Eligibility/Coverage related Denials - How to avoid

If claims are denied for eligibility reasons, the following steps should help resolve the denial and obtain reimbursement for covered dates of service for eligible recipients.

Step 1—Check for Errors on the Claim

Compare the recipient’s eligibility information to the information entered on the claim.

If the information on the claim and the recipient’s eligibility information do not match, correct the claim and resubmit on paper or electronically as a new day claim.

• If the claim is over the 365-day claim filing time limit, request a time limit override by submitting the claim and a completed Medicaid Resolution Inquiry form. Include a copy of the Remittance and Status Report (RA) or other documentation of timely filing.

• If the claim was originally received and processed within the 365-day claim filing time limit, resubmit the claim on paper or electronically as a new day claim, ensuring that the recipient’s MID number, provider number, “from” date of service, and total billed match the original claim exactly.

Step 2—Check for Data Entry Errors

Compare the RA to the information entered on the claim.

If the RA indicates that the recipient’s name, MID number, or date of service has been keyed incorrectly, correct the claim and resubmit on paper or electronically as a new day claim.

• If the claim is over the 365-day claim filing time limit, follow the instructions in Step 1 for requesting a time limit override.

• If the claim was originally received and processed within the 365-day claim filing time limit, follow the instructions in Step 1 for resubmitting the claim.

Step 3—When All Information Matches

Verify that the recipient’s eligibility information has been updated in the state eligibility file by utilizing the Recipient Eligibility Verification Web Tool or by calling the AVR system.

If the Recipient Eligibility Verification Web Tool or the AVR system indicates that the recipient is ineligible, submit a Medicaid Resolution Inquiry form to DMA Claims Analysis. Include the recipient eligibility information, the claim, and the RA. Mail to claim mailing address

The Claims Analysis unit will review and update the information in EIS and resubmit the claim. Do not mail eligibility denials to HP Enterprise Services, as this will delay the processing of your claim.
For further information, refer to Appendix F, Verifying Recipient Eligibility and Appendix A, Automated Voice Response System.