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The purpose of this bulletin is to provide additional information and resources to ensure Medicaid providers file accurate claims, which will increase timely reimbursement. 

How can providers prevent claim denials?

1. Confirm member eligibility and bill the correct plan for the dates of service (i.e. fee for service or Cardinal Care Managed Care (“CCMC”) plan).

2. Ensure all required information is included on the claim.

3. Confirm that all information is accurate.

Examples: Member/Patient full name, date of birth, Cardinal Care ID #, Provider Name, Provider NPI #, CPT codes, modifiers, dates(s) of service, service authorization number (if applicable), etc.

1. Submit all claims before the deadline. See below for MCO links. 

2. Review DMAS fee for service claims and billing information and instructions that can be found at: Claims and Billing (virginia.gov) 

What if a denial has been received?

1. Review : DMAS Claim Denial and Edit Codes with Description and Resolutions – 2023, which can be found at: Top 50 Billing Error Reason Codes With Common Resolutions (virginia.gov)

2. Providers should consider submitting a new claim that includes corrections on the claim. After reviewing the above link, if you are unclear about why the claim was denied, DMAS encourages you to contact the Provider Helpline at 1-800-552-8627 before correcting the claim. 

3. Resubmitted claims will be processed as quickly as possible (within 30 days or sooner). 

4. Providers can appeal claim denials.  Filing an appeal can be a lengthy process and can delay provider reimbursement. Many claims are denied due to missing or inaccurate information.  When an appeal is filed for a claims denial, it will only address the denial reason(s) set forth on the remittance advice. Filing an appeal does not correct the denial reason(s) nor does an appeal involve reprocessing claims. If you are seeking to correct your claim, do so and resubmit your claim with the claim corrections for payment rather than filing an appeal.  If another denial is received, that remittance advice will carry new appeal rights.  Appeal information is available at Provider Medicaid Appeals (virginia.gov)

Additional Resources

For more information on claims and billing information, including resolving claim denials, please visit Claims and Billing (virginia.gov)

The Virginia Medical Assistance MediCall System offers Medicaid providers twenty-four-hour-a-day, seven-day-a-week access to current member eligibility information, check status, claims status, prior authorization information, service limit information, pharmacy prescriber identification number cross reference, and information to access member eligibility and provider payment verification via the Internet.  Please visit How to Use the MediCall System (virginia.gov) for instructions on how to use the Medicall System.

The telephone numbers are: 

1-800-772-9996 Toll-free throughout the United States 

1-800-884-9730 Toll-free throughout the United States 

1-804-965-9732 Richmond and Surrounding Counties 

1-804-965-9733 Richmond and Surrounding Counties 

If you have any questions regarding the use of MediCall, contact the Medicaid Provider “HELPLINE.” The HELPLINE is available Monday through Friday from 8:30 a.m. to 4:30 p.m., except State holidays, to answer questions. 

The HELPLINE numbers are: 

1-804-786-6273 Richmond Area and out of state long distance 

1-800-552-8627 In state long distance (toll-free)

CLAIMS STATUS 

For claims status information, the MediCall system will prompt the Provider to Press 2 to check claims status.  Then the Provider can choose among the following invoice types to check claims status. 

• Press 01 for inpatient care 

• Press 02 for long-term care

• Press 03 for outpatient hospital, home health or rehabilitation services

• Press 04 for personal care 

• Press 05 for practitioner (physician CMS-1500 billing)

• Press 06 for pharmacy 

• Press 08 for independent labs (outpatient lab services)

• Press 09 for Medicare crossover 

• Press 11 for dental

• Press 13 for ambulance transportation (Not NEMT) 

 For claims status, the “from date” cannot be more than 365 days in the past. The “thru date” cannot be more than 31 days later than the “from date”. After keying the member identification number and the “from and thru date(s)” of service, MediCall will provide the status of each claim up to and including five claims. MediCall will prompt for any additional claims or return to the main menu.