# Billing Medicaid for claims denied by medicaid managed care plans.



## JesseL (Apr 7, 2015)

We have a claim denied for being out of network by a medicaid managed care plan.  I'm trying to bill straight medicaid for it through epaces but keep getting the denial as below:

"(F2 ) - Finalized/Denial-The claim/line has been denied. (97 ) - Patient eligibility not found with entity. Note: This code requires use of an Entity Code. (PR ) - Payer"

Any ideas?  I figured straight medicaid is payor of last resort so trying to get this paid.


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## tonishagentile (Apr 8, 2015)

*Billing Medicaid*

Traditional Medicaid will not pay this claim because patient has a managed care plan.


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## mitchellde (Apr 8, 2015)

tonishagentile said:


> Traditional Medicaid will not pay this claim because patient has a managed care plan.



It is a good denial with no appeal posdible.  When a patient signs up for Medicaid they are placed on a specific plan according to many factors.  So straight Medicaid is not a payer of last resort, it is the payer some patients are assigned to and some are not according to their needs.  If you knew the patient was a Medicaid HMO patient, and you are not a provider for that payer, then the patient should have been immediately referred to the appropriate provider by the front desk staff, unless this was an emergency.


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## KN (Apr 8, 2015)

You will need to do an eligibility check through Epaces and it will tell the status of the straight Medicaid coverage.  If the patient is not eligible you will can  appeal to the Medicaid Managed Care Plan for reimbursement.  Even though you provider is out of network the member may have out of network coverage of some kind.   Did you verify eligibility with the Medicaid Managed Care Plan prior to the services?  If so, you may want to base your appeal on what you were advised.  If all fails you will have to bill the member.  Good Luck


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## JesseL (Apr 8, 2015)

mitchellde said:


> It is a good denial with no appeal posdible.  When a patient signs up for Medicaid they are placed on a specific plan according to many factors.  So straight Medicaid is not a payer of last resort, it is the payer some patients are assigned to and some are not according to their needs.  If you knew the patient was a Medicaid HMO patient, and you are not a provider for that payer, then the patient should have been immediately referred to the appropriate provider by the front desk staff, unless this was an emergency.



Yeaa what happen was she was in-network but I think she had to recertify or recredential with the payer and they issued no warning to the provider that she had to do this.  SOme rep from that payor assigned all her patients to another PCP (who probably paid/bribed him to do this), at least that's what the provider thinks..  So the end result is we saw a lot of patients with that plan and didnt get paid for it due to the payer considered the provider to be out of network for not doing the re credentialing. 

Was hoping to get straight medicaid to pay for these


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