Nebraska Medicaid Program

Provider Information

Claims Processing Frequency Asked Questions

Can I submit my claims electronically?

Yes!! Your claims will be received and processing will begin immediately. Electronic claim submission benefits both providers and payers.  For more information , see Electronic Data Interchange Frequently Asked Questions.

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I am new to billing Medicaid. How do I get started?

Welcome! Here are some basic steps to help you get started with billing.

1. Familiarize Yourself With the DHHS Web Site and Sign up for Email Notifications

The Medicaid Provider homepage is at: www.dhhs.ne.gov/med/provhome.htm. Take some time to review the information posted and use the site as your reference. The “Recent Web Updates” link allows you to check for recent postings, but we strongly encourage all providers to enroll to email notification with the “Subscribe to this page” feature. After subscribing, you will receive notification when Medicaid information is updated or added to the web site.

2. Sign Up for Direct Deposit of your Medicaid Payments

Electronic funds transfer (EFT) saves time and money. We are beginning to phase-in mandatory EFT requirements for all providers and encourage you to sign up now. For instructions and a printable form, go to: www.dhhs.ne.gov/med/edieft.htm.

3. Familiarize Yourself with Your Medicaid Provider Handbook

Handbooks are published on the DHHS website at: www.dhhs.ne.gov/med/ph.htm. Each handbook includes three sections: Regulations, Appendices and Provider Bulletins

Regulations include: information about program administration (Chapter 1), provider participation (Chapter 2), payment (Chapter 3) and one or more chapters about the type of service you are enrolled to provide.

Appendices include: billing instructions, procedures, forms, explanations of reports, fee schedules, how to check client eligibility, etc.

Provider Bulletins are issued as needed. The bulletins that apply to the services you provide are included with your Provider Handbook.

4. Review General Billing Instructions

Consider submitting claims electronically. You will see the benefits of immediate receipt, fewer denials and faster payment. It will assist DHHS in moving toward a more efficient payment system. Dental, institutional and professional claims can be submitted to Medicaid electronically, including claims with third party payment information, paper attachments, and even claim adjustments.

Billing instructions are included in your Provider Handbook. If you submit paper claims, make sure every claim includes the correct information in each field. Minor billing omissions or errors are the number one reason your claim will not process quickly and accurately. If you submit electronic claims, you will also need to review the Implementation Guides and Nebraska Medicaid Companion Guides on the EDI web page at www.dhhs.ne.gov/med/edireq.htm. The web site also includes frequently asked questions and EDI report examples.

5. Review Service-Specific Coverage and Billing Instructions

Claims for certain services require special documentation. You will find these requirements in Chapters 1, 2, 3, the chapter for the type of service you provide, the general billing instructions, fee schedules, and Provider Bulletins. If you are unsure or unclear about billing requirements, contact your Medicaid Program Specialist. A contact list is posted on the website at www.dhhs.ne.gov/med/contacts.htm.

6. Review Billing Instructions for Medicare Crossover Claims

If you provide Medicare-covered services to dual-eligible clients, remember that Medicare will automatically send (“crossover”) your claims to us for processing and payment of coinsurance and deductible. Do not send us a claim unless the service you provided is one that is never covered under Medicare.

It is important that we have your Medicare provider number or we cannot process the claims sent to us from Medicare. Also, remember that each Medicare provider identification number is linked to a single Nebraska Medicaid provider number for processing crossover claims. You may need to specify that provider number when checking status of your Medicare crossover claims.

7. Establish Your Claim Tracking System

Important Medicaid claim information and dates to track for each claim includes:

• Patient Name, Medicaid ID Number, Date of Service, and Patient Account Number

• Date Initial Claim Submitted to Medicaid

• Date and Reason Claim Returned (or Rejected, for electronic claims), and Date New (Replacement) Claim Submitted

• Date and Reason Claim Deleted, and Date New (Replacement) Claim Submitted

• Date Claim Reported on “Medicaid Claims In Process Over 30 Days” Report.

• Date Remittance Advice Received, Status (Paid or Denied), Payment Amount and Denial Reasons

• Date Claim Adjustment Submitted, Date Response Received, and Status (Paid or Denied)

Of course, if your patient also has Medicare or private insurance, you will need to track date submitted to insurance, date insurance remittance advice received, insurance adjudication status (paid or denied), denial reason, date of appeal, etc.

8. Track Status of Your Initial Claim Submission

After you submit your first claim, do not send in a duplicate claim unless you have received notice that your first claim could not be entered or processed (see #9). If you submit a duplicate claim, it will be denied as a duplicate billing.

Most claims are processed in less than 30 days, however some claims take longer than 30 days. One of the best ways to follow claim status is to review your “Medicaid Claims In Process Over 30 Days” report. This report lists all claims that have been in process for over 30 days. It is mailed to your payment address each week for institutional claims and monthly for professional and dental claims. The monthly report is printed on the last Saturday of each month. Claims that have been in process for less than 31 days will not appear on the report.

If your claim does not appear on the report as expected, or if your claim was listed on a prior report and is no longer on the report, the claim was either processed (check your Medicaid remittance advice) or deleted (check your deleted claim report). Remember, if your claim was returned, rejected or deleted, and you submitted a new (replacement) claim, the 30-day timeframe starts again with receipt of the new claim. If you are unable to locate a claim on the report, contact Medicaid Inquiry (877-255-3092).

9. Watch For Notices about Returned, Rejected or Deleted Claims

After you submit a claim, you may receive a notice telling you that your claim could not be entered and/or completely processed. Following is an explanation of each notice and what you need to do:

• “Medicaid Claim Return Notice:” This notice is sent with paper claims if we are unable to enter the claim for processing because information on the claim is missing or invalid. The original paper claim is returned (mailed) to the address on the claim. The notice explains the reason the claim could not be entered. What you should do: If a claim is returned, make corrections on the claim or complete a new claim and submit it within one year from the date of service.

• “Deleted Medicaid Claim Report:” This report lists paper claims that were unable to be processed completely. The claims on this report were successfully entered, but certain problems with the claim prevent us from finalizing processing. We call this a deleted claim. This notice of deleted paper claims is sent to your payment address. It lists each claim and reason for deletion. It is important to understand that deleted claims are not considered ‘denied’ claims; they are claims that must be corrected and reprocessed. What you should do: If a claim is deleted, submit a new claim within one year from the date of service. All claim attachments initially sent with a deleted claim must be attached to the new (replacement) claim. Attachments to deleted claims are not used in processing the new claim.

• “Electronic Claim Activity Report:” This notice is for electronic claims. It includes both rejected and deleted claims. It is sent to your electronic submitter/clearinghouse. The claims listed in the Rejected Claims section of the report are those that could not be loaded for processing because data is invalid or incorrectly formatted. Claims listed in the Deleted Claims section of the report are those with problems that prevented final adjudication. The reasons for rejection and deletion are listed on the report. What you should do: If a claim is rejected or deleted, submit a new claim within one year from the date of service. All claim attachments initially sent with a deleted claim must be attached to the new (replacement) claim. Attachments to deleted claims are not used in processing the new claim.

10. Review Your Medicaid Remittance Advice and Follow Up Promptly

The “Medicaid Remittance Advice” is issued when claims have completed adjudication. These claims can be paid or denied (paid at $0). The remittance advice includes information to identify the claim, the Medicaid claim number, payment amount, and denial reasons. The denial reasons on your remittance advice are national Claim Adjustment Reason Codes and Remittance Advice Remark Codes. These national codes are listed on the following website: www.wpc-edi.com/codes. What you should do: If your claim was denied, billed incorrectly or was not processed as expected, follow up immediately with a Claim Adjustment Request.

11. Understand How to Submit Claim Adjustment Requests

Familiarize yourself with the Claim Adjustment Request procedures in your Provider Handbook ( 471-000-99). The adjustment request must be received within 90 days of the date on the Medicaid Remittance Advice. (There are certain exceptions to the 90-day time limit, for example, situations with third party liability or other extenuating circumstances.) What you should NOT do: After a claim has been reported on the Medicaid Remittance Advice, do not resubmit the claim. It will be denied as a duplicate.

12. Track Your Claim Adjustment Requests

When we receive your adjustment request, the date of receipt is recorded. Processing of claim adjustments usually takes longer than initial claim processing, sometimes up to 60 days.

To make sure we received your adjustment request, call Medicaid Inquiry at 877-255-3092 or 471-9128 before the end of the 90 day time limit. When calling, tell the customer service representative that you are checking on an Adjustment Request. Have the Medicaid claim number (from the Medicaid Remittance Advice) ready.

After processing your adjustment request, you will receive one of two responses. Claim adjustment requests that are approved and result in payment changes are reported on the “Medicaid Remittance Advice.” Claim adjustment requests that are denied are reported on a paper “Medicaid Claim Adjustment Denial Notice” mailed to your payment address.

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I need help coding my claims. Who can I ask?

First, review the billing instructions in your Provider Handbook. Nebraska uses national code sets for procedures, procedure code modifiers, diagnosis and most other claim information. The specific code sets used are outlined in billing instructions.

For help with coding medical equipment and supplies, use the Centers for Medicare and Medicaid Services (CMS) website at http://www3.palmettogba.com/dmecs/do/home.

As the provider, it is your responsibility to appropriately and accurately code your claims. If you have questions about billing requirements, contact your Medicaid Program Specialist.

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I submitted my claim, but I haven’t heard anything. What should I do?

Claims that have been entered into the Medicaid claims processing system go through a series of edits and reviews to determine if the claim is payable. During this time, they are referred to as “instream,” “pending,” or “not finalized.”

To check status of processing claims, review your “Medicaid Claims In Process Over 30 Days Report” or contact Medicaid Inquiry at 877-255-3092 or 471-9128.

To help us process your claims as quickly as possible –

• While a claim is processing, do not submit a duplicate or replacement claim. Receipt of a duplicate claim delays processing of both the original and duplicate claim and results in denial of the duplicate claim.
• Submit a duplicate or corrected claim copy only after notice has been received that the original claim was returned, rejected, or deleted.
• Do not submit a duplicate claim if you received a notice of denial on your Medicaid Remittance Advice.  Send an Adjustment Request for review of the denied claim.

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Medicare paid my claim. Do I need to submit a claim to Medicaid?

After Medicare processes claims, they are electronically “crossed over” to Medicaid. Your Remittance Advice from Medicare will include a remark telling you the claim was forwarded to Medicaid. If it has been forwarded, please do not send another claim.

Medicaid will process the electronic claim and pay the Medicare coinsurance and deductible amounts due. If Medicare denied a service, Medicaid will not pay for it on the “Medicare Crossover” claim. In some cases, you may submit the service on a separate paper or electronic claim. See your Provider Handbook ( 471-000-70) for details.

If you do not receive payment of coinsurance and deductible within 45 days of the Medicare payment, contact Medicaid Inquiry to determine status.

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My claim was ‘deleted’. What is a deleted claim? What should I do?

Some claims processing requirements do not allow a claim to be finalized. These claims must be deleted from the Medicaid claims processing system. If the deleted claim was submitted on paper, you will receive notice on a “Deleted Medicaid Claims Report.” Deleted electronic claims are reported on the “Electronic Claim Activity Report” sent to your electronic submitter/clearinghouse. The reason for deletion is listed on the reports.

If your claim was deleted, it does not mean it was denied. Instead, your claim had certain problems that need to be addressed before it can be processed. A new, corrected claim must be submitted within one year from the date of service. If your deleted claim had attachments, be sure to send the attachments with your replacement claim. The attachments to the deleted claim cannot be used to process the new claim.

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My claim was denied. What should I do?

First, look at the type of notice you received.

• If your claim was reported on your Medicaid Remittance Advice and one or more lines were paid at $0.00, then your claim was denied. You must submit a claim Adjustment Request within 90 days from the date of the Medicaid Remittance Advice. In this case, please do NOT submit a new claim. (See “What is an Adjustment Request? How Do I Submit One?”)
• If your claim was not reported on your Medicaid Remittance Advice, it was not ‘denied.’ Your claim was either returned, rejected, or deleted. In these cases, you will need to submit a new claim.

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What are the codes on your Remittance Advice and other reports?

Nebraska Medicaid uses national codes for reporting on the electronic remittance advice and other reports. Go to Washington Publishing Company (WPC) HIPAA Code List to connect to the web site where the national codes are maintained.

• Medicaid Remittance Advice uses “Claim Adjustment Reason Codes” and “Remittance Advice Remark Codes.”
• Medicaid Deleted Claims and Medicaid Electronic Claim Activity (ECA) reports use: “Claim Status Codes” and “Claim Status Category Codes.”

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What is an Adjustment Request? How do I submit one?

If you need to change the information on a paid claim or request reconsideration on a denied claim, you must submit an Adjustment Request. The request must be received within 90 days of the date on the Medicaid Remittance Advice.  There are certain exceptions to this time limit, such as for claim denials related to third party resources.

Adjustment requests must be clearly marked and contain the following information: Client ID, provider ID, date of service, Medicaid claim number and the reason the adjustment is being requested. A copy of the Medicaid Remittance Advice is preferred. A new claim should never be submitted as an ‘adjustment request’ or to correct a claim that has been reported on your Remittance Advice.  For complete instructions, see 471-000-99.

Approved claim adjustment requests that result in payment changes are reported on the “Medicaid Remittance Advice.” Denied claim adjustment requests are reported on a paper “Medicaid Claim Adjustment Denial Notice” sent to your ‘pay-to’ address.

To make sure we received your adjustment, you may call Medicaid Inquiry at 877-255-3092. They will not be able to give you the status, but will be able to verify receipt. Remember to check before the 90-day time limit expires.

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What is the “Deleted Medicaid Claims” report?

This report is your notice of paper claims deleted from the Medicaid claims processing system. The reason(s) each claim was deleted is printed on the report. The report is mailed each week if you have claims that were deleted the previous week. The report is mailed to your ‘pay-to’ address, the same address used for your Medicaid Remittance Advice.

If the Medicaid Provider Number on your claim is incorrect, the claim will not be listed on the report. A notice of these deleted claims will be mailed to the address on your claim.

Review the report weekly and submit a new, corrected claim, if needed. If the deleted claim had attachments and you will be sending in a new, corrected claim, make sure all the original attachments are sent with the new claim.

For an example and explanation of this report, see 471-000-127 (for CMS1500, dental and nursing home turnaround claims) and 471-000-129 (for CMS1450 and electronic 837 Institutional claims).

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What is the “Medicaid Claims In Process Over 30 Days” report?

This report lists your paper and electronic claims in process that were received at least 30 days prior to the report date. The report mailed to your payment address and is sent only if you have claims in process over 30 days. The report is mailed weekly for institutional claims and monthly (on the last Saturday of each month) for professional claims.

If your claim does not appear on the report as expected, or if your claim was listed on a prior report and is no longer on the report, the claim either completed processing (check your Medicaid Remittance Advice) or was deleted (check your Deleted Medicaid Claims report). Remember, if your claim was returned, rejected or deleted, and you submitted a new claim, the 30-day timeframe starts again with receipt of the new claim. If you are unable to locate a claim on the report, contact Medicaid Inquiry (877-255-3092).

For an example and explanation of this report, see 471-000-128 (for CMS1500, dental, nursing facility turnaround and electronic 837 Practitioner and Dental claims) and 471-000-129 (for CMS1450 and electronic 837 Institutional claims).

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What is the “Medicaid Remittance Advice” report?

This report shows processed/finalized claims, refunds, and processed claim adjustments. The remittance advice may be sent on paper or electronically. For an example and explanation of the report, see 471-000-85.

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Why was my electronic claim ‘rejected?’

Electronic claims are initially processed through software that verifies the claim data is in the correct format. Claims that do not meet these requirements are rejected before entry into the Medicaid claims processing system. Rejected claims are reported on the “Electronic Claim Activity Report” sent to your electronic submitter/clearinghouse. If a claim is rejected, a new claim must be submitted within one year from the date of service.

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Why was my paper claim returned?

Paper claims are screened as soon as they are received. Claims are returned if they are missing information required for entry into the Medicaid claims processing system. The original claim is returned to the provider address printed on the claim. A “Medicaid Claim Return Notice” is attached explaining the reason the claim could not be accepted. You should correct the claim or submit a new claim within one year from the date of service.

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