Investigating Unpaid Medicaid Claims

Overview

Even with the best process, errors can happen. If a Medicaid claim has gone unpaid, the following checklist helps rule out issues on the provider's end before reaching out to Support.

Checklist

837 Billers: Check for B13 ("Already Paid") Responses

When a visit type is scheduled more than one time per day, some payers will refuse to pay more than one visit. If a visit type is scheduled more than once per day, request an Ankota adjustment to NOT allow billing until all scheduled visits of that visit type per day are closed and ready to bill. Duplicate visits for a visit type in one day is the most common reason for receiving a B13 ("we already paid you") response even though the visit is not paid.

Check Authorizations

For any form of Medicaid billing, verify that claims were not billed without an authorization and that authorization information is up to date. If authorization notifications were previously turned off, consider turning them back on.

Check Visit Types & Payer Descriptors

Verify that visit types and payer descriptors (for those that use payer descriptors) are correct. A more detailed walkthrough on identifying and correcting these issues is available separately.

Check for Data Delivery

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

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

Check Responses

Review any errors returned by the clearinghouse. These will likely point to what needs correcting, such as a wrong primary diagnosis code, wrong DOB, wrong Medicaid ID, or misspelled name. Error codes are usually integrated directly into the Visit Approval Dashboard, and are also available in claim confirmation files from the state (such as EMOMED's claim confirmation file) and in 835 response files (see the Exceptions report for a list of the error codes after uploading the 835). It is critical to include these errors when reaching out to Support.

Reaching Out to Support

If no issues can be found on the provider's end, it is time to reach out for Support help. If claims were already accepted into a clearinghouse, normally speak to the clearinghouse first and gather as much error information as possible before reaching out to Ankota Support.

For the fastest response, provide Support with key details, as in the following examples.

Example 1

Hi, Support!

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

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

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

Thanks! Jim Doe, ABC Billing Department

Example 2

Hi, Support!

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

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

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

Thanks! Maria Doe, DEC Billing Department