MedCost Provider Manual 2025
The 2025 MedCost Provider Manual can be found here. This latest edition has been revised and consolidated for easier navigation. As always, the Provider Manual is a complete guide for MedCost Network providers and serves as an extension of your MedCost Participation Agreement.
If you have any questions, please contact our Customer Service Contact Center at 800-824-7406 or via Live Chat at www.medcost.com.
New Claim Correspondence Requirements for MedCost Benefit Services Effective April 1
To expedite processing for solicited correspondence requested by MedCost Benefit Services (MBS) and facilitate identification of associated claims, the following information will be required to be included/attached to all solicited documentation effective April 1, 2025:
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Claim ID (located on EOB)
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Patient Name
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Patient Member ID Number
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Date of Service
You may begin including this information immediately to expedite claims processing.
Effective April 1, 2025, failure to submit the required information on solicited correspondence, resulting in our inability to identify the corresponding claim/s, will result in the correspondence being returned to your office to allow the required information to be resubmitted.
Filing Corrected Claims and Claims Appeals/Disputes
Guidelines for Filing a Corrected Claim to MedCost
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For UB-04 claims, a “7” must be present as the third digit of the Type of Bill field. For paper claims, the original claim number should be entered in Field 64.
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Professional claims also should reflect a claim frequency code of “7.” For paper claims, the original claim number should be entered in Box 22.
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Edit the claim with the corrected information.
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Include the payer’s original claim number in the 2300 claim loop - segment REF01=F8 and REF02=the original claim number with no dashes or spaces.
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Enter the original claim number of the paid/denied claim when submitting a replacement with frequency of “7” (Replacement of Prior Claim). CLM05-03 (837P).
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In the 2300 Loop, the REF02 segment [Original Reference Number (ICN/DCN)] must include the original claim number issued to the claim being corrected. The original claim number can be found on your Remittance Advice.
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Resubmit through normal channel. Failure to include the original claim number and/or use a corrected claim indicator may impact the processing of your claim, with potential denial of the claim as a duplicate. Please note, a corrected claim does not constitute an appeal.
Corrected Claims for MedCost Benefit Services (MBS)
All corrected claims should be sent to MedCost for applicable repricing. The original claim # is required to be submitted on the corrected claim.
The preferred method to submit corrected claims is electronically to EDI 56162.
If sending via paper, please send corrected claims to the following address:
MedCost
PO Box 25307
Winston-Salem, NC 27114-5307
Leased Payer Claim Appeals/Disputes
For leased payer partners, the EOB will provide information on where to submit disputes and/or appeals. If a corrected claim is included as part of the appeal, it must be sent to MedCost for repricing if there are any changes in reimbursement.
Appeals related to benefit denials, such as plan exclusions, timely filing limit, or patient responsibility disputes (co-pay, deductible, coinsurance), should be sent to the applicable payer listed on the member’s ID card. Benefit appeals could be for denials related to services not covered by the plan or reconsideration of a non-covered service.
MedCost Benefit Services (MBS) Claim Appeals/Disputes
MBS follows CMS guidelines on reimbursement related to NCCI (National Correct Coding Initiative) editing including, but not limited to, procedure-to-procedure edits and medical unlikely edits.
All appeals, claim disputes, or claim denials related to code editing should be sent to the following:
Zelis
Attn: Inquiries Department
2 Crossroads Drive
Bedminster, NJ 07921
[email protected]
Fax# 855-787-2677
For any benefit appeals, you can send to:
MedCost Benefit Services (MBS)
Attention: Benefit Appeals
PO Box 25987
Winston-Salem, NC 27114
Fax# 336-774-4420
If a corrected claim is included as part of the appeal, it must be sent to MedCost for repricing if there are any changes in reimbursement.