Medicaid Expansion Provider Manual Updates

Updates have been made to the Medicaid Expansion provider manual.

New sections include:

  • Documentation Requests
    • Third-Party Documentation
    • Insufficient Documentation
  • Institution For Mental Diseases
    • Added new section
  • Coordination of Benefits
    • Added new section with coordination details
  • Unsolicited Refunds
    • Unsolicited refunds refer to refunds that were not requested by BCBSND. Also referenced as a refund/return of overpayments
  • Payment Integrity Program
    • Added information about the reconsideration process

Revised sections include:

  • Covered Services
    • Updated the information regarding transportation and eye exams to match the book language
  • Referrals for Out-of-Network Services
    • Added clarifying information regarding Indian Health care providers (IHCP) providers
  • Documentation Requirements
    • Added requirements for non-emergency medical transportation (NEMT) documentation
  • Services Requiring Precertification
    • Added link to Predictal guide
  • Approval for Meals, Lodging and Transportation
    • Added clarification to members requesting services to utilize providers outside of their community.
  • How To File and Correct Claims
    • A claim should only be submitted with one Billing Provider and one Rendering provider. Availity Essentials may have the option to submit additional rendering NPI's on each claim line, but our system will not recognize that information for claims processing. A separate claim should be filed for any service(s) that are rendered by a different provider, NPI.
  • Claim Corrections: Criteria
    • Updated language
  • Electronic Remittance Advice (ERA) and Electronic Funds Transfer
    • Added information about Claim Adjustment Reason and Remittance Advice Remark Codes
    • Added information about bank accounts
  • Definitions
    • Updated language under Precertification

Contact our Medicaid Expansion Provider Service Center at 1-833-777-5779.