As part of our commitment to our provider partners, MedCost continues to review opportunities for improvements in repricing and/or adjudicating your claims. After extensive examination of our current claims processes, we have identified several enhancements to increase efficiency and align more closely with industry standards. These enhancements (described below) will be implemented effective November 1, 2021.
This communication is a courtesy outreach to ensure you and your staff have awareness of these enhancements.
Multiple Surgery Claims (Modifier 51)
Under our current process for multiple surgery claims billed with modifier 51, the procedure with the highest billed amount is considered the primary procedure, unless your contract specifically states otherwise.
When this enhancement is implemented on November 1, 2021, multiple surgery claims will be processed as follows:
Adjustment for Multiple Surgical Procedures
Charges for secondary or subsequent surgical procedures (modifier 51) will be approved at 50% of the MedCost allowable fee for that procedure unless your contract states otherwise. MedCost will consider the highest allowed procedure as primary unless your contract states otherwise.
The appending of modifier 51 on any CPT code designated exempt may result in denials by our payer partners.
MedCost Moving to Availity as Exclusive EDI Gateway
Currently, MedCost is contracted with several clearinghouses—Allscripts (Payerpath), Availity, Change Healthcare (Emdeon), and Smart Data Solutions (SDS)—for receipt of EDI 837, institutional, and professional claims. To ensure consistency in application of edits and gain efficiency in processing, MedCost has made the decision to contract with Availity as our exclusive EDI Gateway. This means all EDI claims, regardless of type (institutional or professional), submitted for MedCost Payer IDs 56162 and 56205 will be received by MedCost through Availity.
Availity will work with your current submitting clearinghouse to ensure claims are forwarded to Availity and from there to MedCost for processing. If you wish to submit claims directly to Availity or would like to obtain more information, please contact Availity Client Services at 1-800-282-4548.
The switch to Availity as our exclusive EDI Gateway offers MedCost the ability to apply claims edits more consistently, and we will be enforcing the following edits on all submitted claims:
Standard National Implementation Process (SNIP) Edits 1, 2, 3 and 5:
- SNIP 1 – Message syntax and valid data types (currently enforced)
- SNIP 2 – Additional format edits and valid values (currently enforced)
- SNIP 3 – Balancing service levels to claim level (currently enforced)
- SNIP 5 – Code set verification, i.e., ICD, CPT, etc. (new enforcement)
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Provider NPI Format must be valid wherever submitted on a claim (new enforcement).
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Claim must be for a MedCost member with current eligibility (new enforcement) - specifically:
- For MedCost Benefit Services members, the NM 109 element will be checked for valid subscriber/member ID.
- For members of leased payer groups, Loop 2000B Segment SBR03 Data element 127 will be checked for a valid group identifier.
Claims failing any of the above edits will be returned to the submitting provider for correction. Claims rejected back will not be published on your Provider Claim Activity report.
Paper Claims
Paper claims filed with information that is not compliant with CMS 1500 and UB04 requirements will be rejected back to you in the form of a letter to notify you of the claim rejection reason. Claims submitted on paper and converted to 837 EDI files will not be affected if filed correctly. Claims rejected back will not be published on your Provider Claim Activity report.
Expanded Rejection Codes on 277CA
Historically, MedCost has published information regarding rejected claims to your Provider Claim Activity Report (PCAR) rather than including rejection codes on the 277CA transaction acknowledgment. Beginning November 1, 2021, providers submitting EDI 837 claims will receive a 277CA to indicate whether a claim was accepted or rejected, with a reason for any rejection. This will inform providers of any issues with a particular claim in a more timely manner and enable MedCost to phase out the PCAR report by the end of the year. There will be a transitional period as we move away from the PCAR report, so please continue to check it regularly throughout the fourth quarter of 2021.
In conjunction with the enhancements described above, we have updated our MedCost Provider Manual. The updated version will be posted to our website and viewable online or available as a downloadable file. As a reminder, the MedCost Provider Manual is the complete guide for MedCost Network providers and serves as an extension of your MedCost Agreement.
If you have any questions, please contact MedCost Customer Service at 1-800-824-7406, via the web, or via Live Chat on MedCost.com. Please feel free to forward this email to the business unit or appropriate staff members responsible for submitting your EDI claims to MedCost.