MaineCare General E-Message - June 09, 2016

Reminder When Billing MaineCare as Secondary Payer

 

When billing MaineCare as a secondary payer, please attach an Explanation of Benefits (EOB).  You must also include the Primary Carrier paid date on the claim. This is required for billing MaineCare by all claim submission methods (electronic data interchange, direct data entry, or paper).  The claim will be denied if either one are missing. 

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Issue Corrected: Claims Denying for No Prior Authorization (PA): Incorrect PayTo National Provider Identifier (NPI), CR 56406

The issue where claims were denied for no PA with an incorrect denial reason has been corrected.  Affected claims will be reprocessed.

Please see the e-message from April 1, 2016 that originally described this issue:

Claims Denying for No Prior Authorization (PA): Incorrect PayTo National Provider Identifier (NPI), CR 56406

We have discovered an issue where claims are denying for no PA correctly but the reason given is incorrect. They are denying with the incorrect Remittance Advice Remark Code (RARC) 45: “Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement. Note: This adjustment amount cannot equal the total service or claim charge amount; and must not duplicate provider adjustment amounts (payments and contractual reductions) that have resulted from prior payer(s) adjudication. (Use only with Group Codes PR or CO depending upon liability).”

In many instances, these claims are denying because the PayTo NPI submitted on the claim does not match the PayTo NPI on the authorization. An analysis of claims has revealed that, although the PayTo NPI used on the claim is incorrect, it is a PayTo NPI associated to the same entity that is on the authorization. As a reminder, when requesting a PA, you must ensure that the PA request has the same PayTo NPI as the PayTo NPI used when billing for the service.

Claims should have denied for no PA with the following Claim Adjustment Reason Code (CARC) and RARC: 

• CARC 15 - “The authorization number is missing, invalid, or does not apply to the billed services or provider.”
• RARC N517 – “Resubmit a new claim with the requested information.”

We will notify you when this issue has been corrected. When it’s corrected, the claims will be reprocessed to deny with the correct CARC and RARC and you will be able to resubmit affected claims at that time.