MedCost is the leading Preferred Provider Organization (PPO) in the Carolinas. We work alongside insurance companies to offer an extensive network of "preferred" providers who provide cost-effective health care services. For more information on MedCost, visit our About Us Section.

If you are calling to verify insurance benefits, patient eligibility, or payment status on a claim please contact the insurance company. The phone number is listed on the member’s insurance ID card under benefit eligibility or benefit verification.

Because MedCost is not the insurance company, we do not have information about members and dependents in our system. When a claim is received, we determine if the employer participates with MedCost. At MedCost, our system contains all participating employers and their group identification number. This allows us to forward applicable claims to the insurance company.

Identification cards are not issued by MedCost. MedCost currently has repricing contracts with over 100 claim administrators. While we make every effort to support the claim administrator by requesting specific elements that are unique to MedCost patients/participants, we have very little control over the format or specific headers on the card.

Participating MedCost providers can file electronic claims to MedCost. Our EDI filing number is 56162. Participating providers can also mail claims to PO Box 25307 W-S NC 27114-5307. All other providers please mail all claims to the out-of-network claim mailing address that is listed on the members ID card.

56162

MedCost negotiates with selected physicians, hospitals, and facilities to arrange reduced fees for a broad range of medical services. MedCost receives claims from our network providers, reprices the claims to these lower negotiated rates, then forwards the claims to the insurance company for payment.  

The average turnaround for claim repricing is less than 2 days. 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, repricing verification is provided to you on a weekly basis in your MedCost Provider Claim Activity Report or your MedCost Hospital Fee Reduction Report. This report will give you a record of all claims received and repriced at MedCost within the previous week. You will also receive a provider sendback report, which will give you a list of any claim that has not been repriced, along with instructions to refile or contact MedCost with information to expedite the handling of the claim.

You may also verify the repricing of a claim on-line via the MedCost Claim Repricing Inquiry Product. This product will allow you to review the following information about each claim filed to MedCost:

• Verify MedCost’s receipt of a claim.
• Determine the discount amount.
• Review messages from MedCost regarding your claims.
• Determine the claim administrator and obtain contact information.
• Claim detail information such as billed amounts and dates of service.

This product was designed to be user friendly and assist in the claims follow up process. In addition to verification of information, this product will allow you to complete tasks associated with claims follow up, including:

• Links to more than 45 claim administrators who have online status checks. If there is not a link provided, there will be other contact information.

• Information regarding your non-repriced claims can easily be sent to MedCost by using the “Contact MedCost” feature. Once the necessary information is received, MedCost will reprice and forward your claim to the administrator for payment consideration.

If you are not registered for the product, click here to view a demo and register for your password to gain access to this valuable tool.

You may also contact our Customer Service Contact Center at 800-824-7406 Monday through Friday 8:30-5:00 EST.

Claims that cannot be repriced can be found on the sendback portion of your weekly Provider Claim Activity Report. A paper claim may also be returned to your office with a cover sheet indicating the reason for no repricing. You will also be notified of a claim that could not be repriced when using the MedCost Claim Repricing Inquiry Product. At times you can respond to MedCost on information needed for your non-repriced claim via the MedCost Claim Repricing Inquiry Product.

Sometimes duplicate policy numbers are assigned by the claim administrators. MedCost often has no control over the policy numbers assigned. Therefore, when the group name is supplied on the claim along with the policy number, we are able to process your claim under the correct policy/group. This ensures that the claim is delivered to the correct claim administrator for payment. When the group name is not given on a claim that is filed with a duplicate policy number, the claim is returned to the provider for this information, creating unnecessary delay. 

Payment is issued by a third party administrator or insurance company. Payment is not issued by MedCost. Medcost is a Preferred Provider Organization (PPO) and does not issue payment on claims. The entity issuing payment for medical claims should be indicated on the patient’s identification card or explanation of benefits.  

Through our provider Web-based claim repricing inquiry product, you will have 24/7 access to repricing information at MedCost. In addition, you will also have a direct link from our Web site to the Web sites of more than 45 of our claim administrators, providing you with payment status for your repriced claims. You will be able to reduce overhead costs, telephone charges, and will increase efficiencies in your billing and collections areas. For more information, please click here.

The MedCost Provider Manual covers:

• multiple surgical procedures
• hospital admits w/ a surgical procedure
• globals for surg procedures
• starred vs. non-starred procedures
• ED visits with hospital admits
• mod 25
• mod 26
• surgical assistants
• medically unnecessary charges
• limits on in-hospital visits by attending
• multiple E&Ms on the same day
• incident to
• requesting operative notes
• PA/FNP reimbursement
• universal childhood vaccination program

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. 

A MedCost QuickClaim is a paper printout of an EDI claim that contains the MedCost repricing. 

While you’re on our Web site 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 can also verify participation by calling MedCost’s Customer Service Contact Center at 800-824-7406. 

Email your request for directories to Michelle Shoaf at mshoaf@medcost.com
Please include:
Contact name
Company name
Street address and zip code
Telephone number
Number of directories requested, and for which state

Certification requirements are stated on the insurance card along with the number to call for precertification. 

MedCost will need the following information to initiate a review request:

• Company name and policy ID (something other than a Social Security number)
• Inpatient or outpatient
• Patient name
• Patient date of birth
• Is the patient the employee or a dependent?
• The name of the employee
• The Social Security number of the employee
• Address of the employee
• Is this primary or secondary insurance?
• Name and phone number of the admitting physician
• The date of admission or procedure

Clinical information:

• Diagnosis and procedure: Is this an r/o or confirmed diagnosis- how confirmed?
• Co-morbidities, old or new diagnosis
• Presenting signs and symptoms: duration, significant history leading to admission
• or procedure, system assessment, test and lab results, vital signs
• Treatment plan-medications-routes, dosages, dates started and discontinued, tests and labs, diet, activity level, treatments
• Discharge needs or plans

Sources of information for Milliman Care Guidelines include medical literature, textbooks, and nationally recognized guidelines published in all fields of medicine, practice observations, and database analyses.

In weighing and grading the evidence, Milliman USA uses the following hierarchy of evidence, with the first level being the most important:

• Evidence Grade 1: Randomized controlled trials
• Evidence Grade 2: Nonrandomized published research
• Evidence Grade 3: Unpublished research:
• Large databases
• Quality improvement projects
• Expert practitioner reports

Certification is not a guarantee of payment. The certification process confirms the medical necessity of the service. It does not confirm the member eligibility or coverage for the service. All questions of eligibility of a specific patient and coverage for the requested service should be confirmed by contacting the claim administrator.  

MedCost health management programs are accredited by URAC. MedCost is also accredited under URAC provider credentialing standards. 

At MedCost, registered nurses collect medical information and review it against Milliman Care Guidelines. If there is any question of medical necessity, the medical information is reviewed by a physician. MedCost has a panel of over 90 consulting physicians. All physicians are board certified in various specialties and are in active practice. 

All MedCost consulting physicians are board certified in their various specialties and are in active practice. 

Our recredentialing process consists of re-verifying and updating providers’ credentials.

MedCost cannot make an effective date retroactive. The effective date given is the date credentialing is complete and signed off.

MedCost recredentials providers every three years. 

All providers are not due for recredentialing at the same time. The recredentialing anniversary is the date initial credentialing was completed, reviewed, and signed off by our medical director. 

MedCost is fully compliant with all of the requirements of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) to date.

MedCost conducts an annual Provider Satisfaction Survey.

Yes. Our quarterly newsletter, The Provider Connection, is posted online for download. Please click here to view the current edition or access past editions.