Tuesday, March 14, 2017

Denial - Enrolle not eligible on DOS

0318 Enrollee not eligible on DOS

Claim will deny if the client is not eligible during dates of service billed. Check enrollee eligibility status through MediCall to verify eligibility on the date of service being rendered. If the enrollee is not eligible no payment will be received from Virginia Medicaid. If upon verification you find that the client is now eligible on that date of service resubmit the claim.

0313 Enrollee is covered by private insurance, refer to third party information of this R/A

Our system indicates that there is a primary carrier, which needs to be billed prior to Medicaid. This carrier is now listed on your remittance advice under the claims information for that particular client. Please refer to this other coverage information which should be billed as primary.
*NOTE: If the client states there is no other coverage then they will need to contact their case worker at the Department of Social Services to have this information corrected

0039 Qualified Medicare Beneficiary Only Enrollee. Medicaid coverage limited to deductible and coinsurance.

Qualified Medicare Beneficiary (QMB) Only clients are eligible only for payment of Medicare premiums, deductibles, and coinsurance. If a QMB Only claim is denied by Medicare then there will be no reimbursement by Medicaid.

0983 Enrollee Not on File 

Verify the enrollee’s Medicaid ID number.

0456  Enrollee Not Covered for this Service

Verify the enrollee is covered for the service you are billing.

0004 Enrollee ID Missing or Not in Valid Format

Verify the enrollee number for eligibility. The twelve digit enrollee number should appear as it is on the Medicaid Card.

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