Medicaid claims rejection issue resolved

We’ve resolved our recent issue with Medicaid claims rejecting for “non-approved provider types” when they shouldn’t. We’re now reprocessing the impacted claims.

Do providers need to rebill rejected claims?

No. Providers don’t need to rebill claims rejected for “non-approved provider types.” They’ll be automatically reprocessed and paid if appropriate.

What are the allowable provider types?

Pay close attention to the provider types you enter into the Attending, Referring and Ordering fields for Medicaid claims. Below are the allowed provider types per Medicaid policy:

Dates of service before Jan. 1, 2022

For dates of service before Jan. 1, 2022, the provider types below are allowed* in the Attending, Referring and Ordering fields:

  • Physicians (MD/DO)
  • Certain mid-level practitioners (Nurse practitioners, certified nurse midwives, physician assistants)
  • Podiatrists
  • Optometrists
  • Chiropractors
  • Dentists

*For Federally Qualified Health Centers (FQHCs) and Rural Health Centers (RHCs), the Attending field should be limited to Physician (MD/DO), Nurse Practitioner and Physician Assistant.

If you’re experiencing claim rejections for dates of service before Jan. 1, 2022, check the following:

  • All providers in the Attending, Referring and Ordering fields are allowable provider types as described above
  • Type 2 (Facility/Group) NPIs aren’t listed in the Attending, Referring or Ordering fields
  • The taxonomy code assigned to the provider in the National Plan & Provider Enumeration System (NPPES) is up-to-date and corresponds to an acceptable provider type as described above. For example: If the provider still has the specialty “Student” in NPPES, the claim will reject.
  • The provider is registered in CHAMPS and has both an active business status and an active specialty

Dates of service on or after Jan. 1, 2022

For dates of service on or after Jan. 1, 2022, the allowable provider types vary by claim type:

  • Inpatient Attending: Physicians (MD/DO), Dentist, Certified Midwives and Podiatrists only
  • Outpatient Attending: Many different provider types are allowed. See the full list here.
  • Home Health, Hospice, Nursing Facility Attending: Physicians (MD/DO) only
  • FQHC, RHC, THC Attending: Refer to MSA 21-47 for a list of allowable provider types
  • DME Referring/Ordering: Physicians (MD/DO), Nurse Practitioners, Certified Nurse Midwives, Physician Assistants and Podiatrists only

If you’re experiencing claim rejections for dates of service on or after Jan. 1, 2022, check the following:

  • Type 2 (Facility/Group) NPIs aren’t listed in the Attending, Referring or Ordering fields
  • The taxonomy code assigned to the provider in the National Plan & Provider Enumeration System (NPPES) is up-to-date and corresponds to an acceptable provider type as described above. For example: If the provider still has the specialty “Student” in NPPES, the claim will reject.
  • The provider is registered in CHAMPS and has both an active business status and an active specialty
  • For FQHC / RHC / THC, Limited Liability Social Workers aren’t allowed in the Attending field. Check the provider’s registration in CHAMPS to see if it needs to be updated.
  • With the exception of claims from Local Health Departments, Physical Therapists, Occupational Therapists and behavioral health professionals cannot be listed in the Referring or Ordering fields

When are Attending and Referring provider fields required?

The Attending field is required on all Institutional claims.

The Referring field is required on the following claim types: medical supplies / DME / prosthetics and orthotics contractors, hearing aid dealers, hearing or speech centers and laboratory.