As part of our commitment to our MedCost Virginia provider partners, MedCost Benefit Services continues to review opportunities for improvements in adjudicating your claims. After extensive examination of our current claims processes, we have identified some enhancements to increase efficiency and align more closely with industry standards. These enhancements (described below) will be implemented effective November 1, 2021.
This communication is a courtesy outreach to ensure you and your staff have ample awareness of these enhancements. The information below only pertains to members and clients of MedCost Benefit Services.
MedCost Benefit Services Moving to Availity as Exclusive EDI Gateway
Currently, MedCost Benefit Services is contracted with several clearinghouses—Allscripts (Payerpath), Availity, Change Healthcare (Emdeon), and Smart Data Solutions (SDS)—for receipt of EDI 837, institutional, and professional claims. To ensure consistency in application of edits and gain efficiency in processing, MedCost has made the decision to contract with Availity as our exclusive EDI Gateway. This means all EDI claims, regardless of type (institutional or professional), submitted for MedCost Payer ID 56162 will be received by MedCost through Availity.
Availity will work with your current submitting clearinghouse to ensure claims are forwarded to Availity and from there to MedCost for processing. If you wish to submit claims directly to Availity or would like to obtain more information, please contact Availity Client Services at 1-800-282-4548.
The switch to Availity as our exclusive EDI Gateway offers MedCost the ability to apply claims edits more consistently, and we will be enforcing the following edits on all submitted claims:
Standard National Implementation Process (SNIP) Edits 1, 2, 3 and 5:
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SNIP 1 – Message syntax and valid data types (currently enforced)
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SNIP 2 – Additional format edits and valid values (currently enforced)
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SNIP 3 – Balancing service levels to claim level (currently enforced)
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SNIP 5 – Code set verification, i.e., ICD, CPT, etc. (new enforcement)
Provider NPI Format must be valid wherever submitted on a claim (new enforcement).
Claim must be for a MedCost member with current eligibility (new enforcement) - specifically:
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For MedCost Benefit Services members, the NM 109 element will be checked for valid subscriber/member ID.
Claims failing any of the above edits will be returned to the submitting provider for correction.
For questions or additional information, please contact our Richmond office at (800) 989-3837 or email us at [email protected]. Please feel free to forward this email to the business unit or appropriate staff members responsible for submitting your EDI claims to MedCost.