Benefits And Eligibility Verification
Network Provider Verification
Benefits And Eligibility Verification
1. How does a provider verify benefits?
If you are calling to verify insurance benefits, patient eligibility, or payment status on a claim, please contact the claim administrator. The phone number for the claim administrator is listed on the member’s insurance ID card under benefit eligibility or benefit verification.
2. Can MedCost verify patient eligibility?
MedCost is not the insurance company, and we do not have information about members and dependents in our system. When a claim is received, we verify that the company participates with MedCost using the employer’s group identification number. This allows us to forward repriced claims to the appropriate claim administrator.
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1. Is pre-certification required? What number does a provider call for pre-certification?
Certification requirements are stated on the insurance card along with the number to call for pre-certification. Phone numbers for precertification also can be found in the MedCost Reference Guide.
2. How does a provider complete a pre-certification request for a MedCost member who uses MedCost Health Management?
A provider can log in to access the following online Health Management tools:
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- Client Query – used to verify whether MedCost performs Utilization Management for
an employer group
- Web Certification – used to initiate certification of an inpatient acute care stay or certain outpatient procedures; tool walks providers through the pre-certification process and all necessary information
- Certification Status –used to verify whether a medical procedure has been certified, non-certified, or is still in process.
1. Where should medical claims be filed?
If you are a participating MedCost provider, you can file claims to MedCost electronically using our EDI filing number, 56162; or mail claims to MedCost, P.O. Box 25307, Winston-Salem, NC 27114-5307. All other providers should mail claims to the out-of-network claim mailing address listed on the patient’s ID card.
2. What is MedCost’s Payer ID number?
56162 Location: 2010BB, NM109, Data Element 67
3. Which HIPPA transactions does MedCost support?
MedCost supports Claim Submission (837) for receipt and repricing of claims, which are then forwarded to the appropriate claim administrator for payment. The claim administrator should offer other HIPPA transactions, such as Claim Status (276/277), Electronic Remittance Advice (835), Eligibility (270), and Precertification (278).
4. Who is our contact for electronic claim filing issues?
Please call our Customer Service Contact Center at 1-800-824-7406, Monday-Friday between the hours of 8:30 a.m.-5 p.m. EST.
5. Why do claims come to MedCost?
If you are a participating MedCost network provider, claims are sent to MedCost to be repriced to your network contracted rates. The claims are then sent to the appropriate claim administrator for payment.
6. How can a provider verify if claims have been received and repriced?
The average turnaround for claim repricing is less than 2 days, but MedCost recommends that you allow an additional 30 days for the claim administrator to process your claim. If you are a participating provider in the MedCost network, you should register to access our web tools for easy claim follow-up:
- Provider Claim Activity Report– This report contains information on repriced and non-repriced claims and can be run daily, weekly or monthly for all claims or by a specific member.
- Claims Repricing Inquiry – This tool can be used to verify MedCost’s receipt of a claim, determine the discount amount, and review any messages from MedCost regarding your claims. A "Contact MedCost" feature allows you to provide patient policy information on non-repriced claims without refiling the claim to MedCost and also make requests to have non-received claims sent to the payer. With this tool, you can find contact information and links to websites for over 45 payers who provide online claim status. (Click here to view a demo of the Claim Repricing Inquiry.)
- MedCost Reference Guide – This resource gives providers information on all active, as well as inactive, companies that access or previously accessed the MedCost PPO network. It includes company name, group number, effective and termination dates, claim administrator name and web site, eligibility phone number, and pre-certification vendor and phone number. (Available as an Adobe Acrobat PDF file.)
If you have not registered yet to use our online tools, click here to sign up and gain access to these valuable resources. You also can request a password by calling our Customer Service Contact Center at 1-800-824-7406, Monday through Friday, 8:30 a.m.-5:00 p.m. EST.
7. How are providers notified about claims that are not repriced?
Claims that cannot be repriced can be found on the send back portion of the Provider Claim Activity Report, or a paper claim may be returned to your office with a cover sheet indicating the reason for no repricing. You also will be notified of a claim that could not be repriced when using the online MedCost Claim Repricing Inquiry tool. MedCost’s web tools are vital for managing your account.
8. Why does MedCost require group name and group number on claims?
Employers determine the group/policy numbers assigned for their specific group, and sometimes the same group/policy number can be assigned by another employer, resulting in duplicate policy numbers. Therefore, MedCost uses the group name along with the group/policy number to ensure that your claim is processed under the correct group and delivered to the correct claim administrator for payment. If the group name is not provided on a claim that has a duplicate policy number, the claim will be returned to the provider for this information, creating unnecessary delay.
9. Where is a listing of employer groups and their corresponding employer group numbers?
MedCost publishes a Reference Guide that lists all employer groups accessing the MedCost network and includes the group number, effective and termination dates, claim administrator name and web site, eligibility phone number, and pre-certification vendor and phone number. No benefit information appears in the Reference Guide. Your office may download the Reference Guide through our Provider Web Applications. To learn more about the Reference Guide and the Provider Web Applications, please click here.
10. Is a MedCost member entitled to receive the MedCost discount for non-covered services?
Participating providers agree to accept the MedCost allowable for non-covered services. See the Provider Manual for more information.
11. Where can I find information about claim repricing guidelines?
Please refer to the MedCost Provider Manual for detailed information regarding our claim repricing guidelines.
12. 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.
13. How do modifiers affect MedCost repricing?
Only a few modifiers affect MedCost repricing. For a complete list and a detailed explanation of each, please refer to the MedCost Provider Manual.
14. Who pays providers’ medical claims?
Payment for medical claims is issued by the claim administrator indicated on the patient’s identification card or the explanation of benefits.
15. How do I check claims payment status?
Our web site includes direct links to more than 45 claim administrators who have online claim status. To view the list of claim administrator web links, please click here. This list is updated regularly. If the claim administrator is MedCost Benefit Services, click here to login and check status.
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1. What is MedCost’s (re)credentialing process?
Before a provider can be added to the MedCost Network, he or she must be credentialed and approved. MedCost requires that all providers meet our credentialing criteria during the initial and re-credentialing process, including the verification of active and approved licensure and accreditations. New applicants will be notified within ten (10) business days of completion of credentialing and approval by the MedCost Credentialing Committee. A provider is not considered a participant in the MedCost PPO program until the credentialing process is complete and a letter is sent to your practice indicating the provider’s effective date. Please note that MedCost does not assign retro-effective dates.
Participating providers are re-credentialed every three (3) years. MedCost notifies providers by letter when re-credentialing is due; it is extremely important that the re-credentialing information is returned as soon as possible to avoid possible termination. Providers should consider themselves to be re-credentialed unless otherwise notified.
If you utilize CAQH, we will obtain your credentialing information directly from the UPD. To avoid credentialing delays, please review/update your information every 120 days as requested by CAQH to ensure that it is complete and accurate. Any attached documentation should also be reviewed to make sure that nothing has expired.For your Certificate of Liability Insurance, it is important to upload a copy of the actual policy in addition to completing the information in the CAQH application.
For more information about credentialing or re-credentialing, please refer to the Provider Manual on our web site. The MedCost credentialing program has been accredited by URAC since 2000.
2. How can a provider obtain information about the status of a credentialing application?
MedCost strives to complete applications within 30 days; per the NC Department of Insurance, MedCost has up to 60 days. Providers can obtain information about the status of their credentialing applications at any point during the credentialing or re-credentialing process by calling our Customer Service Contact Center at1-800-824-7406. For more information about credentialing or re-credentialing,please refer to the Provider Manual on our web site.
3. Will MedCost make an effective date retroactive?
MedCost cannot make an effective date retroactive. The effective date given is the date on which the credentialing process is completed.
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Network Provider Verification
1. How can you verify if a provider is in the MedCost network?
You can easily search our online directory of in-network providers. This provider database is updated monthly. Click here to access our online provider directory. You also can verify participation by calling MedCost’s Customer Service Contact Center at 1-800-824-7406.
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1. How does MedCost keep providers up-to-date on procedural changes, company news, and other pertinent topics?
MedCost sends important news and information to our providers electronically, including quarterly issues of the Provider Connection newsletter. If you would like to receive these communications directly to your inbox, click here. Please include your name, practice name, tax ID, and phone number in the body of the e-mail.
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To view the current edition of the Provider Connection online or access past editions, please click here.
1. How does a provider register to use MedCost’s online tools?
Click here to begin the registration process. MedCost issues only one administrative user ID per practice, based on a practice’s tax ID. Once this ID has been registered, the administrator then can create and/or delete staff accounts to give access to individual staff members for one or all of our web services. There is no limit to the number of staff accounts that can be created.
You should receive your user ID and temporary password within 48 business hours after registering. It will be sent to the e-mail address supplied during registration, so please make sure to enter a valid email address. If you do not receive a user ID and temporary password within the 48-hour time frame, please click here to contact us or call our Customer Service Contact Center at 1-800-824-7406. Please include your name, practice/facility name, Tax ID and phone number in the body of the email.
2. Can more than one person in a practice have an administrative user ID?
We can issue only one administrative user ID since it is based on a practice’s tax ID. This also allows MedCost to have a main contact person for any questions or issues concerning the web site. However, there is no limit to the number of staff accounts that can be created.
3. How can a provider request information regarding an administrative account?
If you are unsure of the previous administrator’s login information or if the administrator is no longer with your practice, please click here to contact us or call our Customer Service Contact Center at 1-800-824-7406. Please include your name, practice/facility name, Tax ID and phone number in the body of the email.
4. What is the process for obtaining a staff account?
Please contact your Supervisor/Office Manager first to request a staff user ID and password. If he/she is not sure your practice is registered, or has forgotten the administrative user ID and password, please click here to contact us or call our Customer Service Contact Center at 1-800-824-7406. Please include your name, practice/facility name, Tax ID and phone number in the body of the email.
5. Who should be contacted if a user ID and/or password is forgotten or lost?
If you are the administrator of the account and have forgotten your password, please select the “Forgot Password” link on the Log in page and enter your user ID. If you have lost your administrative user ID, please click here to contact us or call our Customer Service Contact Center at 1-800-824-7406. Please include your name, practice/facility name, Tax ID and phone number in the body of the email.
If you have a staff account and have lost your user ID/password, please contact your Supervisor/Office Manager or staff administrator.
6. Can the same administrative user ID and password work for multiple practices?
If you have a large group with multiple practices under the same or different tax IDs and would like online access using only one administrative user ID, please contact us. To process this request, we will need the name of the practice(s), address(es), tax ID(s)and your contact information.
Many of the answers above also can be found in our Provider Manual. If you have any other questions, please call our Customer Service Contact Center at 1-800-824-7406, Monday –Friday, 8:30 a.m. – 5:00 p.m. EST.
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