1. How can I become a contracted claim administrator with MedCost?
If you are a claim administrator interested in utilizing the MedCost Network or Health Management programs, please click here for more information.
2. What is the process for notifying MedCost of new business?
Please notify MedCost of new business by completing a New Client Form. Instructions for submission are listed on the form.
3. Where should I submit a change of address for a company or claim administrator?
Click here to submit address changes.
4. What is the process for notifying MedCost of employer terminations?
Please notify MedCost of employer group terminations by completing a Termination Form. Instructions for submission are listed on the form.
5. What is considered late notification for additions and terminations?
If a request to add or terminate a client is received 30 or more days after the requested effective or termination date, it is considered late. For incomplete forms, the date of receipt is the date that MedCost is provided with all the information necessary to process the request.
6. Why would a company not show as being effective in the MedCost system?
Companies are added to the MedCost system but not assigned an effective date when:
- An ID card is not provided to MedCost with the New Client Form, or an ID card is provided that does not meet our criteria.
- A New Client Form has not been received from the claim administrator.
- Benefit plan information is not fully completed on the New Client Form.
1. How does MedCost calculate the cost to savings ratio?
The cost to savings ratio is your savings divided by the administration fees paid. This number shows the total dollars saved for every dollar spent for network access.
2. What accreditations does MedCost have?
MedCost is accredited by URAC in Utilization Management and Provider Credentialing.
1. What geographical areas does the MedCost Network cover?
MedCost’s network of providers is located primarily in North and South Carolina. We also cover border counties in Virginia and Georgia.
2. How do I verify whether a provider is in the MedCost Network?
Click here to easily search for in-network providers using our online provider directory. (The directory is updated monthly.) You also can verify a provider’s participation in the network by calling our Customer Service Contact Center at 1-800-824-7406.
3. How can I get provider directories?
MedCost does not offer preprinted provider directories. You can download a statewide directory by specialty or a custom directory based on a user’s zip code through our online provider search option. Click here to access the online provider directory. (Directories are downloaded as PDFs.)
1. What clinical criteria does MedCost use to make certification decisions?
Our experienced team of registered nurses collects the medical information and reviews it against MCG (formerly Milliman Care Guidelines). These guidelines are developed by health care professionals and based on actual practices of clinical care providers throughout the United States. MCG outlines the most efficient treatment for a given condition and the typical progress that patients can expect.
2. Who makes "medical necessity" decisions?
If there is any question of medical necessity after our registered nurses have reviewed the medical information against MCG (formerly Milliman Care Guidelines), the information is reviewed by a physician. MedCost has a panel of over 70 consulting physicians who are board certified in various specialties and are in active practice.
1. Is a MedCost member entitled to receive the MedCost discount for non-covered services?
Most participating providers agree to accept the MedCost allowable for non-covered services.
2. How do modifiers affect MedCost repricing?
Only a few modifiers affect MedCost repricing.
|| Effect on MedCost Repricing
|| Allows unrelated evaluation and management services by the same physician during a postoperative period.
|| Allows significant, separately identifiable evaluation and management service by the same provider on the same day as other procedures.
|| If no allowable has been established reduces the MedCost allowable to 40% of the global allowable.
|| If no allowable has been established reduces the MedCost allowable to 60% of the global allowable.
|| Reduces the MedCost allowable to 150% of the global allowable.
|| Reduces the MedCost allowable to 50% of the global allowable.
|| Allows the evaluation and management service when billed on the same day as a non-starred surgical service.
|| Reduces the MedCost allowable to 20% of the global.
|| Reduces the MedCost allowable to 14% of the global.
|| Reduces the MedCost allowable to 14% of the global.
3. Is MedCost repricing affected by global periods?
Our current repricing system does not provide the analysts with global days. However, should a single claim be filed with inpatient E&M codes and surgery, the E&M codes will be reduced to zero on the day of the surgery and every day following until discharge.
4. What is a MedCost QuickClaim?
A MedCost QuickClaim is a paper printout of a claim that contains the MedCost repricing. You will receive a QuickClaim when we are unable to transmit the claim to you electronically.
5. Do you support coding software?
MedCost does not have an online coding software product. Please click here if your organization wishes to implement coding software.
6. What is MedCost’s EDI Payer ID number?
7. How do I start to receive claims electronically from MedCost?
MedCost routes repriced physician and facility claims via a clearinghouse. Click here to request more information.
8. How do I handle misdirected MedCost participating provider claims?
Misdirected claims filed on a standard CMS1500 or UB-04 form should be mailed to MedCost at the following address:
PO Box 25307
Winston-Salem, NC 27114
9. Whom do I contact for Priority Claim Repricing Requests?
For priority requests, please call MedCost’s Customer Service Contact Center at 1-800-824-7406.