HealthCare Eligibility, Coverage and Benefit Inquiry (270) and Response (271) EDI Transactions
The 270/271 EDI transaction set used to verify eligibility/benefits is not intended to provide direction on where or how to file claims. Please file claims according to the health plan ID card presented by/on file from the member which clearly provides the payer ID number and claim filing information.
You must include the group name/number and the member ID on all claims submitted to MedCost for repricing.
Rejections From Availity
You currently may receive rejection information from Availity, MedCost’s exclusive EDI Gateway, specific to claims that do not have a valid policy/group number or valid/eligible Member ID number. In most instances, the reason for the rejection is because the group number was not included on the claim or the group number provided is invalid. To ensure the reason for the rejection is clear so the provider knows what steps are needed to refile the claim, we are updating the rejection messages from Availity as noted below. Please refer to the member’s ID card when compiling information on the claim for submission to MedCost to ensure your claim is processed timely.
For electronic claims:
- Claim cannot be processed due to invalid policy/group number or invalid/ineligible Member ID number.
For paper claims:
- Claim cannot be processed due to invalid policy/group number or invalid/ineligible Member ID number. Refer to member’s ID card for this information.
Eligibility For Coverage
MedCost and MedCost Virginia Networks have multiple payer partners, and both networks offer resources to help provide eligibility information for members.
MedCost Network providers can check eligibility for MedCost Benefit Services members here. Links to other TPA websites, when applicable, can be found here.
MedCost Virginia Network providers can access the EDI Claims Submission Report in the Provider File Repository here that shows group numbers and EDI addresses.
If you still have questions regarding benefits for a member, please contact the payer listed on the member’s ID card.
Update Insurance Policy Information on CAQH
To make credentialing and re-credentialing as seamless as possible, it is important to update and maintain your insurance policy information (Certificate of Insurance/COI) on CAQH. Ensuring you maintain current information and documentation helps us to complete the credentialing process efficiently and avoid delays. You can update your information here.
Multiple Surgery Claims (Modifier 51)
Adjustment for Multiple Surgical Procedures
Charges for secondary or subsequent surgical procedures where Modifier 51 is appended will be approved at 50% of the MedCost allowable fee for that procedure unless your contract states otherwise. MedCost will consider the highest allowed procedure as primary unless your contract states otherwise.
For our payer partner, MedCost Benefit Services, Zelis will review your claim and the remark will reflect "Identify Primary Procedure and Utilize Modifier on Secondary Procedures." For other payer partners, claims will be reviewed by MedCost and sent to the appropriate payer to adjudicate the claim based on the member’s plan design.
Distinct Procedural Service (Modifier 59)
Adjustment for Distinct Procedural Service
As a reminder, Modifier 59 is used as a “Distinct Procedural Service.” This modifier is used under certain circumstances where the physician may need to indicate that a procedure or service was distinct or independent from other services performed on the same day. The modifier must be used appropriately for claims to process correctly.
(Here is a reference for Modifier 59 to provide additional information.)