Claims Management February 2016
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Overview
• Claim Submission
• Remittance Advice (RA)
• Exception Codes
• Exception Resolution
• Claim Status Inquiry
• Additional Information
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Claim Submission
Life of a Claim
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Claims Intake
Claims are submitted using various methods.
• Electronic Claims
‒ Health Enterprise
‒ Practice Management Software
‒ Payerpath
‒ Crossover Claims via Medicare
• Paper Claims
‒ CMS-1500, Professional Health Insurance Claim Form
‒ UB-04 (CMS-1450), Institutional Claim Form
‒ AK-04, Transportation Authorization and Invoice
‒ J430, American Dental Association Dental Claim Form
‒ AK-05, Adjustment/Void Request Form
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Transaction Control Number (TCN)
Once received, all claims are entered into the system, either electronically or
by data entry, and assigned a TCN.
• TCNs are unique to each claim and determined by multiple submission factors
• The format of this number is YYJJJMBBBBDDDDDDT
•YYJJJ - Year and the current Julian calendar date
•M - Media source code
•BBBB - Conduent internal use
•DDDDDD - Conduent internal use
•T - Transaction code
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Julian Date Calendar
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Transaction Control Number
Media Source Codes Transaction Type Codes
1 - Web submitted claims
2 - Electronic crossover claims
3 - EMC claims
4 - System generated claims
8 - Paper Claims
9 - Pharmacy
0 – Original claim
1 – Void
2 – Credit of adjustment
3 – Debit of adjustment
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Claims Processing
After being assigned a TCN, all claims enter the automated adjudication
process.
• Automated Adjudication
• Claims that are automatically processed
• Manual Adjudication
• If the claim has certain attachments, requires specific or specialized justification
to process or is for a diagnosis or procedure that requires review, it will be
suspended from the automated process for manual processing by a claims
representative
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Suspended Claims
Common reasons for suspended claims:
• Review third-party liability and any attached Explanation of Benefits (EOB)
• Review medical justification
• Manual pricing
If all necessary documentation was properly submitted, no action is required by the
provider while a claim is in suspended status unless contacted by DHSS or
Conduent for further documentation
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Claim Resolution
All claims will adjudicate to a final status of paid or denied.
• Paid
‒ All paid claims will be reflected on your RA
‒ There may or may not be EOB exceptions
• Denied
‒ All denied claims will have EOB exceptions listed on your RA
‒ Look through all of the EOB codes, not just the first few, to decide whether or
not to correct and resubmit
‒ Also use to determine if other actions, such as an appeal may be appropriate
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Remittance Advice
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Remittance Advice
A Remittance Advice is a notice of payments and adjustments sent to providers.
• Once a claim has been received and accepted, it is processed and the appropriate
payment is determined
• Informs provider of submitted claims status
• Adjudicated claims (paid and denied): Claims adjudication in health insurance refers to
the determination of an insurer's payment or financial responsibility, after the member's
insurance benefits are applied to a medical claim
• In-process claims
• Adjusted and voided claims RA Claims Status Codes to look
for:
P – Paid
D – Denied
S – Suspended
O – To Be Paid
C – To Be Denied
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Remittance Advice
RAs, especially the EOB exception codes, can help providers correct denied claims and
prevent future ones
Your RA can tell you how to proceed with denied claims:
• Some denied claims may require additional documentation, such as an EOB or medical
justification, for resubmission
• Some denied claims may be corrected and resubmitted, such as correcting your
NPI/taxonomy information or including a service authorization number
• Some denied claims may require providers to take other actions, such as billing TPL or
getting a service authorization, before resubmission
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Electronic RA – 835
• If you are using approved practice management
software, you may receive your RA a little differently
• If you are submitting HIPAA compliant 837 transactions,
you may receive an 835 transaction as a response
• The 835 is the electronic version of the RA
• You might notice some differences:
– Remark codes returned on an 835 will be HIPAA compliant v5010 X12 remark codes rather than the 4-
character Enterprise codes
• These codes can be found in your Technical Report Type 3 (TR3) guides
– Only one transmission is available - providers must indicate if they want to receive the 835 or if it should be
sent to their billing agent
– The appearance of the 835 will vary depending on the provider’s software
Provider Notice: If using practice management
software, it is your (or the billing agent’s)
responsibility to be able to interpret 835 remark
codes. The Provider Inquiry department does
not have that capability.
- TR3 guides are available for purchase from
www.wpc-edi.com.
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RA Sections
RAs are separated into several different sections, each containing very important information
regarding claims processing.
RAs contain:
• Cover Page
• RA Messages
• Adjudicated Claims
• Adjustments
• Voids
• In-Process Claims
• Explanation of Benefits
• Financial Transactions
• Summary
Helpful Tip: Review all
areas of your Remittance
Advice. It will help you
identify any errors, ways to
correct denied claims, and
prevent future issues. It also
contains helpful notes,
reminders, and training
opportunities, as well as
useful accounting information
throughout.
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Cover Page
The cover page identifies the
provider to which the RA applies.
Provider ID Provider Name Provider Address
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RA Messages
Every RA will start off with a message section. Providers and billing agencies should
read these messages each week.
It contains:
– New information
– Changes in billing procedures or program coverage
– Messages from Department of Health and Social Services (DHSS) and Conduent
– Billing procedures/reminders
– Training schedules
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Example RA message page
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Adjudicated Claims
Adjudicated claims are those that have reached final disposition since the
last payment cycle.
• Paid
• Denied
• Explains how claims were adjudicated
• If claim contains errors or is denied, EOB, or exception, codes will be
listed next to the line item or beneath the individual claim
• Any exception code listed in the RA will be in the EOB Description
section at the end of the RA for quick reference
• If there are multiple exception codes, be sure to look at all of them, not
just the first 1 or 2
• Shows payment date of previously paid claims
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Adjustments are used to make minor corrections to paid claims.
Processed adjustments appear in two parts on the RA:
• Credit: Alaska Medical Assistance credits our account by taking back the money
that was paid incorrectly
– Credit TCNs will end in a 2
• Debit: Alaska Medical Assistance takes money out of our account to pay the
claim correctly
– Debit TCNs will end in a 3
Adjustment Claims
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Voided Claims
A processed void request will result in:
• Reversal of the original transaction
‒ Removal of service and payment information from the provider and
member history files
• Refund back to Alaska Medical Assistance for the full claim amount
• Reduction in claims paid year-to-date dollar amount on RA summary
Any claim with a status of P, D, O, or C may be voided. Suspended claims
cannot be voided.
Common Voids on Paid Claims
• Wrong member ID number
• Wrong provider ID number
• Services not rendered
• Voids related to Medicare
crossover claims:
If paid by Medicaid and also
received payment from
Medicare, provider must void
the claim submitted to Medicaid
and re-bill using the crossover
format.
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In-Process Claims
In-process claims are those claims that have not fully adjudicated. They may require
additional processing steps (status S) or are complete but missed the billing cycle
deadline (status O or C).
• Common reasons for claims to suspend:
• To review third-party liability
• To review medical justification
• No action is required by the provider while a claim is in suspended status, unless
contacted by DHSS or Conduent
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Explanation of Benefits (EOB)
The EOB Description is a complete list of exception codes found on the remittance advice,
including a brief description of each code.
For further explanation or assistance you may:
• Look up more in-depth descriptions using Health Enterprise www.medicaidalaska.com
‒ Documentation>Documents & Forms>Exception Code Lookup
• Call Provider Inquiry
‒ Claim status and other inquiries – 907.644.6800, option 1,1 or 800.770.5650 (toll-free),
option 1,1,1
1140 The Through Service Date on Claim Header is Missing or Invalid.
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Financial Transactions
Financial transactions are payment or recoupment transactions: for example,
provider reimbursements or processing a voided claim that was already paid out.
• This section only populates on the RA if there are applicable financial transactions
for the pay cycle
• Financial transactions may appear on consecutive RAs as each part of the
payment or recoupment process takes place
Provider Tip: If you notice this section but the full
transaction doesn’t appear on that particular RA,
look at the RA from the previous week or wait for
the next pay cycle for the rest of the specific
transaction.
This is an example of what a Financial Transaction section would look like if a provider were overpaid as a
result of paid claims that are then voided.
The 1st part shows how the particular
transaction(s) will affect the current pay
cycle.
Negative amount = provider overpayment
The 2nd part contains details of
each transaction affecting the
current pay cycle.
The RA Summary accounts for
financial transactions as a separate
line item that is applied to cycle totals
and applicable balances. Any negative
balance will be deducted from the total
cycle payment. If overall cycle total is
negative, the negative balance will be
carried forward to the next cycle for
recoupment.
The financial transaction(s) would show here
for accounts receivable purposes.
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This is the next week’s RA for the previous example showing the overpaid balance from the voided claims
being applied to the next cycle.
The 1st part again shows how the particular
transaction(s) will affect the current pay cycle.
Postive amount = provider payment reduction
The 2nd part contains details of each
transaction affecting the current pay
cycle.
For example, recoupment of previous
week’s negative balance.
The RA Summary shows how the financial
transactions were applied to cycle totals
and applicable balances.
In this case, a reduction of payment to
account for prior overpayment due to void.
The recoupment shows here as a prior
balance that is deducted from the current cycle
in the full amount.
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Summary Page
Each RA includes a summary of all provider claims data.
• Shows the current cycle and year-to-date total dollars paid to and collected from
the provider
• After each calendar year, Conduent sends each provider a 1099 tax statement
showing total calendar year Alaska Medicaid reimbursements
‒ Information will match year-to-date total paid on last RA issued for calendar
year
‒ Contact Conduent regarding discrepancies
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Exception Codes
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What is an “Exception”?
Some claims have what is called an exception attached to it.
• Exceptions are codes signifying an issue on a submitted claim
• Listed as Explanation of Benefits (EOB) codes
• Generated manually (claims personnel) or automatically (MMIS)
• Composed of four numeric digits
• Appears on your RA in multiple areas
• Used as information to help correct errors or help rebill denied claims
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Hierarchy of Exception Codes
Claims data is reviewed in a “hierarchy”, from most important details to least
important to determine if the claim needs to be suspended, reduced, or
denied.
• For example, member and provider eligibility are reviewed before the rest
of the claim; if either is determined ineligible, the claim is denied before a
full review of the submitted claim is complete
• Review and correct entire claim before trying to resubmit
• A complete list of exception codes identified throughout the RA can be
found in the EOB Description section of the RA (just before Summary)
Header Level EOB
Line Level EOB
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Exception Code Online Inquiry
Exception codes can be looked up online using www.medicaidalaska.com
• Under Documentation, select Documents & Forms
• When the documents and forms page comes up, select
Exception Code Lookup
• Enter the code you want a description for and click Submit
A complete exception listing can be
downloaded by clicking on the
Exception Listing for Providers link.
If you need more information about an
exception code, contact Provider
Inquiry at 907.644.6800, option 1,1 or
800.770.5650 (toll-free), option 1,1,1.
It is important to review all exception codes associated with each claim, being careful to look at details, to determine a
course of action.
• For example, this claim has five exception codes attached to it:
Reading Exception Codes
The code attached tells you that this claim is in a
suspended status for further review
Based off all attached codes, there is an issue with the
Medicare Crossover and the NDC listed on the claim
These errors could be as simple as making a NDC
typographical error and mislabeling timely filing
justification attachments; a complete review of the
claim would help you determine what is actually
happening
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Suspended Claim Codes
A “suspended” claim is one being held for manual review by:
• Conduent
• State of Alaska
No action is required by the provider unless directly contacted.
These are all examples of exception codes that indicate a claim has been suspended for
further review:
1922 – Explanation of Medicare Benefits (EOMB) requires review
4076 – Review for Medical Justification - Professional Claim Types
4427 – The Procedure Code and Modifier submitted on the claim require manual review
6430 – Cost Avoid for no TPL dollars but EOB exists
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Denied Claim Codes
A denial code indicates a denial and reason for the denial.
• Providers should review all denial codes
Some denied claims can be resubmitted after correcting errors:
• may require resubmission with additional documentation
• may need corrected information before resubmission
• may require providers to take other actions, such as billing TPL, before
resubmission
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Denied Claim Codes
These are examples of common denial exception codes:
1030 – Billing provider number missing or invalid
1320 – Member number missing or invalid
1882 – Claim exceed timely filing and no proof of timely filing attached
2006 – The Dates of Service on the claim are after the Member's eligibility end date
2020 – Claim DOS after Member DOD
3005 – Billing provider not actively enrolled on DOS
6512 – Code pairs found to be unbundled in accordance with National Correct Coding Initiative
(NCCI) for Practitioner or ASC
6600 – Exact duplicate
8040 – The Number of Units on the Claim have exceeded the Service Authorization Approved
Number of Units
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Exception Resolution
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Exception Resolution - TPL
Exceptions related to Third-Party Liability (TPL)
• If member has other health benefits that may be responsible for partial or total payment of
a claim, those benefits are primary and must be billed first
• Exceptions:
• Indian Health Services (IHS)
• Services for which a federal TPL waiver has been granted
• Providers will also receive a denial exception code if the explanation of benefits of the TPL
is not attached to the claim
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Exception Resolution - TPL
How can I tell if a member has other coverage?
• Alaska Medical Assistance eligibility coupons and cards
• Resource code / carrier code
• Automatic Voice Recognition System (AVR)
• Look up the member’s eligibility information in Health Enterprise
• Provider Inquiry
• 907.644.6800, option 1,2 or 800.770.5650 (toll-free) option 1,1,2
• You can review the specific carrier codes on http://medicaidalaska.com under
Documentation>Documents & Forms>TPL Carrier Lookup
TPL Carrier Lists can be found on
http://medicaidalaska.com
• Documentation > Documents & Forms
• Select TPL Carrier Lookup
Exception Resolution – TPL Verification
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If the member is covered under another government program, they will have one of the following resource codes listed:
Government Agency
Resource Codes
G/H/J
Medicare
M
Tricare
N
Veterans
Administration
(VA)
N2
Veterans Greater
than 50%
Disabled
P
Alaska Area
Native Health
Services
Y
No Other
Insurance
Exception Resolution – TPL Verification
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Exception Resolution – Member Eligibility
If a denial is received because of member eligibility:
• Verify member eligibility dates
• Member may be eligible for retroactive eligibility to cover date of service
• Member should provide updated information to provider
• Refile claim to Alaska Medicaid after eligibility has been updated
These are examples of possible member eligibility exception codes:
2005 – DOS is prior to Member’s eligibility begin date
2006 – DOS is after Member’s eligibility end date
2008 – Member’s eligibility does not cover entire period between From and
Through DOS
2011 – DOS is after Member’s eligibility end date with attachment
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Exception Resolution – Procedure Code
If a denial is received because procedure code/item not covered for Medicaid:
• Check procedure codes on the claim
‒ Was the most appropriate code reported on the claim?
‒ Are you qualified to provide that service per your specialty?
• Review billing manual or fee schedule for a list of covered services
‒ Is procedure code covered?
• If procedure code is not valid:
‒ Determine correct billing code
‒ Verify validity of new code
• Send in new claim with corrected information
Provider Tip: Make sure you are using
the appropriate fee schedule for the DOS
time period. Billing manuals and fee
schedules can be found on
http://medicaidalaska.com in the
Documents & Forms section
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Exception Resolution – SA
Some denials result from service authorization requirements.
• If proper SA was obtained, was SA number and associated information correct
and recorded on the claim?
‒ If not, rebill claim with correct SA information
• Does procedure code match service that was authorized?
‒ If not, rebill with correct code or have service authorization amended to correct
code
• If SA was not obtained but required, contact appropriate authorizing entity to
obtain SA
Provider Tip: Refer to fee schedules and
billing manuals to determine which
services require a service authorization.
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Exception Resolution – Timely Filing
Some claims deny because they exceed the 12-month timely filing limit.
• All claims must be filed within 12 months of the date services are provided to a
member
• 12-month timely filing limit applies to all claims, including those that must first
be filed for TPL or Medicare crossover
• Claims denied with this type of exception code cannot be corrected and
resubmitted; you may only appeal the decision
• A claim denied for timely filing may be appealed within 180 days from the initial
denial date
Member Retroactive or
Backdated Eligibility
There are times when a
member is granted
retroactive or backdated
eligibility. If this occurs, the
member should forward all
appropriate documentation
to their provider. Providers
have the ability to file claims
for the retroactive timeframe
if this documentation is
attached to the claim. Even
with this documentation,
there is still a time limit to
file, so don’t delay.
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Exception Resolution – Other
Other common exception codes include incidental procedures and medical
justification requirements.
• A procedure is considered incidental when carried out at the same time as
a primary procedure and is clinically integral to the performance of the
primary procedure; these procedures should not be billed separately
‒ Provider will receive a denial but it is possible to appeal with proper
justification
• A procedure code billed might require medical justification/records for
service rendered; fee schedules and billing manuals denote supporting
documentation requirements for procedure codes
‒ Rebill with supporting documentation attached
• Medical records
• Chart notes
• Doctor’s orders
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Exception Resolution – Duplicate Billing
A duplicate billing error occurs when two claims are submitted with some or all of
the same information.
• This can include, but is not limited to:
‒ Dates of service
‒ Charges
‒ Member’s ID
‒ Provider’s billing ID
‒ Procedure codes
• This can happen if:
‒ Two different providers bill for the same/overlapped DOS or same procedure
for the same member
‒ Same provider sends the same claim more than once
‒ Entire bill resubmitted to add/change charges on a previously paid claim
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Exception Resolution – Duplicate Billing
These are examples of possible multi-provider duplicate exception codes:
6610 – Inpatient or Nursing home claim vs. Personal Care Services - duplicate
6604 – Possible Conflict/Different Provider
To resolve this type of error:
• Check your records – rebill with corrected information if necessary
• Contact other provider to address the issue
• If the paid provider billed incorrectly, they must void their claim
• Second provider can bill once the incorrectly paid claim is voided
Provider Tip: If both providers did actually
provide the same service on the same date to
the same member, the provider submitting their
claim first is paid. The other provider will need to
appeal the denial documenting the duplicated
service.
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Exception Resolution – Duplicate Billing
These are examples of multiple submission duplicate exception codes:
6600 – Exact Duplicate
6602 – Possible Duplicate
To resolve this type of error:
• Keep up-to-date records of all claims
• If duplicate services medically necessary, appeal with proper justification
• If you filed electronically and think the duplicate submission might be the result of a glitch,
contact your vendor
• When charges need to be added, deleted or changed, file an adjustment
‒ Do not rebill the whole claim as an original
• If the change involves TPL, be sure to include EOB with your adjustment
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Prevent Duplicate Billing
Many duplicate denials can be prevented.
• Routinely check claim status, especially before trying to re-bill
• When adding charges to a DOS, adjust the already paid claim instead of rebilling
• Be careful of duplicate revenue codes and HCPCS when billing both inpatient and
outpatient claims for the same member and DOS
• If “duplicate” services are medically necessary, be aware appeal may be necessary
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NCCI Exceptions
National Correct Coding Initiative (NCCI) exceptions were developed by CMS to
promote appropriate coding methods and reduce improper coding that could lead to
payment errors.
• Part of the Patient Protection and Affordable Care Act of 2010
• In effect October 1, 2010
• Any NCCI exception on a claim will cause a denial and requires an appeal for
reimbursement; first level NCCI exception denials go to Conduent
• Members cannot be billed for services denied for NCCI exceptions
• For appeals questions and information, contact the Appeals Department at
907.644.6800 option 8 or 800.770.5650 (toll-free), option 1,5
• http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Data-
and-Systems/National-Correct-Coding-Initiative.html
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NCCI Exceptions
Two types of NCCI exceptions:
• Procedure-to-Procedure (P-P)
– Defines pairs of HCPCS/CPT codes that should not be reported together
• Medically Unlikely Edits (MUE)
– Defines the maximum number of units of service for each HCPCS/CPT code a
provider would report under normal circumstances for a single member on a
single date of service
• Applied to practitioners, ambulatory surgical centers, outpatient services, and
durable medical equipment claims
• Each NCCI exception has a Correspondence Language Example Identification
Number (CLEID) that gives a rationale and is used for all related correspondence
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Claim Status
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Claim Status Inquiry
There are many methods for checking a claim’s status.
• Login to your Health Enterprise account
‒ Under the Claims tab, select Claim Status Inquiry
‒ Enter the search criteria for the claim(s) you are looking for
• Fax a Check Amount and Claim Status Inquiry form to Provider Inquiry at
907.644.8126
‒ Be sure that all included information is legible if handwritten
• Call Provider Inquiry at 907.644.6800, option 1,1 or 800.770.5650 (toll-free),
option 1,1,1
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Claim Status Form
This form can be found on
http://medicaidalaska.com
•Documentation > Documents & Forms >
Forms
•Select Check Amount and Claim Status
Inquiry Form
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Electronic Claim Status Inquiry
• If you are certified to submit a HIPAA compliant 276 inquiry transaction and
receive a 277 response transaction, you may check your claim status
electronically.
• You must successfully test these transactions
• Contact the Conduent Electronic Data Interchange (EDI) Coordinator
‒ 907.644.6800, option 3 or 800.770.5650 (toll-free), option 1, 4
• You must have some form of practice management software that supports these
transactions
‒ Refer to companion guides for electronic transaction information:
http://manuals.medicaidalaska.com/docs/companionguides.htm
‒ Refer to the applicable TR3 for further information: http://www.wpc-edi.com
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Additional Information
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Alaska Medicaid Compliance & Ethics Training
• Compliance & Ethics: Alaska Medicaid 101 is a computer-based training which includes
an interactive video presentation and a supplemental handbook
• This training serves to:
‒ Familiarize providers with the responsibilities and requirements associated with being a
Medicaid provider
‒ Guide providers through the laws and regulations Medicaid providers must follow
• The training is available at http://learn.medicaidalaska.com
‒ Select Provider>Compliance & Ethics
• Alaska Medicaid provides a certificate for completing this training
• Please direct any questions to the Provider Training department at 907.644.6800 or
800.770.5650
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Additional Resources
Alaska Medicaid Health Enterprise website at http://medicaidalaska.com
– Information necessary for successful billing
– Includes provider-specific Medicaid billing manuals and fee schedules
• You may also call:
– Provider Inquiry
• Eligibility only – 907.644.6800, option 1,2 or 800.770.5650 (toll-free), option 1,1,2
• Claim status and other inquiries – 907.644.6800, option 1,1 or 800.770.5650 (toll-
free), option 1,1,1
– EDI Coordinator
• Electronic transaction inquiries – 907.644.6800, option 3 or 800.770.5650 (toll-free),
option 1, 4
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