11/27/2023
Medicaid Fee-for-Service Claim Denials & Reprocessing
Ohio Department of Medicaid (ODM) and its Ohio Medicaid Enterprise System vendors are diligently focused on providing transparency and visibility regarding care and services. As part of this effort, ODM audits a selection of denied fee-for-service claims each week for payment accuracy.
When ODM finds that claim denials result from a configuration error within the Fiscal Intermediary, ODM proactively reprocesses the impacted claims to pay providers.
Following a recent audit of claims submitted up to October 12, ODM released roughly 95,000 previously pended claims. Just over 80,000 of those claims were denied with a combination of the following reason codes:
- CO-16: Claim/service lacks information which is needed for adjudication.
- MA112: Missing/incomplete/invalid group practice information.
Based on the ODM policy and system adjudication process, these claims were denied appropriately for the billing provider. However, if you have received a denial and believe the denial is not within ODM policy, please contact the ODM Integrated Helpdesk at 800-686-1516 option 1 or IHD@medicaid.ohio.gov. Representatives are available M-F 8 a.m.-4:30 p.m.
Are you receiving frequent denials that are impacting practice revenue and staff time?
Join OSMA’s Live Webinar:
Understanding & Managing Claim Denials
January 23, 2024
11:30 am – 1:00 pm
Live Zoom Discussion with Q&A Opportunity!
Denials and appeals can be one of your largest areas of financial risk. Join Health Care Management & Reimbursement expert, Diane Zucker, M. Ed, CCS-P, as she reviews common coding errors and prevention strategies, medical necessity compliance, and other potential risk areas. This webinar will review the most common denials, miss payments and claim mishaps with proven strategies to get the care provided paid. Situation examples will also be provided for “take home” review to reinforce the learning.