Last Updated 8/18/2011 1:45 PM
My claim was rejected. What should I do?
|Claim Rejection||What that means||What to Do Next|
|Incorrect/Invalid primary diagnosis code||The diagnosis code that was submitted on your claim is incorrect. ODJFS is now using a newer, more specific set of diagnosis codes that CareStar does not have which is causing your claim to deny.||Rhino Bill will automatically resubmit your claims without a diagnosis code to bypass this problem. You will not need to do anything!|
|Patient has missing/invalid other insurance||Your patient has other insurance. Even if the insurance does not pay you for your services you still must list it on the patient's profile.||Other insurance can be obtained directly from the patient, from the new MITS portal, or we can look that information up for you. Once you obtain the correct insurance information you will need to add it to your patient's profile and resubmit your claim.|
|Duplicate claim/service line||You have already been paid for this date on this procedure code for this patient.||Press the "Resolve" button next to your claim to take it off of your Unresolved Caims list. No further action is needed.|
|Entity's name, address, phone and id number are invalid||Either your name, address, or phone are not matching what ODJFS has on record for your Medicaid ID/NPI number.||Log into the new MITS portal at ODJFS and verify and correct your information and your patient's information. Make sure that the information in MITS matches the information Rhino Bill has for you and your patient in your Rhino Bill account under "My Account" and "My Patients". Once this is complete you will need to resubmit your claim.|
|Authorization/certification number||(Updated 8/18/2011 1:45 PM) According to what ODJFS has on file which may currently be inaccurate, current Prior Authorization is required. The Prior Authorization referenced on the claim has expired.||(Updated 8/25/2011 10:45 AM)
According to ODJFS, providers billing for PDN services for consumers on the Ohio Home Care Waiver, Transitions DD, and Transitions Carve-Out Waivers do NOT need a Prior Authorization.
These are the services that have an authorization to bill for PDN services from CareStar. If you fit into this category, these rejections are related to patient eligibility. ODJFS says they have fixed most of these eligibility issues as of 8/23. If any of your claims still show a status of Rejected in your Rhino Bill account, you will need to resubmit these claims.
|No payment due to contract/plan provisions||This is most likely due to ODJFS having an incorrect information about your services on the patient's account.||
(Updated 8/25/2011 10:40AM) These rejection reasons are related to patient eligibility. ODJFS says they have fixed most of these eligibility issues as of 8/23. If any of your claims still show a status of Rejected in your Rhino Bill account, you will need to resubmit these claims.
|Claim assigned to an approver/analyst||(Updated 8/12/2011 9:30AM) This claim has been denied.|
|Entity not approved for services||ODJFS does not have you or your patient approved for this service for your patient.|
|Service is not authorized||This service is not authorized for you to perform on your patient in ODJFS's records.|
|Ineligible for benefits for submitted dates of service||According to ODJFS records the patient's Medicaid benefits were not avalible during your service date.|
|Days/units for procedure code are invalid||The days or units that you submitted were not valid for the procedure code that you used.|
|Invalid procedure code or modifier(s)||The procedure code or modifier that you used is not valid for your patient according to ODJFS records.|
|Incorrect procedure code||The procedure code that you used is not valid for your patientaccording to ODJFS records.|
|Benefit maximum has been met or exceeded||Each month every patient is allowed a maximum amount of base units and regular units to be divided among their care workers. Your claim has gone over the allowable number of units that this patient was given.|
Why did so many claims reject?
As you may know, ODJFS recently upgraded its computer systems for processing Medicaid claims. The new system called MITS checks the validity of much more information than the old system did. Therefore, it is rejecting many claims that would have paid just fine with the old system. Once your patient data is updated to match what MITS expects, your claims will pay just fine again.
Why did providers have to wait 2+ weeks to be paid?
During the transition to MITS, ODJFS stopped processing Medicaid claims for 2 weeks. If a claim submitted during this time (July 28 to August 1) did not get rejected, it will pay on Thursday, August 12. However, once ODJFS started processing again, some claims were rejected and could not be fixed in time for the next pay cycle. These claims, depending on when they are fixed and resubmitted, may pay out on Thursday, August 18 or Thursday, August 25. To know when your claim is expected to pay, log into your Rhino Bill account and view your claims. The Expected Pay Date is listed next to each claim.
What is being done to get claims paid?
Rhino Bill, ODJFS and Carestar are all working together to help you get the correct information into your claims so they will pay out. It has taken some time to diagnose the various issues that the new, more sensitive system has caused, but we now know what needs to be done for each rejection code. Please follow the instructions above getting your rejected claim paid.
Why does it take so long to reach Rhino Bill right now? I need answers!
Because of the large number of rejected claims, the customer support staff frankly cannot keep up with the pace of emails and calls at this time due to the large number of rejected claims caused by ODJFS’s transition to MITS. Our team has working around the clock to answer phone calls, voice messages and emails. We hope that you will be able to assist us by following the instructions above to fix the issues with your claim.
Will these rejections keep happening?
No, this is a one-time event, and we cannot imagine that ODJFS would make such massive changes to their system for years to come. Once your patient and claim information has been updated to match what the new ODJFS system expects, your claims will typically pay out every week as they have in the past, and when you have questions, you’ll get the typical speedy Rhino Bill response. In fact, we expect that once your claims are fixed to meet the expectations of the new ODJFS system, you’ll have an even better and more reliable experience than you had in the past.