inpatient stays only. It is institutional. Medicare Part B is for everything else. It is more for professional use.
3. Is it a manual process to match the EOB to the electronic claim or will the EOB be scanned in, and the system logic tries to match the EOB to the claim?
This depends on what we are talking about. If you mean by sending in the paper claim through EDI, then we do scan those in and those are automatically matched to the claim based on the attachment control number that was submitted in the EDI batch as well as on the attachment and the attachment form. If you are going through the Provider Portal and you send it as part of the scan into the portal, then those are automatically attached at the time it is submitted to that claim.
4, I have an outpatient claims on a UB04. Should that be Part A?
No. Outpatient claims should be Part B.
5. If the details are added in step 1, are we not to enter details per line in step 3? It is an outpatient crossover and inpatient crossover 851 and 111 181 bill types. It is a Part C crossover claim. When entering the Medicare crossover details on step one, it still does not balance.
If you are entering an inpatient claim, then you will not have to enter it on step 3. For outpatient claims, if you enter the crossover information on the header, which is step 1, when you get to step 3 and have multiple lines, the Medicare information on each line will have to equal the information within the header. So, it must balance out.
6. Not all EOMBs have the revenue code listed. Will our claims be denied for this?
This is something that just came up last week. We have seen an example recently (last week) with Part C – especially with Part C – where the billed amount and coinsurance matches but there is no revenue code. There was nothing to indicate that it was matching up other than the dates of service and billed amounts. So, we are taking this as an example, and we will coordinate with the Mississippi Department of Medicaid to make sure this is acceptable. You may have had a denial in the past because our team was specifically looking to match up codes from the EOMB to the claim that is billed. We are aware that they do not always have them, and we are working through that issue. Secondly, if you have a Part C member and that member is in a long-term care facility, there are claims coming in that are hitting and denying because we are expecting it to be billed as a Part C. Those things may or may not be included in the per diem, but you must bill those to Part C. We do not have those as carve outs of Part C currently. Therefore, those items must go through Part C first so we can see what Part C says before we will cover the claim.
7. We have patients that have full Medicaid benefits that have Part C as primary. They are in SNF, and we receive authorization to bill Medicaid as primary since they have full benefits. We are getting denials for patients having Part C and wanting a Part C denial. Should we have to get that denial from the primary even though they have full Medicaid benefits?
This is something that we are currently looking into. There will be more information forthcoming.
8. When submitting a Part C SNF crossover, do we have to mail the EOB? I have been attaching the EOB, and the claims keep denying.
You need to attach an EOB. You need to make sure that the claims details you are billing match the EOB that you are submitting. It is suggested that you go back and check what was submitted on the claim, make sure it was professional or outpatient crossover, and make sure that the detail information for the EOB matches the attached EOB.
9. We are also having this issue on DME items not covered by Medicare. With Conduent, we did not bill to Medicare because the items were not covered, we billed Medicaid as primary, and the patient had full Medicaid benefits. The claims were paid without requiring the Medicare denial.
We are reviewing the issue and more information will be forthcoming probably in the form of a “Late Breaking News”.
10. We still can’t pull remit or see any payments for Medicaid. I have contacted Medicaid, Gainwell, and emailed our representative. The problem persists that we can’t pull MESA and legacy reports. When we put their Medicaid number in to check claims nothing comes up. We can’t see anything or pull anything.
You need to have the trading partner ID added to your profile. Then, you should be able to download 835s. Otherwise, they can go through the payment history and then select download within the “Resources” section. Also, you can go to a particular claim and download the RA.
11. Also, when to use Medicare Part B versus Part A. Part A is used on *all* UB04 crossovers, correct?
You are correct. Part A is for all UB crossovers.
12. I think the confusion is that the first question is TYPE OF CLAIM: Professional or Crossover. It is my understanding from past webinars you wanted the selection to be Professional. If it is traditional Medicare, you wanted Crossover on the very first selection
It would be crossover. Part C claims are treated as crossovers. So, if you have a professional claim Medicare, a Medicare Part C makes the payment, it’s a crossover claim.
13. Will Aetna Medicare be billed as a crossover professional claim?
AETNA Medicare, assuming this is an advantage plan, that would be a crossover claim, which would fall under Part C. You would use the 16 filing indicator, if using the portal. If they made a payment on the claim and there’s coinsurance, copay or deductible due, that’s crossover claim.
14. Would Medicaid Part C be 16 indicator?
Yes. Filing indicator 16 is essential; it’s what tells us it’s Part C. One difference I sometimes see is Medicare Part C will have a copay, where we don’t traditionally see Medicare copays with Parts A and B. So, MA or MB wouldn’t have a copay whereas indicator 16 may have a copay instead of coinsurance.
15. Why would we use claim filing indicator Medicare Part A for all UB04 crossovers, as was answered above in chat? They are not all inpatient claims. They are institutional crossover outpatient claims and traditional Medicare is primary.
You would not. The only time you choose Medicare Part A is for when you’re submitting an institutional inpatient stay. All other institutional and professional would be Medicare B or Medicare C.
16. Can we also do a professional crossover with no payment from the primary but with an adjustment only? Would we use the adjustment as the payment? Humana didn’t pay.
If Medicare makes an allowable and takes the percentage of what they allow, they apply it to the deductible. Then yes, we would process that deductible at crossover, and we would consider the deductible and or coinsurance. But if Medicare denies the claim or they allowed zero on the claim. Then it’s at that point, not a crossover. There’s no adjustment/write off.
17. Could we see a Medicaid as tertiary example?
This is where Medicare has denied the service, and they’re just billing it as a primary. So, they would not select crossover; they would select professional or outpatient or inpatient. Then they would enter the information and submit the reason for denial as an attachment.
18. I still have the same questions about Part C primary denying total charge as noncovered…how to bill? I am confused on if that is professional or professional crossover, and if it is going to be considered a FFS? Also, will it be required to have a PA?
Yes, you’ll submit it as a professional claim. You’re going to submit the attachment showing why they denied. If the reason they denied is not because they went out of network or they didn’t follow the rules (meaning it’s just a non-covered service under Part C), then we’ll consider it as primary. Also, yes, if it’s a service that typically requires PA, it’s still going to require PA. Because at that point, it’s essentially going through all the fee for service rules, the traditional Medicaid plan rules, if the member has it.
19. When you say you need the reason codes, do you mean that the legend showing the meaning of CO45 with the EOB must be sent as well? Or do you accept that reason code CO45 as a contractual discount?
Yes, they need the legend at the bottom. These are important. Anything on the EOMB that helps explain what our team needs to look for is critical. CO45 is not something they need to pay attention to, but the patient responsibility (PR) is, along with denial reasons.
New FAQs added in response to December 8 workshop
1.We have crossover 1500s (with Medicare Part C Primary) that were keyed on Envision/Conduent’s site in late August and early December that were submitted with the EOMB. MESA has denied the claims citing EOMB not attached. We feel Gainwell didn’t bring the files over. We have about 80 claims that denied (we wouldn’t have keyed 80 and *not* attached the EOMB on the web portal).
If the claims were submitted to the Conduent system and denied in the Gainwell system, you would need to resubmit to the MESA system following the new guidelines. If it was submitted again, please remember all crossover claims suspend for manual review because we do need to validate that the Medicare information entered in on the portal detail or claim matches what was on the Medicare EOB.
2. I have a question about claims that I submitted yesterday on the portal on the same patient. Patient has Blue Cross Blue Shield (BCBS) as primary to Medicaid and one claim went through as finalized payment, but the second claim states it denied saying member is covered by a commercial health insurance on the date of service. I did upload primary EOB to claim. The only thing that was different from each claim was that primary insurance paid on one date of service yet applied to patient’s deductible on the other date of service.
In order to analyze this scenario and provide the correct feedback, please submit through the provider inquiry email box or contact the provider call center staff.
3. Can you explain how to resubmit denied claims for crossover claims?
We recommend that the provider resubmits such claims because they are unlisted procedure codes. We have identified where providers have already resubmitted several of them on their own, and we want to ensure that it does not cause duplicate payments on additional claims.
4. How long does it take for the claim to process and pay?
The goal is to turn them around as quickly as possible, so it really varies on the number of claims that are coming in. Our goal is to try to get things reviewed, processed, and turned around as finalized as quickly as possible. It is dependent on what our total inventory is for that day or that week, and we work to process them in the order of the claims that are suspended.
5. If we have an authorization for more than six per day from Alliant, do we need to attached the CMN, medical records, and the authorization to the claim? We are getting a denial for exceeding the limit.
Yes, you will want to also include the supporting documentation.
6. If supplies are shipped out each month and the Alliant authorization is for 12 months, should we still attach this every month with claim?
Yes, you will still need to attach this information every month with a claim.
7. How to adjust a professional claim that Gainwell did not pay correctly? Can we search the original claim by the ICN number and do an adjustment to it?
Yes, going through the portal and finding an adjustment ICN, you can do as many adjustments as needed, if they are in a paid status. If for some reason that adjustment was to deny, then it has to be resubmitted as a new claim.
New FAQs added in response to December 6 workshop
1.Will you please put in the chat what you just stated about the crossover claims?
This may change a bit, but this is the update shared: Attention COBA Crossover Providers – The Mississippi Division of Medicaid (DOM) will reprocess COBA submitted crossover claims that denied in error for Medicare EOMB is “Missing or Does Not Match the Services on the Claim”. Gainwell will be resubmitting those COBA claims this week. The resubmitted COBA claims will appear on the December 9, 2022, Remittance Advice. No further action is required from the provider. This has not been posted on the “Late Breaking News” yet it is one being reviewed by the Mississippi Division of Medicaid and should be out there this week.
2. When resubmitted the hospice claims that denied for Part C, do they need to be resubmitted as adjustment claims or as a new claim?
These would be new claims because the whole claim would have been denied for those COBA submitted claims that were denied stating that there was not a Medicare EOB attached.
3. On the Medicare crossover claims that Kathie was talking about, is she talking about Medicare and Medicaid claims, or is this for HMO and Medicaid claims?
These were strictly for Medicare crossover claims submitted by COBA and not for HMO and Medicaid claims. These would be for COBA submitted claims that we processed that were automatically crossed over from COBA that were denied for missing EOMB, which was in error.
4. We have denials from Medicaid for EOMB and primary insurance is HMO INS. Please explain.
If that was coming in on an 837 from the provider and if that was before the “Late Breaking News” that update went out with the following instructions stating: “If you are billing an 837 claim and you are including the appropriate PWK segments and submitting a tracking number, then you would need to fill out the claim attachment form and mail that in”. Then, we would match that up to make sure the EOMB is compared to the electronic crossover claim that was submitted by the provider.
5. For Medicare crossover claims that are submitted electronically, and the EOB is mailed with the claim attachment form, we are getting denials for these claims even though they are not reviewed yet. Will there be an update so we will not get these denials immediately?
If these were submitted as 837 by the provider and the EOMB was mailed with the claim filled out attachment form, then these should have been processed. In some circumstance, we have seen the wrong PWK segment was submitted. It needs to be submitted with the PWK in the 06 with a BM (by mail). We have seen some of the 837 claims being submitted with other indicators by fax, etc., which would get denied because MESA only accepts the claim attachment form along with the Medicare EOMB submitted through the mail process.
6. Instead of copying the claim on the portal and attaching the EOMB, all we need to do is fill out the PWK form and fax the EOMB?
You do not have to copy the claim on the portal if you are submitting your crossover claim as an 837 claim. You would submit the 837 crossover claim and indicate using the PWK segments that the indicator is BM (by mail). Then, you would also include the ACN number and pull down to enter the information on the claim attachment information. Then, you would attach the EOMB along with that form and mail all of that in. MESA does not accept faxed forms. They have to come by mail at this time.
7, Is the information about Medicaid reprocessing the COBA submitted crossover claims that denied in error going to be posted in the “Late Breaking News”?
The goal is the “Late Breaking News” will be updated by December 6, 2022,with the COBA information for resubmitted claims.
8. Will claim deny if we enter a patient number?
No, the patient number field is used by providers to uniquely identify their member. It is not a required field. MESA does not use this field for processing.
New FAQs added in response to Nov. 29 workshop
1.How can you tell if it was a COBA crossover versus a claim we submitted?
If the 837 claim file is from COBA/Medicare, you do not need to submit the claim attachment form. If the 837 claim is not submitted by COBA, the EOB is required to be submitted using the claim attachment form and sending the Medicare EOB.
2. On my claim receipt it is saying “The claim status is finalized payment”. Does that mean it is approved?
Finalized payment means the claim has paid.
3. Is the system accepting an electronic attachment? We are doing crossovers and attaching the Medicare EOMB.
At this time MS Medicaid will only accept mailed in attachments for EDI submitted claims with the PWK segment.
4. What does the acronym “COBA” stand for?
Coordination of Benefits Agreement (COBA) is the Medicare processor. They will send Medicare processed claims directly to Mississippi Medicaid for members that have both. GWT identifies COBA submitted crossovers by the Entity type 41 and the PR ID is TP001501.
5. The attachment can only be mailed in…not faxed?
Correct, at this time Mississippi Medicaid will only accept mailed-in attachments for EDI Submitted Claims with the PWK segment.
6. Where on claim is the PWK segment?
When you go to the 837 Companion Guide, do a search on PWK and it will take you to the segment and instructions.
7. Can we write on the form, or do we have to type on it?
You can do both— write or type the information on the form.
8. Is it correct to say that the claim and EOB cannot be stapled together?
Correct, claims cannot be stapled.
9. For every secondary claim submitted, will it need the PWK form submitted by mail?
For every Medicare/Medicaid that is submitted via paper, web portal or 837, then yes a copy of the EOMB is required.
10. If a hard copy claim is mailed in with the primary EOB is the attachment control form still needed?
The attachment control form is only needed if the claim was submitted via an 837 transaction.
11. So that form would be for Medicaid crossovers and consents. Would that apply for the commercial EOB that needs to be sent as well?
You do not need to attach a Commercial Insurance EOB, only Medicare Part A, B and C.
12. Is there a list that gives more detail on the plans provided under eligibility?
We (Gainwell) have this request and plan to work with the Mississippi Department of Medicaid (DOM) to develop a guide to the various Member Benefit Plans.
13. Could we mail a lot of those claim forms together in a large envelope, or does each need to be mailed separately?
Each attachment will need its own Claim Attachment Form, but you can mail as many together in one packet as you need.
14. Are we using filing indicator MB and not Filing Indicator 16 for ambulance transport?
Use Filing Indicator 16 for Part C, MA for Medicare Part A and MB for Medicare Part B.
15. What are crossover claims?
Crossover claims would be when a member has Medicare Primary or an HMO Primary.
16. Do you use crossover professional for traditional Medicare, or do you use crossover for Medicare advantage plans also?
Crossover professional.
17. What documents do we have to add to the crossover claim?
The Medicare EOMB.
18. Can you explain Part C HMO?
The only difference on a Part C HMO claim is to use clam identifier code 16 instead of the MB for Medicare Part B.
19. Is there a way to verify that a paper attachment was received and being reviewed/approved?
When you attach a document, you will receive a control number. Once you submit, your claim will go into a pending status. If you receive a paper remittance, you will be able to see that the claim is either pending waiting for the attachment, or if the claim is pending for review to verify the EOB against what was entered on your claim.
20. If we are a SNF, should we bill under claim institution or claim professional?
This is currently being worked on as we speak. More information to come on this, so please continue to check “Late Breaking News”.
21. So the EMOB is the code they give us once it is denied, correct?
No, if the claim denies, you will receive an edit code, numeric. The EOMB is the explanation of benefits showing what Medicare of the HMO paid and allowed.
22. If BCBS is the primary is the proper claim type PROFESSIONAL or Crossover PROFESSIONAL?
Professional.
23. When a claim has already been processed and an updated claim needs to be submitted for the same service, should the original claim be ‘adjusted’ on the portal OR can a Replacement (7) or Void (8) be submitted electronically?
If the original claim was paid, you can adjust it via portal or EDI using the Frequency code of 7. There is no need to void and replace at all.
24. I am confused by the acronyms: pwk06 and pwk02 in the “Late Breaking News”. Where are these places on the claims I’m submitting electronically?
If you go the 837 Companion Guide for the specific transaction (Dental, Professional, Institution), and search ‘PWK’, and it will take you to the exact field.
25. We have hundreds of Part C claims that were submitted electronically and have been denied. Can we use the copy claim function and attach the EOB for processing, or do we have to manually key the claim into the portal using the crossover form?
Yes, you can use the copy function, but please make sure any details that need to be changed on the new claim are changed and correct before submitting.
26. It is also required when a Medicare Advantage claim is primary, correct? That would also be considered a crossover claim, correct?
You are correct. Medicare Advantage claims also include the EOMB to be attached.
27. Medicare advantage plans need which claim filing indicator?
Filing Indicator 16.
28. Why are crossover claims denying one of LT RT as duplicates?
This is something that we are looking into for all provider types. Please monitor “Late Breaking News” for additional information.
29. Do we need to attach an EOMB for Part C Crossovers if the claim was paid by the primary?
If it is a Medicare Advantage as primary, then Mississippi policy does require for the EOMB from Medicare Advantage Plan.
30. For outpatient, do I just put the Medicare info at the header now and not at the service lines?
Outpatient claims do need to have the detail information submitted.
31. All of our COBA claims from Medicare that Gainwell has processed denied for rendering provider not on file. Is this a system error that will be corrected?
I would contact our Call Center and have them pull up one of the denied claims and look at what is coming over from Medicare and what we have on file for that specific rendering provider for that location. It may be that we are missing a rendering provider for that specific location.
32. For outpatient crossover claims with multiple line items, can you combine line items with each other, like revenue and CPT codes? Or, should they be entered line for line like the claim?
They have to be entered line for line based on the EOB. For example, if you submitted to Medicare with a line by line then they must be submitted to Medicaid the same way.
33. If we need to mail in the attachment form and the EOMB, can we mail multiple forms in the same envelope? Can we staple the form and EOMB together?
No, claims cannot be stapled.
34. In theory, if Humana paid claim on May 11, 2022, and we submitted the crossover on the end of August, MCD denied to submit in the new system. The claim in question would be timely right?
If the claims are still within timely filing, you can resubmit the claims to Gainwell for reimbursement. The timely filing process for claims past timely is still under review.
35. If a secondary claim is mailed with the EOB, is the attachment form still needed?
No; If you mail in the CMS1500 or UB04 and the EOMB is with that claim, then no attachment form is needed. The attachment form is only needed if you file the claim through the electronic process (EDI) and state with the claim that you have attached an attachment control number and are submitting the claim by mail. Then, you will need the cover letter with that attachment control number that was submitted on the EDI claim on the cover sheet, so that it can be matched up when it gets to Medicaid.
36. So, am I understanding correctly that we are going to have to fill out that form and mail it with the primary EOB for all secondary Medicaid claims? Will this be true going forward? Or just the ones that have already been submitted that they did not get the attachment?
As of right now and moving forward, unless it comes directly from Medicare, if it is being submitted by the provider, it will have to have the EOB submitted with the claims. So, if it is through EDI, then you would need to fill out the PWK segment, fill out the attachment form, and mail that in.
37. Do you only have to attach the Medicare EOMB, or was that attachment supposed to have both payers in it?
If you have Medicare (Part A or B) and Medicare makes a payment, then the secondary insurance makes a payment. We need the Medicare EOMB – that is all that needs to be attached. We do not need to see the secondary insurance; just the Medicare EOMB.
38. Can we still mail in tertiary claims? If so, what is the average time to allow for processing?
If referring to paper claims, yes. I am guessing you are referring to a paper CMS 1500, UB04, 80A, or dental claim?
39. If that is the Mississippi Division of Medicaid (DOM) policy to only accept 837 Medicare Crossovers without an EOMB for 837s directly from Medicare, why have I been getting paid since December of last year on crossover claims I have submitted through our software as a 837 with the EOB information in an electronic format? None of them were submitted with the PWK segment. Gainwell might need to clarify the policy.
The policy has been clarified with DOM policy teams, and it stands as it currently is. As to why the legacy system was allowing it, that I cannot answer.
40. When mailing multiple claims together at the same time, please clarify what you mean by cover letter? Do you mean the UB/1500 form, or do we need to create a facility letterhead cover letter for each claim sent?
For mailing in claims themselves, you do not need a cover letter. The cover letter is ONLY for when mailing in attachments that go with claims submitted via 837 EDI
41. If Gainwell is not accepting the attachments through the 837’s files and the issue is not on our end, how does Gainwell intend to remedy the issue? The timely filing issue is a lot of reconsiderations to send, and also, to have to enter them through the portal. Also, the other day I was looking for a reconsideration/appeal form, and I did not see one on the site anymore. Can someone assist?
We do accept Medicare Crossover Claims through EDI with the PWK segment stating the attachment is being mailed. Electronic attachments not being accepted will not stop timely filing.
42. Was there ever a fix for voiding claims prior to MESA or editing them?
Yes, we did put in a change that should resolve the issue of voiding or adjusting claims that processed in the prior system. Please see “Late Breaking News” for more information on this topic.
43. What does denial code “4071-ICD procedure code is 1-3 days outside of the header DOS” mean? We have several claims with this code on inpatient claims.
You must have a surgery date associated with one of the ICD procedure codes that is outside of the “From” and “Through” date on your claim. If you do not see a surgery date that is outside of the “From” and “Through”, then I would contract our Call Center and give them the claim ID, and they can look into the denial.
44. Are we to attach the EOB in the 837 and then send you the form in the mail so it can be researched and located?
You will need to put the ACN for the attachment in the PWK segment on the 837 claim. Then, you will need to mail in the EOMB with the cover letter and the same ACN, so that the EOMB will be attached to the claim for review.
45. This is an issue with commercial insurance primary but may also be with Medicare. If the secondary claim denies with code “798- TPL amount less than % specified”, how would we need to submit for payment?
MS Medicaid states that the TPL paid amount cannot be less than 20 percent of the billed amount. If you are getting this error, then that is the issue.
46. Are you saying that if we submitted crossover electronically with 837, the claim will be denied, since we didn’t submit the PWK segment with the EOMB?
Yes. You need to resubmit these claims and get them back into the system with the PWK attachment.
47. What do we need to do for all the claims that have denied previously for attachment not received, including the automatic crossovers from traditional Medicare?
Automatic crossovers from COBA do not require EOMB Attachments. If you have any that have, please send them to your provider reps for review. For the 837 claims that are denied, you need to resubmit with the PWK attachment. For those COBA (Medicare Part A & B) crossovers directly from Medicare to Medicaid that deny for whatever reason, you need to figure out why it denied whether it was something on your end that needs correcting or something going on with your provider file; then, you will need to resubmit the claim on either via portal, batch format, or paper.
48. What do we need to do to all the claims that have denied previously for attachment not received?
These will need to be resubmitted with the attachment. You can do that through the Portal, EDI with Attachment mailed in, or through paper.
49. Is it required to have the MESA number in Box 33B, if we have the group NPI in 33A? There is some confusion on this with what we are reading in the Provider Manual.
33A is the NPI, and 33B is the taxonomy for your billing purposes. If you are a group who has multiple renderers, then that is where you get into the 24J, which is your NPI taxonomy with the white area versus shaded area.
50. I was told by the Mississippi Division of Medicaid (DOM) that there should be the option to send Medicaid secondary claims electronically with Part C Medicare primary. Maybe an option to attach the Part C EOB electronically.
At this point in time, Medicare A & B will come over automatically from Medicare as long as Medicare has associated with them that the member is part of Mississippi Division of Medicaid. For Medicare Part C, there is no way for Medicare Part C to come to Medicaid automatically. That has never been set up and is not mandatory by Medicare for all the different Medicare C Advantage plan companies to do that. The provider themselves have to submit that to Medicaid and you do have to submit it just like any other Medicare claim with the EOMB. As for the EOMB coming in electronically, you have must send that with the new process of submitting the control number and then, sending it the EOMB by mail.
51. What is the attachment control number?
It is what you pick yourself to associate the claim and the attachment you are sending for that claim. It can be anything. It is usually unique to your company or your billing process.
52. Our COBA claims should be paying 50 percent of the remaining patient balance (coins/debt) and adjusting the remaining 50 percent. However, the payments are coming back paying different percentages (none of these are consistent). Did the reimbursement policy change? These are fee for service (1500s).
The Mississippi policy is to pay the amount submitted for the Co-insurance and Deductible for Medicare Part A and Part B or the total of the reported Medicare Part C Co-insurance, Deductible, and Co-pay. There is no part of just paying 50% of the remaining that Mississippi Division of Medicaid has put out.
53. Will there be a way for Part C primary claims to be electronically crossed over to Gainwell for Medicaid secondary to pay the copay/deductible?
There is actually no way for Medicare Part C to be sent directly over to Mississippi Medicaid.
54. Will sending EOB electronically be a future option?
DOM is looking at this as a future enhancement.
55. Can crossover claims be submitted electronically instead of mailing them or keying them on the web portal?
Yes, as long as you follow the process laid out for mailing in the EOMB attachment. You can do it through an EDI 837 transaction but make sure you remember to do the attachment.
56. For paper claims, do we still have to have the provider’s signature and paid date on the claim?
Paper claims require provider signature and date.
57. Patient presents with a letter of Medicaid retroactive eligibility for July. However, MESA shows the eligibility began on November1, 2022. Which is correct…the letter presented by the patient, or what is shown in MESA eligibility feature?
If the dates are not showing the same, please have the member contact the eligibility department to have it corrected. Claims will only be processed based on what is in MESA.
58. Is there a document anywhere that lists who the provider representatives are for each county?
This will be posted in the December bulletin. It will contain all of the provider representatives for each county with their corresponding contact information. If you have questions before it is posted, please contact the Call Center or email Justin Griffin.
59. Where are MESA tips located?
The MESA Tips are located on the portal home page underneath the blue “Provider Login” button.
60. Are there any instructional guides for submitting the crossover claims?
The MESA Tips will have PowerPoints posted to help walk providers through submitting crossover claims. These are located on the portal home page under the blue “Provider Login” button.
New FAQs added in response to Nov. 22 workshop
1.What do you mean by a “converted claim”?
In the prior system before Gainwell took over those claims processed within that system (whether paid or denied), we converted all those claims (up to a certain date) over into the new MESA system. We take those prior claims and copy them into the MESA system, so you can adjust them, void them, use them against limit history, reporting, etc. This is done so we don’t lose the history of those claims. So, when we say converted claim, it means that we took those prior claims from the previous system and converted them into the new MESA system.
2. All of the secondary claims entered on the MESA portal have denied for “0273-Resubmit charges for Medicaid covered service denied by Medicare and Medicaid claim”. Is this something that will be covering next week with our crossover?
This code means you entered zero in the coinsurance and zero in the deductible, and zero Medicaid paid. So, yes and no. We would need to look at the example and see how it was submitted. Jenny said she would grab the EOB and description and put it in the chat.
3. How far back can we search for a claim? Can we go back to 2020 or 2021?
Technically, you can go all the way back to 2015.
4. Will the converted claims be in legacy for us to look at if needed?
The converted claim will only be in MESA. The prior system is no longer available for us to access.
5. The changes were on the production site yesterday. Today the production site crossover claims are exactly where they were originally. All of the changes were taken off of the production website. Why?
Yes; the changes were promoted a little earlier than expected. We planned to have the training guides and the training webinars timed with updates showing on the Web Portal.
6. All of the secondary claims I entered on the MESA portal denied for “0273 – resubmit charges for Medicaid covered services denied by Medicare” on a Medicaid claim. None of my services were denied by the MCA plan. I called MD. However, the CSR had no clue how to assist me. She stated the denial on her side was because the claim was not in balance with the EOB submitted. I have reviewed several and they matched the EOB exactly. How do I solve this problem?
If you get a denial of EOB 0273, the Medicare paid amount is zero, the Medicare deductible is zero and the Medicare coinsurance is zero, thus indicating this is a Medicare denied detail. The detail must be submitted to Medicare as Medicaid primary with a copy of the EOMB.
7. I am having trouble with claims being denied when the patient has a commercial insurance as primary and Medicaid secondary. I am putting all the primary insurance info in and attaching the EOB, but they are still being denied because the “member is covered by a commercial health insurance on date of service”. The claims will go through for some but not for others. It’s very time consuming to put all of the info in just to have it denied.
If the insurance paid, the claim would go through, and it will process. If the insurance denies that service, then we look at that EOB carefully to see what was billed, the reason the other insurance was denied, and whether the information matches up/does it make sense. Sometimes the EOB just doesn’t match up and sometimes the team has a hard time matching up which provider goes with the claim in the case of bulk payments. So, it is always good to highlight and identify the one that you want our team to focus on. So, sometimes it just simply doesn’t match up, and it will deny. In some cases, it matches up, yet the reason that it denied is because the member failed to follow the guidelines or the rules of their primary insurance. Those EOBs are heavily scrutinized. Therefore, you want to make it obvious within your attachments that this is the member who goes with the claim, that the services match up, billed amounts match up, and then, the reason will be clear as to why it denied. If you have done all those things, then you need to take the claim ID and call the Call Center for them to look at the claim.
8. Where do we enter the related claim ICN?
If you are adjusting a paid claim within the web portal, you can start with the actual claim ID. When you do that and click edit or adjust, then it knows that is the “mom” claim, or the original claim. Once you click “edit”, it associates that claim with the newly adjusted claim and it stays together during the process. So, you do not have to re-enter the original paid ICN anywhere else.
9. Where do we enter the related claim ICN for claims that are not paid?
You must copy that claim and it will create a new claim with essentially all of the same information from the prior claim. Then, you can go in and change what you need to change and resubmit. So, once you find the denied claim, you copy and resubmit it. If it is a paid claim, you can void it and start over or you can select edit, adjust it, and change what you need.
10. So, if we need a re-consideration or correct a claim, then is it better to copy the claim and correct that way or follow the appeal process?
You may save more time by copying the claim and making changes to how you want it billed. If the claim you want to make changes paid, then you will need to edit and do an adjustment.
11. If my claims have already been adjusted and it is still not correct, do we need to void it and submit a new claim?
You have two options. One option is if the claim that had previously been adjusted is in a paid status, then you have the option of adjusting it using that internal control number/claim ID and make modifications. The other option is that you could void it and then re-submit as a new day claim.
12. Can it be a printed signature on the claim form?
No, it must be stamped or a hand signature. They will not accept any typed signature.
13. The Paper Claim Guidelines do not seem to require the taxonomy on the CMS1500. Is it required?
Visit the website link for the paper billing Paper Claims Billing Manual here: https://medicaid.ms.gov/providers/billing-manual.
14. What is the number for the call center when we need to have an individual claim reviewed?
For Provider/Beneficiary Services, please call 1-800-884-3222.
15. If a primary EOB payment is listed on page 1 and continued on page 2, what is required to alert to continued payment status?
Our recommendation is that you put the word “continued” on the second page of the EOB, and maybe add the member’s name, etc., so we can see clearly the second page has the additional information.
16. If the secondary/crossover issue is not resolved by the end of November as expected, will timely filing be waived/extended? (Since that is a Gainwell issue and not the fault of providers, and since we’re going on two months with having heavy roadblocks in filing secondary claims.)
We are not aware of any waiver of filing limit for crossovers currently. If the claim is approaching the timely filing limit, we recommend submitting what you can at this time. However, we understand your concern and will forward to DOM.
17. Have you all completed the changes on web portal for submitting claims/crossover claims yet?
Yes, we did. In fact, we promoted a little earlier than expected. I believe they have pulled it back out for now. The production changes will be ready next week. We plan to publish the billing instructions and include demonstrations in the December webinars. Please look for “Late Breaking News” for more information.
18. Since the enhancements have been made to the web portal, will there be new videos for training?
There will be job aides created for the enhanced portal for entering crossover information. Please look for “Late Breaking News” early next week.
19. We are filing primarily secondary claims with most being denied. Is it better to keep filing and getting denials, or to try to resolve the problem causing the denial? It is not always the same denial.
It is always best to try to resolve the issue with a denied claim. If unclear why the claim denied, please contact our Call Center to see if they can help clarify.
20. MS House Bill 628 from 2019 calls for interest to be paid to providers for incorrect denials caused by “system errors” on the part of the payer/processor. Will Gainwell be paying interest on incorrectly denied claims? Link here: http://billstatus.ls.state.ms.us/documents/2019/html/HB/0600-0699/HB0628PS.htm.
We are aware of the policy surrounding interest. This is something that is currently under review. Each situation is reviewed independently and in concert with DOM.
21. Diagnosis code not allowed for date of service with EOB 1159.
One or more diagnosis code is invalid for the date(s) of service. Providers should always bill with the most specific and valid diagnosis code available for the date of service, otherwise the claim will deny for Edit 4027.
22. What can I do about denials stating the following: “claims to deny on Envision?”
Please resubmit as a new day claim.
23. Denying requires sterilization form. We copy the claim and add the form on the portal, but it still denies.
Please refer to the MESA EOB you received on the remittance. In many cases the sterilization claim is denied due to no provider signature on the sterilization form, or the signature date of provider does not meet the 30-day waiting period when the provider signs.
24. Can we do a crossover outpatient claim for dialysis?
Yes, you may submit a crossover outpatient claim for dialysis.
25. Is there going to be a correction with Medicare crossovers? We have been getting paid real money but should not be. We are also getting paid for days that there is no coinsurance.
To respond to this question, Gainwell would need the claim IDs in question. Please send an email to the following email address: ms_provider.inquiry@mygainwell.onmicrosoft.com.
26. Can a Medicaid tertiary be submitted on the portal, or do you recommend that those be sent on paper?
Yes, they can be submitted via web portal. When on that first web page of the claim, make sure to check the ‘Other Insurance’ box.
27. What are the upcoming enhancements to the portal for secondary crossover claims?
We have a few things coming up for crossovers. Currently, there are a lot of details to be entered in the web portal. We have removed requirements for additional information that is not needed and removed the requirement to enter it at both the header and detail for detail level claims. We are also implementing a process for you to send paper attachments (EOMBs, etc.) to match up with the EDI claim. We will be publishing an update in “Late Breaking News” very soon. We anticipate doing crossover demos in the December webinars as well.
28. How do I submit a claim when a Member has commercial insurance as the primary payer and Medicaid as secondary?
As you enter the claim in the portal, at the bottom of claim information section will be an “Other Insurance” tab. If it does not auto-populate, this is where you would enter secondary insurance.
29. Are we able to send the EOB electronically with crossover claims?
No, the EOB is not enabled to be submitted electronically (yet). As of now, it must still be submitted on paper.
30. For hospitals, since each servicing location has been assigned to different Mesa provider ID, do they have to enroll each provider ID on the web portal to view claims for that location? All locations have the same NPI and tax ID.
Yes, each individual provider must be registered on the portal in order to view claims for each individual location.
31. If we need a reconsideration or to correct a claim, then is it better to copy the claim and correct it or follow the appeal process?
If you’re not outside of the one-year filing limit it is recommended to always work to edit and copy the claim. The appeal process is recommended when the provider has exhausted other attempts to have a claim paid.
32. The quick guidelines in the billing manual did not seem to require the taxonomy on the CMS 1500. Is it required?
Yes, the taxonomy is required on the CMS 1500. The quick guidelines are a more condensed resource. For full details be sure to review the complete billing manual.
33. Can you explain entering prior authorization numbers?
Yes, please be mindful that the numbers issued by Alliant and Kepro are case sensitive. Please be sure to capitalize and input the characters as they were initially given, when referencing the EPA numbers.
New FAQs added in response to Nov. 17 workshop
1.Is it one year for a correct claim or appeal?
It is one year for a correct claim. Appeals are separate and are handled on a one-on-one basis.
2. I have called the call center for a repeated denial I am getting. I was informed they are not trained on claim denials.
This will be addressed with the call center. If you cannot get assistance from the call center, providers are able to reach out to their assigned representative. As part of training, there have been weekly refresher trainings with the call center staff, and this will be addressed within the next meetings.
3. Dental ICD 10 codes are new, and many providers are confused. Can someone speak to this?
There is a “Late Breaking News” bulletin that specifies as of October 3, 2022, the Division of Medicaid has set up that dental claims require a valid diagnosis code. The bulletin gives a range of ICD-10 diagnosis codes that can be used.
4. Does the claim number have different starting numbers for VOID, corrected, and crossover? What were the numbers when you were showing within the void section during the webinar?
A claim that has the first two digits of “22” is a web portal claim. When you see a claim number that has the first two digits of “59” or “69”, that is a claim that has been adjusted or voided. We also refer to this as the daughter claim.
5. Which box does the ICD-10 code go into on the claim?
Go to the DOM website. Go to the MESA portal. There is an entire video that will guide you on how to submit claims. It will guide you step-by-step on how to input that information. Here is the link to the location on the portal: https://medicaid.ms.gov/mesa-portal-for-providers/ .
6. Can we send our claim via paper with prime remit for payment? For the ones past timely that are denied, can these be sent in by paper?
Any claim can be sent in by paper as long as it is sent on a CMS 1500 or UBL4 claim type. If you are sending in a Medicare Crossover, you can send them in with a remit from a third-party insurance, like United Healthcare, etc. If it is a Medicare C, make sure you submit the full remit for the Medicare C payer. As for the timely filing, you can submit those as paper with an attachment as to why it is coming in late, so it can be reviewed and processed.
7. When will the PWK guidelines be available for electronic secondary claims? The EDI Companion Guide does not state where to send EOMB’s (only provides loop/segments). In a previous meeting, it was mentioned that the EOMB could be faxed or mailed.
We are hoping to have this rolled out by the end of the month. We are currently in the process of testing it, and we will have it out soon.
8. Secondary claims to commercial primary are denying for no authorization. Since Medicaid is secondary, authorizations should not be required. How can this be resolved?
If they are saying that Medicare doesn’t cover it, that means that it comes to Medicaid is primary. We should be requiring prior authorization because Medicare didn’t require one, which means one was probably not obtained. If it truly processed as a crossover claim (make sure that it did come to us as a crossover claim), then it should not require prior authorization. We would need to see an example of this claim to further answer.
9. If it is commercial insurance (for example, they have Blue Cross Plan) but our service requires prior authorization and Blue Cross pays on the claim, and we are just secondary, do we require EPA?
At this point in time, commercial insurance does not override the need for a prior authorization for Medicaid. Only Medicare crossovers as the secondary can bypass the prior authorization. Any primary private insurance will not bypass prior authorization automatically.
10. How do we resolve claims that deny stating, “Bill Medicare first”, although patient was over 65 but no Medicare coverage was found?
This is actually per DOM policy that any member over 65 is required to have Medicare to keep Medicaid. So, the provider would have to go back to the member to get the Medicare number.
11. We have had a few claims that when submitted on the portal and keyed in the primary insurance adjustment, the portal auto calculated a different allowable than what the primary EOB shows. Therefore, Medicaid paid more than the primary left to co-insurance, or we think Medicaid may have paid incorrectly due to the adjustments applied to the primary EOB. What should we do about this?
If it is a Medicare crossover claim, it is not based on what the primary EOB is stating based on the co-insurance and deductibles. If it is primary insurance, the Medicaid doesn’t take into account the amount that the other insurance is stating but it takes into account what the policy is for Medicaid, which is to pay the allowed amount minus what the other insurance has paid.
12. Can we bill a T code and a 5445 on the same claim?
If talking about incontinence supplies, they should not deny being billed together. You should be able to bill T4528 and A5445 together. If this causes a problem, let us know, so we can take a look at it.
13. If Medicaid paid more than what the primary leftover to be paid, do we need to void the claim or correct the claim because it leaves a credit in the patient’s account?
If it is a Medicaid claim, the provider cannot adjust a Medicare claim. For crossover claims, which are Medicare claims, the provider can only void it. You can only void a Medicare claim. If it is other insurance, you can void it or adjust the claim accordingly.
14. The web portal does not indicate whom the OHI (other health insurance) payer is. We have examples of Medicare Managed Care plans as primary and Medicare (over age 65) as primary, however the OHI on the eligibility is blank (MESA would have this info). Conduent provided any OHI payers they had on file for the members even if the payer had termed. We have not found one patient on the MESA portal that showed OHI on the eligibility screen. Is this an issue that needs to be addressed?
In the old system, the portal would tell what type of insurance the patient had as well as the begin date or end date of that particular insurance schedule. The new system, MESA, does not show that currently, yet this may be an enhancement coming down the line at a later time. If it is blank, the member does not have other health insurance (OHI). Only when the member does have OHI, that information is shown. This was covered on a previous webinar. Medicare is not considered other insurance. Other insurance is only for “commercial” insurance information.
15. Can a provider see a broader/longer span of member’s eligibility?
Yes. Go to “Home” page. Scroll to bottom left side and select “Member Focused Viewing”. Enter the Member’s ID and click “Search”. Then, select the member from the Search Results. A panel will display that provides more detailed information of a member’s eligibility.
16. Why are we not being paid for mileage?
Medicaid and Gainwell are aware of errors related to mileage code A0425. This is being worked on to allow mileage when billed with A0427.
17. Is MESA going to reprocess the A0425 for processing, or are we going to have to resubmit these to get paid?
Once the correction has been made, providers will need to re-submit impacted claims.
18. Where can we find the carrier codes?
Go to the home page of the Mississippi Division of Medicaid at www.medicaid.ms.gov, and under the provider portal please note your claim will not be denied for having the wrong carrier code.
19. What do we do if we cannot find the carrier codes?
If you are unable to find a carrier code, then please enter the name of the carrier in that field.
20. Are the Medicare carrier codes available? If so, where is the information posted?
We are looking into creating a carrier code list. Additionally, we are working on updates to ease some of the required information to be entered.
21. Can someone explain the PWK form for Medicaid, or is this something we do on the portal when submitting claims?
The PWK is a segment in an Electronic Claims Submission. You will use this only if you are submitting batch claims through an EDI processor.
22. We are having issues with our DME paper claims that are submitted through the portal. We have attached MSRPs for all of them and half of them pay as they should. We then have others that deny saying the claim is missing the attachment, but when you pull up the claim there is an MSRP attached. However, the error code states no attachment. How do we fix this? These are extremely time consuming to submit.
We are looking into this and will update within “Late Breaking News”.
23. Our DME crossover claims are continuously denying for duplicate claim. Previous Dates of Service do not overlap. Claims will pay one day and deny the next despite being entered and submitted the exact same way. We have no consistency. What is being done to address this?
This is something that is being looked into for all DME providers. More information will be forthcoming as more research and possible corrections are done. Pay attention to “Late Breaking News”.
24. We have claims that were submitted and processed by Conduent that need to be corrected (changes to charge and/or refunds due to Medicaid). We are unable to locate the claims on the web portal. Is there an ETA on updates for this issue?
We are still working on the process of voiding a claim with a Conduent claim in Gainwell’s system. There will be more updates on this matter. Pay attention to “Late Breaking News”.
25. Where is the billing done…county?
The billing is done from our individual offices in each of those counties.
26. Are the training videos on MESA or Gainwell?
The training videos can be found on the DOM homepage: www.medicaid.ms.gov.
27. Do we need to create an account with Gainwell? We have been given conflicting answers for this.
Yes, you need to enroll with Gainwell.
28. Does each office do its own billing, or does it go to a clearinghouse to be submitted to Gainwell?
Each office submits to a clearinghouse.
29. What is the correct Gainwell portal site?
https://portal.ms-medicaid-mesa.com/ms/provider/Home/tabid/135/Default.aspx
30. If we send them on paper and attach a letter as to why it is timely, does this letter need to be attached to each claim? Or can we send one letter with a batch of paper claims?
There will be more to come on timely filing processes. You need to include a copy of the supporting documentation with each claim. You may attach one letter for all the claims you feel timely filing should be reconsidered. Mail these to: Division of Medicaid, P.O. Box 23076, Jackson, MS 39225.
31. Will there be a webinar to go over commercial secondaries step-by-step?
Yes, that will be in an upcoming webinar.
32. Can we still submit Part C crossovers on the MESA portal, or do they need to be mailed? We have had all our secondary claims to Part C denied. These are mainly co-pay amounts. Will Medicaid pay for co-pays?
You can submit Medicare C through the portal just like a Medicare Crossover, but instead of a Filing Indicator of MA or MB, you will use 16. You can submit Part C claims via Web Portal. Make sure to use the Filing Indicator -16. Note, we are going to update the Web Portal Crossover Submissions to make it a little easier by reducing the amount of information that is required. This will be rolled out at the end of November and training will be in early December.
33. Can we attach the Primary EOB for commercial payers through the portal for processing? I know on previous webinars the attachment workflow was still in progress.
Yes, you can do this by scanning the EOB and just attaching it to your portal claim.
New FAQs added in response to Nov. 15 workshop
1. I’m registered in the portal, how can I see the fee schedule, if I’m not an administrator?
Currently, the fee schedule is only accessible by the administrator.
2. Am I able to submit any crossover claims with attachments at this time?
Yes, they can be submitted via paper or the portal.
3. Where on the claim do we enter the ICN for proof of timely filing (to correct a claim, not to retrieve the claim)?
This should be entered under “Search Claims”. Enter the claim number, claim ID, or TCN. You should submit that claim through paper and have it special-batched, showing why it is passed the one-year filing date.
4. Is there any way the timeout feature can be expanded in the portal? I do multiple claims but only 1-2 lines per claim. However, I’m being logged out after I enter about 2-3 claims, even if I am in the middle of entering a claim.
Currently, the portal is configured to time out after after 10 minutes of no activity/ movement. As a best practice, please monitor your activity time and ensure that the internet connection is stable, which can also impact submissions. You may also submit an email for further inquiry: ms_provider.inquiry@mygainwell.onmicrosoft.com
5. Are we going to discuss the submission of authorizations through the Kepro portal?
We are not going to discuss submission of PAs through any of the other vendor portals, only as it relates to MESA and the Gainwell system. All other questions should be directed to those vendors, independently.
6. We are a dental provider. Can you tell me if root canals require a prior authorization?
It ultimately depends on the place of service, but in most cases, yes.
7. How do you submit dental claims secondary to Medicare with the PR 96 denial from Medicare?
It would depend on why Medicare denied the claim. For example, if the claim denied because the service is not covered, then you would submit as a Medicaid primary with a copy of the EOMB. If the Medicare denies because the patient goes out of network, we would deny as well. It is also important to verify the member is eligible. Verify they are not enrolled as QMB only, or a Benefit Plan that does not cover dental. I would contact our Call Center and ask them to look at one of the claims to verify why the claim is denying.
8. Where do we find the Dental Prior Authorization?
Dental Prior Authorization (PA) information is reflected in the dental fee schedule and the OPPS fee schedule. Note that the procedure codes that only require PA in an outpatient hospital setting would be reflected on the OPPS fee schedule.
9. Where is the list of dental procedures that require a Prior Authorization?
Prior Authorization (PA) info is reflected in the Dental fee schedule and the OPPS fee schedule. Note that the procedure codes that only require PA in an outpatient hospital setting would be reflected on the OPPS fee schedule.
10. Eligibility Verification – a member is showing Medicaid State Plan – 075. Can you clarify what 075 indicates?
075 is the aid category of the member. This one is Parents and Caretakers of Minor Children.
Are Medicare/Medicaid crossover claims accepted on paper on the UB04, or does it need to be sent in the portal?
Yes, you can submit crossover on UB on paper.
11. What is the email address to the Help Desk?
The Provider Inquiry email address is ms_provider.inquiry@mygainwell.onmicrosoft.com.
12. Can we please go over claim that has a TPL with a partial payment?
We will walk through those later this month. Please check the DOM homepage for our Webinar schedule.
13. Can you go over how to submit a crossover form in the web portal?
We are planning to walk through those claim types in December. Please check the DOM homepage (www.medicaid.ms.gov) for our webinar schedule.
14. On dental claims, can we add pre-op/post-op x-rays?
We will research this question further and provider more information in the future. Specifically, Code- D3330 does not have any pre/post-op configured in the system.
15. Can we please address the nonpayment of DME claims, specifically incontinence claims that have both T-Codes and A-Codes billed and date spanned. We have been told in the past three webinars that this would be addressed in the next webinar.
Yes. We have said that. Please accept our apologies for the continued postponement, we are planning on walking through that claim type on Thursday. This is partly due to the technical difficulties we had last week. We are already putting the webinar content together, and DME claims will be on the agenda. If you can add any more details, I will see if we can incorporate that into the Thursday session. Thank you for your patience.
16. Does the eligibility not show the Medicare policy number?
Currently, this feature is not available. It is in the works to be updated.
17. When will the interactive fee schedule be up? The fee schedule just shown is by category.
For those looking for the Interactive Fee Schedule: currently, it is only available for those registered in the Web Portal (secure site). Go to “Resources” then “Search Fee Schedule”. The interactive Fee Schedule, Search Drug Code and OTC lists will be available on the public site at a future time. Please monitor the “Late Breaking News” and/or Provider Bulletins for additional information.
18. For prior authorization, I have been seeing a lot of the prices are not matching what Alliant has. It looks like the decimal has moved. Is this a known problem?
Yes, it has been. It has been corrected, going forward. If there are some specific ones that need to be corrected, they can be directed to the help desk: ms_provider.inquiry@mygainwell.onmicrosoft.com
19. We had a lot pushed out of Envision on the last date. These claims were filed timely but now past timely. What information is needed on a letter when mailing these papers as a batch?
You should submit that claims through paper and have them special-batched. Attached to the claims a copy of your documentation of why the claims should be reconsidered for denial and why it is passed the one-year filing date.
20. Are COBA claims going back through September 2022?
Yes, most have already been processed.
21. If I am logged in as a provider and I need to associate my trading partner, do I have to be an administrator in order for that feature to display?
Yes, that is correct.
22. I have had several crossover claims denied. Who can look into this?
Please contact the call center to examine why the claims are being denied.
New FAQs added in response to Nov. 10 workshop
1.Where is the carrier code list located on website?
2. What is COB?
COB is Coordination of Benefits; it’s the amount the provider receives from a member’s primary insurance.
3. How frequently is the “Late Breaking News” updated on the MESA website? It seems behind, compared to DOM.
The MESA portal seems to be a little delayed. Please check the DOM website for the most up-to-date news.
4. On the training courses it stated that the attachment could be in PDF, TIF, TIFF, GIF, JPG, JPEG,PNG and TXT. Is this information not accurate?
Attachments can only be received as a PDF.
5. Can I bypass the Medicare Advantage Plans carrier codes since they are currently unavailable?
No, the carrier code cannot be left blank. Please continue to check the late breaking news for updates on the Medicare carrier codes.
6. Where can the interactive fee schedule be found?
The interactive fee schedule is only available to administrators.
7, How do you update a termination date for other insurance information that would make Medicaid primary?
You can only report the insurance as terminated. It still would have to be verified, internally.
8. Where do I get the form to submit a paper claim?
Paper forms have to be ordered, independently. Please refer to the billing guide on the DOM website for accurate form titles.
9. Did MESA process any crossover claims yet that were entered to MESA portal?
Yes, secondary claims are being submitted. If you are filing a dental Medicare part c claim, be sure to put 16 in the filing indicator line.
10. How do I address having several plans that have no group number?
If the member’s group ID was not captured from their identification card, there still needs to be something entered in the group number field (such as the member’s subscriber ID number). It cannot be left blank.
11. Why doesn’t the “other insurance detail for service line number” show up when you are putting in the service originally? We have to go back into the service line once its added.
This is just a part of the original design of the program. Considerations for enhancements are welcomed.
12. Should I wait on submitting Part C Crossover Claims until December, when system is updated?
You do not need to wait to submit crossover claims; however, t will be a little easier (less information required at the detail) once enhanced.
13. A fee schedule that I need is grayed out. What should I do?
If the Fee Schedule for your specialty is grayed out, it is because DOM is working on updating, and it should be available once they are done.
14. What is the email address for the Help Desk?
The Provider Inquiry Email address is ms_provider.inquiry@mygainwell.onmicrosoft.com.
15. Where can I report TPL termination dates?
TPL Policy Updates TPLPolicyUpdate@medicaid.ms.gov.
16. I am getting a denial when trying to void claims that were prior to MESA. It states “unable to process your adjustment request.” The claim type of the adjustment does not match the claim type of the original claim. How should I address this?
If you are trying to void or adjust a converted claim, we understand that there have been some errors. We are working to correct this in the system.
17. The claims I have used a prior authorization (PA) with have denied. When is this going to be corrected?
Demonstrations on claims with PA will be forthcoming. In the meantime, please ensure that the prior authorization code is exact (capital letters, lowercase letters, etc.).
18. Are there any videos on the website on how to submit a Medicare crossover?
Not at this time; however, there is information the manuals, FAQs, and the posted webinars. Additional information is also available in the “Late Breaking News”. Generally, crossover claims are submitted similarly to any other claim, with changes to the filing indicator code and headers. Once the system is enhanced there will also be additional trainings.
19. Will the portal accept crossover EDI claims?
Please monitor the “Late Breaking News”. Updates for this process will be available shortly.
20. How do I void a claim that is inaccurately denied as a duplicate?
There are two ways this can be addressed:
1.) Enter the claim number in the search. Then, select and void one of them.
2.) Search the claim by the member’s ID or dates of service. Then identify the duplicate claims, select one and void it.
21. Medicare and Medicare Part C insurance are not on the carrier code list. Is it correct that we should put the insurance policy ID numbers on the claims?
You should use the carrier code that is showing up on the EOMB. If it is not there, use that for now. We are working on figuring out why they are not showing up on the EOMBs.
22. I am getting a denial when trying to void claims that were prior to MESA. It states, “Unable to process your adjustment request”. The claim type of the adjustment does not match the claim type of the original claim. I am checking claim status and voiding that claim, so I’m not actually entering anything.
If you are trying to avoid or adjust a claim that was converted over from the prior system, in some cases, it is not able to understand the claim and match it up. Most of the time it is due to the location that the prior system was using, which we have rolled up into a single location. Typically, there is a mismatch that is causing the system not to recognize the prior claim. We are trying to resolve this. There is not a work around in place right now. At this point, we will have to work through it and see how we can resolve those.
23. If we want to key in the claims in December, will they be denied for timely?
If they are Medicare crossover claims, then no because they have a six month from the date of the Medicare payment. Since we just started in October, then they should not have any issues.
24. Will all void claims show denials?
Yes.
25. Please address the Medicare Replacement Plans and Advantage Plans carrier codes. We need to be able to file our claims. Can we put a dash or a zero or the Medicare ID# in the carrier code place, so we can bypass that and submit our claims?
Yes, go ahead and put your claims in. To get through that field on the portal, choose a value you want to use, but make sure it is all numeric. For example, you can choose patient account or patient ID. Create your own dummy carrier code for all of those and put it in that field for now.
26. Will there be a reconsideration form that has the Gainwell logo on it? Currently, there is not one listed under the forms section on the DOM website.
That claim reconsideration form was done away with completely. There will not be a new one. Providers would just follow the process outlined in the billing manual regarding if you feel your claim was processed incorrectly. There was a published notice about this.
27. Did you say on a previous call that all authorization numbers have been loaded from Alliant? If we have received denials on our inpatient claims (that were denied in October) for “INPATIENT PA NOT FOUND”, do we need to rebill these claims?
Yes, if you know that you have a prior authorization out there and you are putting the prior authorization on the claim and it got denied for no prior authorization found, then resubmit. We are seeing a lot of prior authorizations sent over with a lower case ‘a’ and not a capital letter ‘A’ as the starting point. That first letter has to be a capital ‘A’. So, if you submitted with a lower case ‘a’, then this is the reason. We also had some issues with inpatient prior authorizations in October. If you had a problem with those, please go ahead and submit those.
28. I have some claims that are denying for processing pair code invalid or missing taxonomy is not valid for performing provider. I also have some claims that are paying for the same provider. I have not changed anything. Should I resubmit?
Technically, no claim will ever be denied for the processing payer. That was shut off at the very beginning. It will still show up on every claim as paid edit; not a denial edit. So, that is not a reason for the claim to deny. We have done some updates to the provider searches that took place recently. If you have claims that you submitted, the hit edits like the ones for taxonomies and stuff like that, you can go ahead and resubmit those. There are some resubmissions of half claims that denied for those reasons that are now being reprocessed by the department. You may want to wait until the next financial RA comes out and see where you are at first before doing any resubmissions.
29. My physicians are retiring, and the clinic is closing at the end of December. I am running out of time on these claims. I need to know how to get our Medicare Part C claims paid. I just recently filed one through the system but it paid 10 percent of the co-insurance amount instead of the allowed amount. The system will not let you put the allowed amount. It calculates it to the co-insurance amount. Plus, the carrier code list does not include the Part C carrier codes. Please advise.
As far as the payment, the DOM policy for those is to only pay the amount of co-insurance, deductible, and co-pay that it is totaled on those. It does not pay the allowed amount necessarily. If you are only getting the co-insurance that you are reporting, that is the amount you are going to get paid based on DOM policy.
30. I have contacted Medicare, WellCare, Humana, etc. asking for their carrier codes, and they all told me they do not know what I’m talking about. They are not listed on the EOB. I really need these codes. We have not been able to submit a Part C crossover in over a month not counting the ones that were denied out by Conduent with the conversion to Gainwell. This is a huge issue. Can I just use a dash (-) to bypass the carrier code requested on the portal until these can be provided to us?
It should not be denying the claim. Create your own dummy carrier code for all of those and put it in that field for now. You cannot use a dash. You can use a character and a dash or just put in Medicare or Medicare C within that code field, just to get past that field in order to get those claims submitted.
31. Are there any updates on how to submit TPL and crossovers in an RHC?
Any provider, including RHC, FQHC, and IHS should be able to submit claims with both TPL and Medicare on them.
32. Are the Medicare to Medicaid claims that are sent from Medicare fixed yet? Meaning, are they going to be fixed and paid or do we need to resubmit them?
Do not resubmit. We just started getting over those claims, and we have all of the backdated claims from September 23. So, any claim sent from September 23 on that would have been normally sent directly to Medicaid has been sent. Those are processing this week. You should see them on your upcoming RA.
33. While going through the demo, we did not see an option for Medicare Part C; only Medicare Part A or B. Is there somewhere else we can see the Part C?
If doing a physician crossover, whether B or C, you are entering the information. It is just the claim filing code. If entering a B, you are doing a MB. If part C, you are choosing 16, which is Medicare HMO. Otherwise, you are treating it just like a regular crossover. You fill in the values that you are picking up from your EOMB from the payment information you got from that plan, Advantage Plan or Part B. So, when you are thinking of Part C, the difference for us is that claim filing indicator. Everything else you fill out as you normally would any other Medicare crossover. On dental, it is the same way. You would choose indicator 16.
34. We have tried to submit paper claims for Part C, and they have all denied because of an error with the taxonomy. We have asked several times for someone to contact us to help with the issue and have not been contacted. Is there a way to have someone call us, or can we have a direct number to call someone to resolve this?
If it is completely wrong, meaning you have a DME provider and you are a dental provider, then that is one thing, and it needs to be fixed. But if you are using your taxonomy that you previously used with all of your payers, then you need to make sure it is the same within our system. You may have something different for Mississippi Medicaid than you do from your other payers. The taxonomy is what helps us find you in the system for the one-to-one match, and it is critical; so, you have to use the taxonomy that we have assigned you within the system. If you have reached out to us multiple times, please try us again, and let us get you connected with your Provider Representative.
35. Regarding institutional claims, do acute services and therapy services have to be split billed?
In terms of inpatient, acute care processing, we did not change anything from how they were billing from the prior system. You should not have to split out any charges straight to Medicaid.
36. What are the requirements or rules for timely filing?
You have up to one year to file any claim into MESA from the first date of service. If it is a Medicare crossover, then you have up to six months from the Medicare paid date to be able to submit those claims. In the case of the Medicare crossovers for the last month and a half, you will receive a Medicare pay date within the last month and a half, and you will have up to six months.
37. For the voids that cannot be voided, has Mississippi Medicaid been notified? I am asking because they do a six-month audit, and these will still show on open credits for those providers. Should providers issue paper refunds for those that will not void? And if yes, what information should they submit and where for correct processing?
We know about the issue, and we are looking into it. It is not an easy solution, yet the team is looking into it. We may need to look at these on a case-by-case basis.
38. We are part of a group and have to have the rendering provider information. I can see the provider as affiliated, but the claim denied stating “provider is not enrolled under billing group number”. Is there something providers should have done to enroll as existing providers to the Group ID?
If you have a group with a single location or multiple locations, the rendering providers for each of those locations were also converted. So, whether it is a group with one location or 20 rendering providers associated to that group, we converted those rendering providers over. If you have selected a location for a rendering provider that has always been associated to that group’s location, yet it is now being denied, then there might be an issue with how we converted it, and you should contact the call center.
39. What about denied claims for provider taxonomy but some claims are being paid for this same provider?
We recommend contacting the Call Center. We have updated our system since go-live. So, if some claims are going through now and the ones in October did not, then I would re-submit those earlier claims.
40. Conduent required that the payment and contractual be bundled and reported as just a payment amount on the electronic Medicaid secondary claims to commercial primary. Do you require this as well, or do you want the payment and contractual reported separately on the electronic claim?
I am guessing that this would be an EDI claim, not portal. If you are submitting an 837, refer to the companion guide and how it requires the COB loops to be completed.
41. Can we still mail in claims with the HCFA and EOB attached?
We take paper claims. We take the CMS 1500, UBO4, ADA, Pharmacy, and Universal NCPDP forms. We take paper crossover claims, which you have to include the Medicare EOMB.
42. Are you saying that all EDI Crossover claims will need an attachment?
Yes. If you submit a batch of EDI Crossover Medicare/Medicaid claims, you will have to submit a copy of the EOMB. The process for how to match up this paper claim with your electronic claim is currently being worked out and will be rolled out to you all within the “Late Breaking News” soon. You must make sure that you are following the EDI guides that we are updating as well to provide more information. If you are submitting a claim that requires an attachment, you assign an attachment control number and put in the PWK segment. When you do that, it will suspend for 21 days, and it will be awaiting you to mail in the paper attachment. Then when we receive the paper attachment, we will match it with the electronic claim, and the claim will continue processing. However, if you send an electronic claim that requires an attachment, and you do not enter the PWK segment that claim gets turned into an electronic claim with no attachment and the claim will deny.
43. Did MESA processor process any crossover claims yet that were entered to MESA portal?
Crossover claims that are coming through the portal are getting processed. The only ones being held were the COBA Crossover claims, which we have started processing now and there is a backlog of those.
44, We have some claims that Medicare automatically transmits to Medicaid. We have not received any payments to our clinics. When can we expect these payments to show up or do we need to submit them directly to you?
These are the COBA file, and we have started processing these claims. There is a backlog. Start monitoring next week’s RA and see what shows up next week.
45. The last EOB from Envision denied all the crossovers for Part C they had on file. Do we have to re-do them? Are you saying we can see those claims in Gainwell and fix some number to make pay? When I called, they said we had to resubmit.
If the claim is denied in the prior system, then we are going to convert that as a denied claim in the current system. So, yes, you would need to re-submit that claim. Also, keep in mind that within MESA, the Part C claims are being treated as crossover claims.
New FAQs added in response to Nov. 8 workshop
1.What do the different numbers mean after the Medicaid State Plan? We are dental and see different numbers after, and sometimes it will tell their exam date and other times it will not.
The last 3 numbers after the plan description is the category of eligibility. When you see ‘TXIX’ under the Coverage, then that means they are in the traditional Medicaid 19 plan. A lot of members within Medicaid will have a pharmacy benefit plan as well. The ‘019’ is part of what triggers the member to be in one of the pharmacy plans.
2. Can we only check eligibility for the past year?
You can only go back a year, but you can only view 30 days at a time.
3. Can you please advise if individual providers will also need their own portals?
Every provider has to be registered and have their own login. They can be added as a delegate but they still have to be registered and have their own login.
4. Will the benefit details show if they are active in the additional Medicaid plans (UHC, Molina and Envolve)?
So, what you are seeing in the tracking for benefit limits is for straight, traditional Medicaid (aka fee-for-service) plans. The benefit limits is just for traditional Medicaid processing. It does not show the limits for the other plans, such as UHC, Molina, etc. Additionally, the code for eligibility with descriptions are located in the provider billing handbook as well as 270271 companion guides, which are on the website.
5. Will this show if the patient has retro Medicaid and their add date for this?
To see retro, go to the home page. Then, scroll to the bottom under ‘Provider Services’ on the left side. Select ‘Member Focused Viewing’. Select ‘Search’ and enter the member ID number. Then, select ‘Search’. Select the hyperlink for the member. Under ‘Coverage Details’ on the right side, it will list the retro coverage.
6. With retro, is it still based off of the add date?
Yes.
7. Do we have any guidance on how to submit Rural Health secondary claims on the portal?
We are enhancing our web portal crossover claim submission to not make it require as much detail because for many of those claim types (physician, outpatient, etc.) we required information at detail. There was a lot of data being captured that was not necessary and it made it more cumbersome for providers. You will see information going out today within the “Late Breaking News” in regards to crossovers. There will be a webinar just on crossovers within the future.
8. Will there be a secondary dental claims demonstration?
The Claims Submission webinar will be on Thursday, November 8, 2022. Additionally, if you are a dental provider, and you are billing for a member in Medicare Part C Advantage Plan make sure when you are creating the dental claim that you are putting the filing indicator code of ’16’.
9. When are we going to be provided the carrier codes for the Medicare Replacement Plans and Traditional Medicare? The carrier codes listed under Resources>Links are Commercial Insurance, not the Advantage Plans. The carrier codes are not listed on the Medicare Replacement Plan EOB like it was suggested. We cannot file Part C Crossovers through the web portal without these carrier codes.
Carrier codes have always been on the Medicare EOBs, but we have heard that they are not currently showing. We are looking into this, so monitor the “Late Breaking News”. If we are able to get a comprehensive list, then we will put that out there.
10. How can they ensure that providers are also being enrolled in MSCAN and CHIP plans for UHC and Molina?
When enrolling, the provider would specify which plans they would want to enroll within. At the time of application submission, they can select MSCAN or CHIP depending on which plan they would want to enroll into. This would only ensure that the providers are enrolled in those programs but that does not verify that the providers are contracted with the CCOs for those plans. So, the next step that the provider would have to do is work with the CCOs to set up a contract after they are enrolled successfully in Medicaid. Once a provider contracts with the CCOs, we do receive information from the CCOs that we capture on the provider’s file that tells us for the duration that the provider is contracted.
11. Are the effective dates for MSCAN and CHIP plans the same as their effective date for State Medicaid?
The provider can request an effective date on the application, but that is something that will be reviewed by DOM and Gainwell analysts to see if that is the effective date that should be assigned to the provider. Once that date is identified, that would be the same date assigned to all 3 programs, if the provider is enrolled in all 3 programs.
12. Do we always answer “no” to the “were you ‘previously enrolled” question since this is a new location for an existing provider?
If already enrolled in the system, make sure you give us that information as it tells us that you were previously enrolled. For new applications previously enrolled, no. So, only mark “Yes” if it is a provider coming back to the same location.
13. I have noticed that some of the other insurance provided has termed. However, I do not see anywhere to note that information.
If talking about CPA other insurance, we do not reach out to other insurance. You can add it and delete it. To delete insurance, you have to delete at claim level. To add other insurance: click the ‘Eligibility’ tab, enter the member ID, click ‘Submit’, select the ‘Other Insurance Detail Information’ hyperlink under ‘Coverage’ at the bottom of the page. Then select ‘Add’ at bottom of the screen.
14. So what did centralized credentialing do for us if it is still required to apply with each CCO?
The benefit of centralized credentialing is that prior to Mississippi Medicaid implementing this credentialing functionality, when the provider chose to contract with the CCOs, all of these CCOs would credential these providers individually. With centralized credentialing moving forward, if a provider is enrolling in MSCAN and CHIP and the provider is not contracted with a credentialing agency, a contracted vendor will perform the credentialing. Anything outside the Medicaid line of business, CCOs will still continue to credential the provider. With the Medicaid line of business, it is DOM that will be doing the credentialing and CCOs will not have to redo the credentialing for that particular provider. It is saving the credentialing effort that a provider would have to take with each CCO that they used to do previously.
15. Why do so many of the same insurances pop up?
This is a glitch that is being worked on currently.
16. The CCOs keep telling one of our providers that MESA will be enrolling the providers in the managed care contract plan with DOM. Is there someone’s contact information we can provide them to help get them get on the same page so they do not delay our enrollment requests further?
The main process of providers enrolling into the manager care programs is the credentialing aspect of it, which is why this enrollment is taking longer. This is currently being worked on. The help desk information, the email, and phone numbers were shared with providers. We encourage you to forward your questions through one of these contact options. When there are managed care programs on the application, the credentialing may take longer, which is why the applications are taking longer to get adjudicated.
17. Should the CCOs honor the DOM effective date?
Yes, the CCOs will honor the DOM effective date.
18. You stated this centralized credentialing is used to enroll both traditional Medicaid and the CCO plans but you also stated we need to contract with the CCOs in addition to enrolling with DOM. Please explain.
If a provider is enrolling in fee-for-service only, the provider will not be subject to centralized credentialing. However, if the provider is enrolling in managed care programs only, such as MSCAN and CHIP, then that is the only time the provider will be subject to centralized credentialing. The provider will need to enroll in those programs prior to working with the CCOs to start providing those services. So, the provider will have to first be enrolled in DOM and pass the credentialing and all other enrollment requirements to get enrolled in the program. Once the provider is enrolled, they will have to work with the CCOs to contract with them.
19. Will the enrollment application tracking number (ATN) only be available in the portal?
No, the ATN will also be sent via email.
20. Please go over how the “copy” works under enrollment.
This functionality would only work for the submitted applications.
21. Can I use the copy feature to enroll a similar provider? (For example, can I enroll a nurse practitioner and then “copy” the enrollment and change the demographics to an additional nurse practitioner?).
Yes, you should be able to utilize the copy feature in this manner, but please ensure that you have reviewed the prepopulated information thoroughly and update it for the accuracy of each new application.
22. The taxonomy page is grayed out. I’ve tried to use Firefox and Google, and it’s grayed-out on both pages. Several others in the office have gotten the same thing.
This seems to be an internal office issue. You would need to go back through your IT for settings; maybe a firewall has been set up.
23. Where does the claim indicator “16” go on hard copy claims for Part C ?
This is only if doing on the portal electronically. For paper claims, you do not need to put that indicators on the paper claims.
24. Is there anything specific that we need to put on the Part C claims to show they are Part C?
We will go over claims questions on Thursday’s webinar.
25. Dental secondaries, any specific number (like 16) for crossover claims… Do private/commercial with Secondary Medicaid need to add a specific number to have them processed correctly?
This shouldn’t be different as you were doing it prior. The only difference is Dental Part C needs filing indicator code 16. You fill them out as you did previously. Crossover claims questions be discussed in Thursday’s, November 10, 2022, webinar.
26. Will Medicare Part C be covered on Thursday?
No, we will host a separate seminar devoted to Part C at a later time. Please monitor the “Late Breaking News” for continual updates to this process. As a reminder, Part C is completed similarly to Part B crossover.
27. I have a clearinghouse as my trading partner (not myself). Is there a way I can directly access ERA 835 files?
The only entities to receive 835 files would be the trading partners. To acquire access, the trading partners would need to link the provider ID via the trading partner’s reference tab in the portal. The trading partner would then have access to the files via the portal and be able to share the information.
28. I previously registered my provider profile and trading partner profile separately (although I fulfill both roles). Is there a way I can combine them both under one account?
Unfortunately, once a trading partner profile is created, it cannot be linked to an existing provider profile and there is currently no way to delete it. You will have to toggle between the two profiles that already exist.
29. I bill as a group. Should the trading partner ID be added to each individual provider’s registration or only to the group enrollment?
If you only bill under a group, it should be acceptable to only add the trading partner ID to the group enrollment. However, be advised that the information will not be automatically linked under the other accounts. You will only have access to the trading partner information through the group profile.
30. My assigned taxonomy is inaccurate. How will this be addressed?
There are two parts to this answer:
1.) If the taxonomy is simply not as specific to your field of service, it is best to use the assigned taxonomy, as more specific taxonomies are being added frequently.
2.) If the taxonomy is completely wrong and unrelated to your field of service, please address your concerns to the provider enrollment fax number, found in the portal, to have your taxonomy reassigned.
New FAQs added in response to Nov. 3 workshop
1. How do you determine the difference between each Medicaid state plan?
This is only for MS Medicaid. If they are only fee-for-service, it will be evident in their file. If you expand the file and they have a managed care plan (such as MSCHIP/ MSCAN), those details will be there as well.
2. The Part C crossover claims I have submitted electronically have been denied for no EOB. I verified that primary payment was submitted on the charge level and went out on the electronic file. Is there an issue with submitting these electronic?
Updates are being made daily to make the web portal more user-friendly and support the processing of crossover claims. We recently received updates for COBA files, so that process should be more efficient. However, if you submit a claim EDI/batch process without the PWK segment or attachments, it will be automatically denied. Please continue to check the DOM website for updates on this process.
3. Where can Late Breaking News be located on the DOM website?
Late Breaking News can be found on the DOM homepage under “Provider Portal”. It can also be found on the provider portal homepage under “Latest News”.
4. How do you know if a member has dual eligibility?
To be reviewed in a future workshop.
5. As a DME Provider, how should I enter Part C Medicare Advantage claim?
It should be entered as a crossover professional claim with a filing indicator (first page) and set at 16. Complete it just as you would a DME claim on Part B.
6. Does the login information from Medicaid Envision transfer to MESA?
No, a new registration and profile will have to be created, using your Medicaid ID number and the last four digits of your social security number (or tax ID number).
7. What is Fee-f0r-Service?
This is the traditional Medicaid program–not members enrolled in managed care programs. It is also known as Medicaid Primary.
8. In the portal, does the QMB provide the Medicare policy number and managed care plans (if applicable)?
Currently, this information is not available, but it will be a forthcoming enhancement to the system.
9. When conducting an eligibility check, does the system identify inactive status?
No, there will be no coverage details provided. It will be blank.
10. How do I determine the effective dates for managed care plans?
There is no effective date for managed care plans. The effective date depends on their Medicaid state plan coverage, and the search criteria will display if they were enrolled in a managed care plan for the dates of the search.
11. What is Title 19 (TXIX)?
Please refer to the Mississippi Division of Medicaid homepage, for specific definitions and rules, as they apply to the state of Mississippi.
12. My taxonomy is not as specific to the services that I provide. Can I use a different one?
This is a taxonomy-based system, for efficiency purposes, it is best to use the taxonomy that you have been assigned. We are working to add more specific taxonomies, however in the meantime using your given taxonomy is the best practice.
13. What should be in the PWK segment?
If submitting an attachment, fill out section O2 with BM (by mail). In section O6, enter an ACN (attachment control number). The ACN must also be on the attachment when sending to Medicaid, so they can be linked. You have 21 days to submit the attachment to Medicaid. Once done, that will allow the claim to adjudicate. The process of submitting attachments is still being revised. Please monitor the Late Breaking News for updates and step-by-step instructions.
14. Can I edit a claim and add an attachment, while it’s in suspense?
No, once it is in suspense, the claim cannot be adjusted.
15. As a DME provider, is there a work-around for billing prescriptions more than once per 30 days?
In general, the best practice is to complete the prior authorization process in order to bill additional claims. For more specific matters, please contact the call center for personal assistance.
16. Is there a list of denial codes available?
Further research is needed.
17. What should I do if I have a claim that is inaccurately being denied as a duplicate?
A call center representative can assist with this matter. The representative can review the related history of the claim and identify any conflicts.
18. How can I verify a provider’s taxonomy?
Go to the DOM website. Go to FAQs MESA. Click Provider ID Search Tool. Enter provider ID and type (NPI, Legacy, etc.). The results will populate for verification.
19. How can we see that rendering providers in our group have the correct taxonomy code in your system?
Click the FAQs blue box on website. Click the Provider ID Search Tool blue box. Choose a selection from the drop-down list within the “Search Provider” box on the left side. Choose a selection from the drop-down list within the “Provider ID” box on the left side. Then, click the “Search” button. Scroll to the bottom and the assigned taxonomy is listed for the provider. This also lists the mail location, physical location, and other variables for the provider. **Note: We are trying to make this a bullet point on the homepage, so you do not have to go through FAQs to find this information.
20. Before Gainwell took over if the patient had Medicare Advantage primary and Medicaid secondary as long as the primary payment amount was not $0, we could send those electronically. Now they are denying all of those sent electronically stating that an EOB is needed. The primary EOB information is sent in the electronic file.
When we process Part C’s as crossovers, they follow the crossover policy, which is that we are requiring the EOB. We are working on the process to submit the EOB attachments. Since we are working on where the attachments are mailed and how they get matched up with their electronic claim, we are processing Part C’s as crossovers within the system and because of that, they are following the same crossover policy in terms of requiring the EOB. You can send the EOB on paper. To do this, you would fill out the paper claim form and submit it along with the Medicare EOB (A, B, or C). However, COBA files are going to start processing directly from Medicare soon for the Medicare EOB A and B. Medicare C will still require those to be submitted through either the portal or by paper. The portal is going to be enhanced soon.
21. When filing claims such as Rural Health Clinic (RHC) on a crossover, would those need to be keyed as a UB or professional claim? Medicare requires it to be a UB.
* Per the call, Jenni said that we need to distinguish RHCs, FQACs, hospital based and/or the claim forms that we accept.
22. We have to include the billing provider/performing provider on our claims or they will deny the billing provider group. The performing provider individual taxonomy codes are different.
Correct. You could have a group such as a multi-specialty group that has a taxonomy, but the individual renderings will have a taxonomy that might be more specific to them as an individual and their scope of services they perform. So, it is true that your billing as the group could have one taxonomy and your renderings will likely have something more specific to them individually for those individual performers. This is why using the tool that we reviewed on the November 3, 2022, webinar to look everyone up will tell you exactly who has been assigned to what taxonomy.
23. I have a patient who has a commercial/group policy policy and Medicare secondary, how do we file a crossover claim? We have never had a commercial insurance crossover.
This will be discussed within the Provider Webinar next week.
24. We’d like a request for claim demo.
The claim demo will be during the Provider Webinar next Thursday, which will give us time to have our updates in for the crossovers and make sure that we are showing the most current filing process on the web portal.
25. Do we file the Medicare replacement claims using paper?
For the Medicare Advantage Part C claims, paper is an option.
26. We have thousands of claims that have been rejected since we changed over to MESA that previously went through. Why is this happening?
This is hard to answer because there are many reasons for denial. It would depend on the error code. It could be that they are being submitted electronically because we changed SNIP levels, which does require providers to update the submission of batch claims. We need more specifics, such as, are they getting rejected or are they getting denied.
27. If a member has Medicare but it does not show it under other insurance, can the provider add it or how does it get added, if not?
Medicare additions come directly to us from Medicare, so all of those get submitted directly for Medicare to us, based on the member information. You can still submit the claim, but you cannot add the Medicare information through the portal.
28. Our ER group has many claim denials for group taxonomy and rendering provider taxonomy issues. Currently, only the admin user has access to view the rendering provider taxonomy on the MESA portal; delegates do not. Will delegates have the option to have future access to view the individual provider taxonomy on the portal? This is a section on the portal titled “Affiliated Providers”.
The delegate will not have access to that. It is only going to be the admin since they are the ones that add it.
29. Where do we need to go to verify a managed care plan for a member?
To access, select the “Eligibility” tab within the Provider Portal. Enter the Member ID. Select the “Submit” button at the bottom. Click the “Medicaid State Plan” that populates at the bottom of the page under the “Coverage” column. Then, this will bring up the panel that shows member care assignment details. It will show what managed care plan they are in and who they are associated with, such as United, Magnolia, etc.
30. Do we have to submit all secondary claims with an attachment? Previously, we were able to send some of our secondary claims through our clearinghouse if we received a payment from the primary payer and the claims would reprocess. Now, we are receiving a denial for all of our secondary claims for missing an attachment.
All of your secondary claims for Medicare do require the EOMB regardless. If you are talking about other insurance, like private insurance, those do not require a secondary or an EOMB.
31. Where do we find 02 and 06 segment? Is this on claim form or on portal claim?
That is not on the portal claim or paper claim. That is only on the EDI transmission submission. If sending in paper, you automatically send the EOMB in with it. If sending in portal, you will be downloading the EOMB through the attachment section. Within the portal, there is a section that says attachments, add attachments, and you click add. This will give a drop-down to describe the attachments you are adding. Then, you upload your attachment. Then, submit. There is nothing on the portal that specifically says pwk. That is terminology for your EDI.
32. On Tuesday, Curt told us that Medicare carrier codes are on the Medicare EOB, but we have not seen this code on our Medicare remit. Can someone help us with this?
Since the EOMB is a little bit different for each one of those, you would have to get together with your Provider representative. It is not something we could do during this meeting.
33. Providers need written direction on Medicare A, B, and C primary claims.
Linda Cramer will take this back to the trainers, and we will create something for the providers to use and put it out there. Jenni said that we are trying to make the way crossover claims are entered into the portal a little more user-friendly.
34. My agency submits 837 P batch files for crossovers. How will the attachment process affect us? In the legacy process, the required EOB information was included in the file. Will there be a different process for this?
Curt covered this earlier with the pwk information. We will have more communication out there once we have finalized our process for submitting attachments for the electronic claims. This will go out under the “Late Breaking News”.
35. Do we have any kind of process yet on how to handle the unpaid claims carried over from the previous system?
Everything that had already been processed has been converted. There were lots of paper claims that were sent to us, and we have been working through those. We had some batch that were in hold and were released early on and have been processed. We may have some paper claims that are still in flight but in terms of electronic and everything else, we brought everything over. So, if you still have claims that you submitted prior to the new system go live and you have not seen them in the system, we would have processed those to date, if submitted electronically. If they are paper, I do not know what day they are scanning right now, so we would need to check on that. All claims submitted were finalized in the Conduent system prior to us taking over.
36. I have my delegates set up to have all functions except claims. However, they do not have the ability to check eligibility. This is one of their primary jobs. Is this something being worked on?
A delegate can search to verify eligibility. Click “Manage Accounts” on the home page once the provider is logged in to the system. Click on the “Search Delegates” tab. Choose the delegate from the list of names. At the bottom of the page under “Functions”, it will show “Verify Eligibility”. Verify that the delegate’s “Verify Eligibility” box is checked.
37. We have a high volume of institutional crossover claims and it would be impossible for them to key each and every claim. So, we will have to submit some of our claims paper. The paper billing provider manual provides some details on the format of the claim. Will there be a training session on submitting paper claims, and what is required on the claim? Some of the information provided in the paper billing manual is not clear on fields that it states required information should be listed.
We are encouraging electronic billing, so we will have to consider this suggestion. The paper billing manual has pictures of every single field with a lot of details. We want the paper billing guide to have clear step-by-step instructions and not be too cumbersome to go through. If something is unclear there, then we need to clear it up. So, we can work with the operations team to figure out where we need to enhance. Curt said if there are a lot of claims, then he is assuming this is a large hospital and many of these claims will probably come over from COBA. Jenni suggested in this situation if I were a large hospital where most of my claims typically come over from Medicare without incident, then I would not start doing a bunch of paper claims yet. She suggested to wait for the COBA files to funnel through within the next few weeks.
38. I have unpaid crossover claims carried over from Envision. I need to know if all these claims can be accepted with our OLD taxonomy code. If not, we will have to demand over a 1,000 new claim forms. Is black ink acceptable?
Black ink is acceptable. The only ink not accepted is red. You should be submit the CMS 1500 or UVO 4. We will not accept the old self-made claim forms in the old system. For the taxonomy, if they were denied in the old system, then they would have to be resubmitted. If paid in the old system, then no resubmission is required. We need more information regarding these claims. Need email address for Cathy Parrish. You may file with the old taxonomy code. If we can find the one based on that information, then there should not be a problem. If there is a problem, then those claims will get denied for improper provider. So, go ahead and resubmit as they are.
39. We are a rural health clinic and due to the Medicare rate, the payment will always be more than the charge. The HMO EOB will never balance. How should we file those?
You will file those with your current billing rate and if the Medicare rate is over, then that will be set to where we can look at it and make the right payment based on the different rates. We know RHCs and QHCs have certain rates for an encounter, so those are taken into account.
40. Conduent denied all pending parts crossover claims on September 26 for the changeover. How are those denied claims going to be handled?
The Provider would need to resubmit with the correct taxonomy.
41. Do the denied claims from Envision need to be corrective claims in MESA?
If they were denied and brought over as denied, then they would need to be re-submitted.
42. Is the 0AJH payor ID still valid for Part C crossover electronic claims? If not, what payor ID should we use for these electronic claims?
That would still be a good payor ID, if that is what they were originally using.
43. My crossover claim is changing from crossover professional to professional causing my claims to deny for-patient if eligible for Part C. I even printed the claim detail before submitting, and it says crossover professional at the top but changes when the claim is submitted. Any answers to why this is happening?
I assume this was a paper claim that was submitted. When we are scanning and batching the paper claims, we are not catching that they have checked that they are Medicare. They may not have information on the face of the claim to suggest they are Medicare, so we are batching them as physician claim with an attachment. Re-submit the claim for it to be processed as a crossover.
44. We submitted a claim on the portal with Cigna (commercial) EOB. The claim denied stating patient has commercial insurance but when I checked on MESA eligibility, it shows the Cigna Plan that I submitted the EOB on. Why did I get this denial, and what do we need to do?
We have some claims coming in as primary insurance as primary and Medicaid as secondary. The private insurance has applied all of their paid amount to the deductible, so zero private payment is showing, but all amounts are going to the deductible. We may have a potential issue here. However, if you have a prior payment, and we have captured that payment then you should not be getting the denial. We suggest looking at your claim and see if it all has been applied to the deductible.
45. When I correct a claim on the portal for outpatient, would I need to use type of bill 131 or 137?
When submitting the 137 (technically, if you are trying to void that would be a 138), make sure your original claim was an outpatient claim and that you are not trying to submit a void for the non-essential part of an in-patient stay. Make sure the first claim was not considered an 11 X or something like that.
46. What box on the CMS 1500 are you looking for the claim indicator?
The CMS 1500 is automatically listed as a professional claim. If it has Medicare crossover information, then it would be listed as professional crossover.
47. How will we see all claims from Conduent that was previously processed? Will you accept the Conduent TCN?
We do accept the Conduent TCN for adjustments or voids. If submitted by you and you have the rights to see them, you can see them by the member and dates of service. They will show up in the system with a Gainwell ICN starting with a 4. You can also search on the Portal by TCN with a claim ID. There is a box for this.
48. Crossover claim keyed denies with “CALCULATED DETAIL MEDICARE ALLOWED AMOUNT IS ZERO”.
Any outpatient or professional or dental Part C claims coming in are required to have the Medicare information listed for each detail. The detail information should be listed on the EOMBs for those as well because Medicaid started doing that back in 2015.
New FAQs added in response to Nov. 1 workshop
1. Is the MESA ID required on the claim or only the NPI and taxonomy?
Only the NPI and taxonomy are required on the claim; not the MESA ID.
2. What do we do when our assigned taxonomy is wrong? For example, we have an internal medicine physician who has been assigned dermatology as the taxonomy. This is not the type of medicine he practices.
On the DOM website, there is information where you can contact various different entities. Find the provider enrollment fax number and send in a letter on your letterhead stating that the taxonomy assigned is incorrect, list what the taxonomy assigned should be for this provider, provide the NPI, provide any further information needed, and provide a contact name with contact information. The enrollment team will coordinate the approval process with the Division of Medicaid.
3. Are we going to be paid for Medicare to Medicaid crossover claims any time soon?
We are working on this as fast as we can. All entities involved have made this a top priority, including Medicare. There is not an ETA at this time.
4. How can we submit our more specific taxonomy to be added in the future or if they already have it due to it being on our crossover claims?
As a Provider, you do not need to do anything. We are aware of all of the taxonomies out there and we can see them on the claims. You can also let your Provider Association know what things you would like to see in the new system, such as taxonomies.
5. What field does the taxonomy number go in on the CMS 1500? What loop is filing electronic?
1) For the CMS 1500, if you are a group putting something at the performing/detail level, that is in 24 J in the gray area. If you go to the billing manuals on the DOM side, it has screen shots/pictures of the 1500 which shows you where to put your taxonomy. You will put your NPI at the detail and within the gray area above that, you will put your taxonomy. Then, at the billing down in 33, you will see an ‘A’ for NPI and a ‘B’ for your taxonomy.
2) On the electronic claim, I do not have an answer. I am sure a team member can have it by the end of the call and post it on the chat.
6. On the most recent RA, I had a Medicare crossover claim that processed and denied due to taxonomy, so maybe they are starting to trickle through the process?
No, that would probably be something that came in on paper, through the portal, or a batch transaction. We have not processed a COBA file to date.
7. We are receiving denials for group billing providers not allowed for claim type. We never had this issue before our taxonomies changed or were updated to a higher level. Why are we getting this type of denial now?
If you are billing through portal for your individual, we ask that you leave the rendering and facility fields blank. Then, those will process for the individual just fine. If you are a group and need to have the individual rendering, then you will need to enter something in the rendering field. For the individual, there is a drop-down list for the provider to choose the correct location at the top of the portal where you see the provider’s NPI.
8. Is ‘Critical Access’ not an approved taxonomy anymore?
This may be that we do not have that level of specificity, which means we rolled it up into the higher basic, acute care. We are looking into this, but the higher-level taxonomy does not impact your payment structure for Medicaid.
9. I am with Life Help, a Community Mental Health Center. We had a couple of claim payments that were deducted for the co-pay and co-pays do not apply for our services.
In the prior system, there was an alpha character that you would append to the ID to tell it to bypass the code. The system relied solely on that alpha character. In this system, a combination of things are used to validate. For example, we can validate if they are in a long-term care facility, their age, if they are pregnant, or whatever co-pays are created. So, we use whatever is in the system to validate because we do not want those alpha characters on the claims anymore. If it is a service that should bypass co-pay and you see it still happening, then we will need to know about this. The provider will need to provide us with the submitting taxonomy code, the procedure code, any modifiers, and a statement that you believe it should be bypassing co-pay.
10. Once Medicaid starts processing COBA files for Medicare, will you go back and process all remits since MESA went live?
We will go back to the original date that Medicare stopped working with Conduent. We are requesting to get all of those back files, so we can process those. We will also look at the timely filing of those when they come through because we understand that the timely filing affected those.
11. If Medicare processed primary claims under our old taxonomy code, will Medicaid reject those once they start processing?
Our goal is to not reject those claims based on taxonomy. We are trying to put some enhancements in to find that unique match using various criteria on that claim in a way that allows us to verify who you are and the taxonomy code in the system and to not start rejecting out a bunch of crossover claims. We have put in some things that are going to make this better and the team continues to look at the data.
12. Can you provide the Provider Services fax number?
It is 1-866-644-6148.
13. Our Medicare taxonomy codes will be different than the new ones assigned by Gainwell. Will those claims be denied?
Our goal is for them not to be denied. When the claims crossover from Medicare (COBA files), our goal is always not to be denied. We are working diligently to find ways to take what is on that crossover claim and find your Provider (that one-to-one match) and find you in our system and allow the system to utilize that taxonomy we have in the system. The ultimate goal for a taxonomy-based system is to be able to utilize what you are submitting on the claim as your taxonomy.
14. Will the time refiling deadlines be extended due to all of the issues we are having?
In general, no, they will not be waved. For Medicare crossover claims because of the backlog that we would be processing, this is something that we will be considering.
15. Where on the claim will the taxonomy be?
If you go to the Provider Billing Manuals on the MS Division of Medicaid website, the paper claims billing manual will give you this information for the paper claims. If you are doing a web portal claim, a field is provided. If you are doing an 837 claim, the companion guide will tell you where the taxonomies go.
16. Do providers still have a year to file claims?
In general, yes. For any caveats, look in the billing manual.
17. To be paid at this time, do providers have to manually do crossovers?
Yes. If your business does not have massive amounts of crossovers, then we recommend that you go ahead and get those submitted either by paper or portal. If the vast majority of your rendered services are Medicare and Medicaid, then you might want to let us work through the process with Medicare and get those back log of files processed.
18. Why are we using taxonomy codes? Since there are so many taxonomy codes, why not just use the NPIs and TIMs?
The state wants us to be a taxonomy driven system. Your NPI alone does not always give us a one-to-one match in the system. In addition, policy can be configured around taxonomy better than a provider type and specialty in many ways.
19. Can you show us where to find the companion guides?
Click on the MESA Portal for Providers. Scroll down the page and find the ‘Additional MESA Portal Resources’ in blue font. Click the ‘EDI Claims Companion Guides’.
20. Do the taxonomy codes need to match CMS 33 B and 24 J?
If they mean they are billing for themselves on a physician claim, then those two taxonomies should match. If they are billing for a physician group and an individual, then those don’t necessarily have to match. To clarify, if you are a physician group, then you put your group’s taxonomy in 33. Then, in 24J, you put the taxonomy for the doctor who is a part of your group.
21. Is there a list of approved taxonomy codes?
It is on the checklist on the enrollment form. It is also on the portal: enter through the Provider Login. Click ‘Provider Enrollment Access’ link on the left. Click ‘Enrollment Application’ on the left. Scroll to the bottom of the page and click ‘Continue’. Select ‘Click Here’ for the application type that you need.
22. How can Gainwell assign or change a Provider’s taxonomy code when the provider has it linked to the NPI when they registered on the National Plan and Enumeration System, which was thought that all Medicare, Medicaid, or other insurance carriers have to abide by?
Technically, that is incorrect. NPBS only sets up the taxonomy for you as per what you believe is your taxonomy at the time that you set up NPBS. The NPI and taxonomy can be used differently for all different providers or payers. Technically, we can assign you a taxonomy that we believe you were registering for or were registered for at the time. We do double-check those when we do a first initial enrollment against MPES to see if the taxonomies do at least come into the same category, but they do not necessarily have to match. So, you can change your taxonomy based on what payor you are going to. The only thing you cannot change is your NPI.
23. When a delegate leaves the practice, can they be deleted or are they there forever within the portal?
You can go in under that administrator and look for that person who is no longer employed and you would inactivate them, which does not allow them to get back into the provider portal.
24. Does the administrator need to setup as a delegate?
No, it is not necessary, but it is helpful if there are multiple groups. An administrator setup as a delegate can link multiple users together and make selections between providers within the groups.
25. What if I am receiving a 504 Forbidden error message when I try to access the portal?
This is likely due to an internal issue, such as a firewall in place. This can mostly be addressed by contacting your company’s IT department.
26. Can a delegate or staff member access the affiliate provider link?
No, only an administrator can access the affiliate provider link and there can only be one administrator per account.
27. What does it mean if my security question responses are invalid?
This likely means that there is a typo or some other error in the response, such as capitalization, missing or added number or other character. Please double-check your responses. Also, ensure that your user ID is correct. This can be verified by contacting the call center. If the issue continues, return to the home screen, enter your user ID and you will receive a challenge question for further authentication.
28. Does each provider in a group have to create their own account?
Yes.
29. What happens if a staff member doesn’t have a driver’s license?
Enter 1234.
30.How can I access the C-Schedule?
Click ‘Other Resources’, then ‘Resource Links’, then ‘Fee Schedules and Rates’, and then ‘Accept’.
31. Can delegates access the C-Schedule?
Currently, no, but it should be resolved within the next two or three weeks.
32, How does an administrator link to all accounts?
After the administrator account is created, add each delegate to the account.
33. What is the call center number?
The call center phone number is 1-800-884-3222.
34. Do I have to create an account for each provider or can they be added under a group account?
A separate registration must be completed for each individual Medicaid ID.
35. What if my password does not match the security questions?
Click ‘Reset Password’. You will receive an email with further directions. Be sure to check your email’s spam/junk folders.
36. As an administrator, can I add myself as a new delegate and registered delegate?
Yes, this will allow you to have only one username and password and add other delegates from one account.
37. Where can I locate MUE Allowed Units?
There are currently no changes to the information as what is found on the CMS website.
38. What should the PIN be when registering for the provider portal?
For individuals, the PIN should be the last four digits of the tax ID number. For groups, it should be the last for digits of the tax ID number or last four numbers of the social security number.
39. What should I do if I cannot find a claim in the search queue?
Please contact the call center for further assistance. The call center phone number is 1-800-884-3222.
40. Can I submit a crossover claim on paper?
Yes, but you may not do so using the previous form used in Legacy. Any claims submitted using the old form will be rejected. Please review the Provider Manual for further information.
41. Can I manually add carrier codes for Medicare crossover claims?
Yes.
42. Where can the carrier codes be found?
Carrier codes are listed on the provider portal under ‘Resources’.
43. What causes crossover claims to be automatically denied in the portal?
Crossover claims are automatically denied if the UNB is not attached to the claim.
45. Are there delays in processing paper claims?
All claims are processed in order of receipt, as soon as possible.
46. What is the mailing address for paper claims?
Gainwell Technologies, P.O. Box 23076, Jackson, MS 39225.
47. Who can submit secure correspondences to request taxonomy changes?
The administrator can request a taxonomy change.
48. What is the turnaround time of response for secure correspondences?
We have several individuals working to respond as soon as possible.
49. What would cause an account to be denied for no authorization if the authorization has already been approved?
Please re-submit those claims. Also, ensure that the first character is a capital letter.
50. Where can the webinar schedule be accessed?
There is a red banner at the top of the MESA homepage. Once you click it, you will see more information on scheduled webinars.
51. Where can previously recorded webinars be accessed?
This information is currently not available. Please check back for updates.
52. Why are elderly, psych-social rehabilitation providers being denied for prior authorization when it was never required in the past?
Please provide your taxonomy, any modifiers, procedure code, and a note expressing the prior authorization is being required.
53. What if I never received a verification email after registering my account?
Try resetting the password manually and answering the challenge questions.
54. Can I delete a registered account and start over?
No, once an administrator account has been created, it cannot be deleted.
55. Has the error when billing for T1005 procedure code been resolved?
Yes, that was an audit for respicare, and it has been resolved. Please re-submit claims submitted prior to October 17, 2022.
56. Do the billing provider and rendering provider taxonomy code have to match?
Not always, group billing taxonomies will not always match that at the rendering level. Individual providers can leave the rendering features blank.
57. What does ‘Rendering Provider ID Not on File’ mean?
This is more specific and individualized and will need to be examined on a case-by-case basis.
58. What if there are multiple hospitals under one taxonomy – how is it determined which hospital to pay claims to?
Each hospital should be distinguishable by their zip code, and that should determine to which the claims are paid.
59. Is it required that all secondary claims be submitted through the portal?
No, secondary claims can be submitted in any form.
60. Do commercial primary claims have to have a primary EOB?
They can be submitted with an EOB through the portal and on paper, but it is not required through EDI.
61. Can Medicare Primary and Medicaid Secondary claims be submitted through the portal?
Yes, but the must include the Medicare EOB attachment.
62. How are Medicaid Secondary claims being applied to commercial plans, if the entire amount is applied to the deductible?
This is more specific and individualized and will need to be examined on a case-by-case basis.
63. What to do if I receive a ‘denial error’ message while submitting a claim in the portal?
The denial error message will explain the reason for the denial. To save time, there is a copy feature that will allow you copy the claim, make the necessary corrections, and re-submit it.
64. Are paid claims editable in the portal?
Yes, there is an edit feature that will allow you to make necessary adjustments to paid claims.
65. Is it possible to bypass the Medicare carrier codes in the portal?
No, this is a requirement.
66. Why are some codes shaded gray and inaccessible?
There are still updates being made, and this matter is being addressed as soon as possible.
67. Can a legacy claim be voided in the portal?
Any paid claims can be voided.
68. Is there a Mississippi Medicare carrier code?
No, not technically, but the code ‘MS_TXIX’ is available for use.
69. Is the Medicare ID the same as the carrier code?
Yes.
Provider Portal Eligibility Verification
1. Do I have to be logged into the Provider Portal to check member eligibility?
Yes. You can only view member information after logging into the secure
portal.
2. Is eligibility verification a guarantee of coverage?
No. Eligibility verification only indicates the current state of coverage as reflected in the MMIS. Member coverage can change.
3. Why did my new Other Insurance record disappear?
When you enter an Other Insurance record, it is moved to a workflow for the Mississippi Division of Medicaid to verify and approve. The record will appear in the Other Insurance list after approval.
4. What if I enter an Other Insurance record twice?
Don’t worry, duplicate records are easily deleted from the worklist.
Portal Roles – Admin vs. Delegate & Fee Schedule Questions
1. Can a Provider have more than one Administrator?
There is only one Administer that can be registered on the Provider Portal.
2. Does every Provider need a Delegate?
Click here to find archived information and resources from the MMIS Replacement Project
The Delegate functionally is for more employees to register themselves on the Provider Portal with there own User ID and Password.
3. Who assigns Delegates and makes changes to a Delegate’s access/views?
The Administer is the one that grants the access to the delegates.
4. Who can see the Fee schedules & check Eligibility?
Both the Administer and Delegate can access the fee schedules and check eligibility on the portal. Under Resources then click on Search Fee Schedule.
5. Can we add NPIs to a Delegate’s account?
You can not add NPI to a delegate account.
6. Who has access and how do we link Provider’s to a Clinic?
The Administer has access to link providers to the Group.
7. We are trying to log in but it says the Challenge questions are wrong, what do we do?
Make sure the User ID you enter in on the login page is correct.
8. I am a Delegate, how do I get my email address changed and can my administrator see my email address?
The Delegate needs to login on the home screen under My Profile there you will be able to change your email address.
Eligibility Verification Questions
1. When verifying eligibility, the date I enter is the Effective Date of the eligibility. This is different from what we’re used. Will this be changed?
The date entered in the search for Eligibility is the date that is returned for eligibility verification. The panel is designed to return eligibility per Date entered in the search. This is a change from Conduent’s system and reinforces HIPAA security for only that information that is needed at a time.
2. When a member’s managed care medicaid plan changes from one to another plan how do I get the effective date of the change?
The current date of the enrollment that is displayed on the effective date of the Coverage is the first date of eligibility for that plan. There is no audit panel to look at on the web portal for a history of all plan assignments. Instead, enter a specific date prior to the current date to see if the previous CCO is displayed and review the effective dates.
3. Where do I find if a member has MSCAN or Chip?
The Plan is displayed under the Managed Care Assignment details panel under Benefit Plan. It is displayed as either MississippiCAN or MississippiCHIP.
4. How do providers know when the beneficiary has changed payers? For example Magnolia to Molina.
Provider can see this by looking at the current date of the enrollment that is displayed on the effective date of the Coverage. There is no audit panel to look at on the web portal. You can enter a specific date prior to the current to see if the previous CCO is displayed and review the effective dates.
Service History Questions
1. When will the patient’s Dental and Vision limits and amounts be posted?
The fix for the Dental and Vision limits to display on the Portal was put into MESA on Friday, 10/28/2022. These limits and remaining units balances are now displaying for all service limits; including Dental, Vision, Therapy, and Office Visits.
Taxonomy Questions
1. A Taxonomy webinar is being held on Tuesday, November 1, that will questions that arose during this webinar. Please attend and see the FAQ from that webinar for more information.
N/A
Crossover Questions
1. When will Medicare cross-over claims be pulled. Are we going to have to rebill them all online through MESA?
Gainwell Technologies and DOM are currently working with COBA to get all Medicare Crossover claims pulled. We do not have an ETA on when they will be pulled. We are planning on getting the back log from Medicare so that Providers will not have to manually submit these claims.
2. When doing a professional claim, it makes us put in the performing provider id#. it gave a denial until this was added. how are you doing a claim w/out this info?
Rendering Providers are only required when the Billing provider is enrolled as a group. If the Provider is an individual, the Rendering is not only not required, but it is suggested to leave completely blank.
3. Part C crossovers claims are being returned. Reason is claim form not accepted in MESA. For Medicare advantage members, the crossover for is the Part C form. Are there enhancements being made to accept this part C form?
All Medicare Part C Advantage Plan Claims can not be sent using the same CMS1500, UB04 or the 2012 Dental forms. They can also be filed through the Provider Portal or EDI batch. These claims need to be sent with all the information as any Medicare Xover at the correct levels (Header or detail) by setting the “Claim Filing Indicator = 16”. These claims will process as directed by state policy.
4. How do you find out why a secondary claim denied?
This can be done by pulling up the claims in the Provider portal, reviewing RAs/835s, or calling the Provider Call Center.
5. The YouTube video tutorial said NOT to enter Medicare Crossover Details but to check the box instead?
This is in the process of being updated/corrected.
6. How do I submit a Medicare C claim?
Medicare C plans need to be submitted just like Medicare Crossovers with the only difference being that the Code Filing Indicator field in the Other Insurance section of the claim set to 16.
7. We were told on one of the Webinar that we were not supposed to fill in the Medicare part on the first page, that it was supposed to be left blank. Is this still the case?
This is currently a known defect. Currently Providers do need to fill out the Other Insurance portion at the header, but only fill out the Medicare portion at the Detail for Professional Crossovers, Outpatient Crossovers, and Dental Part C Crossovers.
8. My claims are denying for code 1470. What is this code?
EOB 1470 is a PAID edit and is not the cause of a claim denials. This is an informational EOB only. Every Medicaid State has this change in place.
9. Can you file Medicare C claims electronic not thru website?
Yes, you will need to still send the EOB by mail, and you will need to fill out the information in the correct X12 loops for other insurance with the claim filing indicator of 16.
10. Do we add the Medicare crossover details in the header or in the line item?
The Medicare payment information for Professional, Outpatient, and Dental Part C Crossovers will need to have the Detail information sent. Inpatient and Long term Care Crossovers only need the Detail.
11. Do we have to click the include other insurance when filing a Medicaid Part C claim, when a Medicare Advantage plan is primary?
All Medicare Crossover claims, including All Medicare C claims, will have to have the Other Insurance section filled out. For Medicare Part C claims, the Claim Filing Indicator will need to be set to 16.
12. If we have multiple service lines do we enter the information for each line item under the crossover details or do we enter total amounts for the entire claim?
Each detail needs to be filled out exactly as it is listed on the EOMB from Medicare. If there is Detail information on the EOMB, that information must match the Crossover Claim.
13. If it is a Dual plan like United or Aetna as primary, do I submit a crossover professional or just professional?
If none of the Primary and Secondary are Medicare or Medicare C advantage plans, then send as a plain professional claim.
Claims Not Processed by Conduent Questions
1. How are claims being handled that were never processed by Conduent before moving to MESA? I am trying to submit these now and getting a timely filing errror in MESA.
TBD – Gainwell will fill in this answer soon. Please check back at a future date.
2. We submitted claims via regular mail and certified mail to Conduent. MESA says they do not have them. What do I do now?
TBD – Gainwell will fill in this answer soon. Please check back at a future date.
Other/Misc.
1. If the provider is a group, will we always have to add all of the additional information?
If the Billing Provider is a Group Provider, all Details are required to have a rendering provider submitted.
2. Do you have to copy the claim in order to file a corrected claim, rather than use the “edit” option?
The Edit option is only for the Adjustment of a paid claim in the MESA system. Copy is to be used for all other corrections.
3. What is a claim filing code?
The Claim Filing Code is used to determine the type of other insurance is being submitted with the claim. In the case of Medicare Crossovers, it will be MA, MB, or 16 for Medicare C Advantage Plans.
4. How do I fix the following error, INDIVIDUAL BILLING PROVIDER MUST ALSO BE THE RENDERING PROVIDER denial?
Providers that are submitting claims through the provider portal for themselves are having payment issue with the rendering provider field on the detail. This can be mitigated for providers billing for services they themselves rendered by filing a claim without filling out any of the Facility or Rendering provider fields at the header or the detail. Leaving these fields blank will allow for the system to know that the Biller is the rendering provider and the claims will process correct.
