Benefits And Eligibility Verification
Electronic Funds Transfer
Network Provider Verification
Benefits And Eligibility Verification
1. How does a provider verify benefits or claim status?
If you need to verify insurance benefits or obtain the status of a claim, please contact the claim administrator. The phone number for the claim administrator is listed on the member’s ID card. This contact information also can be found in the MedCost Reference Guide under the Provider portal of the MedCost web site. You will need to login to access the Reference Guide. For claims that have been submitted to MedCost for repricing, use the online provider tools, including the Claims Repricing Inquiry, Reference Guide, and Physician Claim Activity Report, to obtain the claim administrator’s contact information. Information specific to claim administrators that offer online claim status and/or eligibility information can be found on the Provider portal under the “Payers with Online Claims Status” section.
2. Can MedCost verify patient eligibility?
MedCost is unable to verify patient eligibility since we are not the claims administrator and do not have information about members and dependents in our repricing system. When a claim is received, we verify that the employer group participates with MedCost using the employer’s group identification number and reprice the claim. Repriced claims are then forwarded to the appropriate claim administrator for adjudication.
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Electronic Funds Transfer (EFT) and Electronic Remittance Advice (ERA)
1. Do the Transaction Operating Rules that were implemented on January 1, 2014, and are specific to Electronic Funds Transfer (EFT) and Electronic Remittance Advice (ERA) impact MedCost?
The Affordable Care Act (ACA) requires all HIPAA-covered entities, which includes clearinghouses, health care providers, and health plans, to be compliant with any applicable HIPAA standards that are associated with operating rules.
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There are three phases to the operating rules that were created by the Committee on Operating Rules for Information Exchange (CORE). CORE is an initiative that was implemented by the Council for Affordable Quality Healthcare (CAQH). The Operating Rules support electronic eligibility and claim status inquiries by streamlining and bringing uniformity to the administrative transactions between health care providers and health plans. They are an addition to the existing standards that make electronic transactions more predictable and consistent.
Phase III of the Operating Rules was implemented on January 1, 2014, and is specific to electronic funds transfers (EFT) and Electronic Remittance Advice (ERA) - 835. As of April 1, 2014, penalties may be assessed against a health plan that has failed to meet the certification and compliance requirements for standards and operating rules for electronic transactions.
MedCost’s claim administrator partners were compliant as of January 1, 2014. With some claim administrators, enrollment for EFT happens automatically, but with others, you may need to contact the claim administrator directly to sign up for EFT. If you are uncertain about your EFT status with a MedCost claim administrator partner, please contact the claim administrator directly at the number located on the member’s ID card. For additional assistance, please call our Customer Service Contact Center at 1-800-824-7406. The contact information for MedCost claim administrators also can be found in the Reference Guide under the Provider portal on the MedCost web site.
1. Is precertification required? What number does a provider call for precertification?
Certification requirements can vary, depending on the employer group’s benefit plan and the procedure to be performed. You should contact the claim administrator directly to verify if precertification is needed. The precertification phone number is located on the member’s ID card. Phone numbers for precertification also can be found in the MedCost Reference Guide under the Provider portal on the MedCost web site. You will need to login to access the Reference Guide.
2. How does a provider complete a precertification request for a MedCost member who uses MedCost Health Management?
A precertification request can be completed online by visiting the Provider portal on the MedCost web site. Choose “Login” from the left menu, and click on the “Certification” link under the “Access Online Tools” section. If you do not already have a Health Management Applications login account, you can request one from the login page.
The tools you can access under this section of the website include:
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- Client Query – verify whether MedCost performs Utilization Management for an employer group
- Web Certification – initiate certification of an inpatient acute care stay or certain outpatient procedures; guides you through the precertification process and all necessary information
- Certification Status – 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 should file claims to MedCost electronically using our EDI filing number, 56162. If necessary, mail claims to MedCost, P.O. Box 25307, Winston-Salem, NC 27114-5307.
Non-network providers should submit claims to the out-of-network claim mailing address listed on the member’s ID card.
2. What is MedCost’s Payer ID number?
The MedCost payer ID is 56162. The location on the CMS claim form is 2010BB, NM109, Data Element 67.
3. Can MedCost accept the revised CMS 1500 claim form?
MedCost has been accepting the revised CMS 1500 form since February 2014.
4. 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).
5. Who is our contact for electronic claim filing issues?
Please call the MedCost Customer Service Contact Center at 1-800-824-7406, Monday-Friday between the hours of 8:30 a.m.-5 p.m. EST.
6. How can a participating provider verify if claims have been received and repriced?
You can verify if MedCost has received and repriced your claims by accessing the Claims Repricing Inquiry or the Provider Claim Activity Report under the Provider portal on the MedCost web site. Additional information regarding our online provider tools is shown below. You will need to login to access these tools. The average turnaround time for claim repricing is less than 2 days. MedCost recommends that you allow at least 30 days for the claim administrator to process your claim.
- 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 web sites for over many of our claim administrators that 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 Network. It includes company name, group number, effective and termination dates, claim administrator name and web site, eligibility phone number, and precertification 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?
Notification about claims that cannot be repriced can be found on the Provider Claim Activity Report (under the Non-Repriced section shown at the top) or by using the MedCost Claim Repricing Inquiry tool to check a specific claim. These online tools are vital for managing your MedCost account and can be accessed by selecting “Login” under the Provider portal on the MedCost web site.
8. Why does MedCost require group name and group number on claims?
MedCost does not maintain member level eligibility information, so we require group name and group number to ensure we process claims accurately. 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. To ensure that your claim is processed under the correct group and delivered to the correct claim administrator for payment, MedCost uses both the group name and group number. 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 payment delays.
9. Where can a provider obtain a list 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. 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?
Yes, participating providers agree to accept the MedCost allowable for non-covered services. See the "billing and Collection" section of MedCost Provider Manual for more information.
11. Where can I find information about claim repricing guidelines?
Please refer to the "Claims Filing" section of the MedCost Provider Manual for detailed information regarding our claim repricing guidelines.
12. Is MedCost repricing affected by global periods?
For claims 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 the patient is discharged.
13. How do modifiers affect MedCost repricing?
For a complete list and a detailed explanation of modifiers that affect repricing, please refer to the "Claims Adjustment Policies" section of 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. MedCost works with many self-insured, or self-funded, employer groups where the employer pays health claims with its own funds.
15. How do I check claims payment status?
Our web site provides direct links to many of our claims 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 Network 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. Providers will be notified that re-credentialing is due or, if you utilize CAQH, your information will be obtained directly from the Universal Provider Datasource (UPD). It is extremely important that the re-credentialing information is returned as soon as possible to avoid possible termination from the network. Providers are considered 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 also should 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 MedCost 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 based on the date that the credentialing process is completed. Any claims submitted and processed prior to the effective date will be considered out-of-network.
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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. 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 recent provider communications, please click here. Current and past provider communications are available under the "News" section of the Provider portal on our website.
1. How does a provider register to use MedCost’s online tools?
Click here to begin the registration process. Please note: If you are a new practice that has joined our network, you will receive a login and temporary password with your packet of information. You can use this to log into the web tools and begin accessing information.
MedCost issues only one administrative 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 30 minutes of registering. It will be sent from MedCost's Customer Service Web Services (firstname.lastname@example.org) to the e-mail address you supplied during registration. If you do not receive a user ID and temporary password within the 30-minute 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 click here and select the “Forgotten Your Password” link on the login page.
If you have a staff account and know your User ID, please click here select the “Forgotten Your Password” link on the login page.
If you have a staff account and have forgotten your User ID, you must contact your Supervisor/Office Manager or onsite administrator.
If you need to contact MedCost Customer Service Web Services, click here 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.
MedCost will review all accounts for activity every 3 months. If there has been no activity, a message will be sent to the e-mail address used to register the account. If no action occurs, the account will be purged.
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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