The Provider Claim Inquiry window in the PROMISe™ Provider Portal is used to search claims, view original claims by ICN, and check the status of one or more claims. Regardless of submission media, you can retrieve all claims associated with your provider number. A search can be narrowed by specifying the ICN, recipient ID number, patient account number, date range, or claim status criteria. You can perform a search only for claims submitted by your provider number and service location(s).
Note: When performing a claim inquiry for claims submitted via a media other than the internet, please allow for processing time before the claim appears in the system. For example, if you submit your claims via paper, please allow 7 to 10 business days before performing a claim inquiry. Alternatively, you may also contact the Provider Service Center at 1-800-537-8862 to inquire on the status of claims.
The original claim must be received by the department within a maximum of 180 days after the date the services were rendered or compensable items provided. Nursing facility providers and ICF/MR providers must submit original claims within 180 days of the last day of a billing period. A billing period for nursing facility providers and ICF/MR providers covers the services provided to an eligible recipient during a calendar month and starts on the first-day service is provided in that calendar month and ends on the last day service is provided in that calendar month.
Resubmission of a rejected original claim must be received by the department within 365 days of the date of service, except for nursing facility providers and ICF/MR providers. Resubmission of a rejected original claim by a nursing facility provider or an ICF/MR provider must be received by the department within 365 days of the last day of each billing period.
The department will consider a request for a 180-day exception if it meets at least one of the following criteria:
To submit a 180-day exception request, you must complete the following steps. (Also see Medical Assistance Bulletin 99-18-08):
Submit a request for a 180-Day exception to the following address:
Inpatient and Outpatient Claims:
Attention: 180-Day Exceptions
Department of Human Services
Bureau of Fee-for-Service Programs
P.O. Box 8042
Harrisburg, PA 17105
Long Term Care Claims:
Office of Long-term Living
Bureau of Provider Support
Attention: 180-Day Exceptions
P.O. Box 8025
Harrisburg, PA 17105-8025
The provider has the option of signing each invoice individually, using a signature stamp, or submitting the invoices with the Signature Transmittal Form MA-307. If the MA-307 is used, a handwritten signature or signature stamp of a Service Bureau representative, the provider, or his/her designee must appear on the MA-307. When the MA-307 is used, claims must be separated and batched according to the individual provider who rendered the services. Individual provider numbers must be provided in the spaces provided on the MA 307. The MA 307 must be submitted with the corresponding batches of individual provider's claims (maximum of 100 invoices per transmittal).
Providers must obtain applicable recipient signatures either on the claim form or must retain the recipient's signature on file using the Encounter Form (MA 91). The purpose of the recipient's signature is to certify that the recipient received the service and that the person listed on the PA ACCESS Card is the individual who received the services provided.
A parent, legal guardian, relative, or friend may sign his or her own name on behalf of the recipient. The provider or an employee of the provider does not qualify as an agent of the recipient; however, children who reside in the custody of a County children and youth agency may have a representative or legal custodian sign the claim form or the MA 91 for the child. The following situations do not require that the provider obtain the recipient's signature:
In all of the above situations, print "Signature Exception" on the recipient's signature line on the invoice.
All physicians licensed in the state of Pennsylvania may bill and be reimbursed for the actual cost of medications administered or dispensed to an eligible recipient in the course of an office or home visit. There is no reimbursement to a physician for medical supplies or equipment dispensed in the course of an office or home visit. Payment for medical supplies and equipment is made only to pharmacies and medical suppliers participating in the Medical Assistance program.
Physicians must bill drug claims using the electronic 837 Professional Drug transaction if using proprietary or third party vendor software, or on the PROMISe™ Provider Portal using the pharmacy claim form. Physicians are required to use the 11-digit National Drug Code (NDC) and assign a prescription number for the medication. For additional information, please refer to the DHS website for information on Pharmacy Services or PROMISe Provider Handbooks and Billing Guides
A claim which has been submitted to the department not appearing on a piece of remittance advice within 45 days following that submission, should be resubmitted by the provider.
If you submit paper claim forms, please verify that the mailing address is correct. Refer to Provider Quick Tip #41-Medical Assistance Desk Reference to verify the appropriate PO Box to mail paper claim forms based upon claim type.
No, "J" codes are not compensable under Medicaid.
No. The ADA Dental Claim form (2012 version) must be ordered from the American Dental Association or associated forms vendors. The ADA Dental Claim form may also be available as part of your office practice software program.
The Provider Claim Inquiry window is used to make an adjustment to a claim on PROMISe™. Regardless of submission media, you can retrieve all claims associated with your provider number. A search can be narrowed by specifying the ICN, recipient ID number, patient account number, date range, or claim status criteria. Claim records that match your search criteria are displayed in the lower portion of the Claim Inquiry window. Note that all ICNs and Recipient IDs are hyperlinked. Click on the ICN link for which an adjustment is to be made. The original claim is displayed. Scroll down the claim window to the Adjustments for Service Line: 1 group. In the Adjustment 1 row, select a value from the Adjustment Group Code drop-down box. Select a value from the Reason Code drop-down box. Enter the amount of the adjustment for this claim in the Amount box at the end of the Adjustment 1 row. Select a value from the Carrier Code drop-down box. To add another adjustment to the claim, click the Add Adjustment button to activate the Adjustment 2 row. Up to eleven additional adjustments can be added. When finished adding adjustment rows, click the Submit button to submit the adjustment to PROMISe™.
Yes. Refer to the appropriate PROMISe Provider Handbooks and Billing Guides and fee schedule and for your provider type for correct usage of modifiers.
Facility provider numbers are available on the PROMISe™ provider portal. After logging on with your unique user ID, challenge question answer and password, click on the Claims tab, then Submit Professional. You will see a hyperlink for Facility Provider Numbers and clicking the hyperlink will allow you to view a list of provider numbers for Acute Care Hospitals, Ambulatory Surgical Centers, Psych and Rehab Hospitals and Short Procedure Units.
Outpatient Hospital providers may bill MA secondary charges when Medicare applies a payment to deductible or coinsurance. The charges may be billed on the PROMISe™ Provider portal using the institutional claim form, on the UB-04 paper claim form or other third-party software.
To bill MA secondary charges via the institutional claim form on the PROMISe™ Provider portal, follow these steps:
In Other Insurance section, press ADD
In Carrier Code field - Select 100-Medicare Part B from the drop-down
In Policy Holder ID Code field - enter the Policy Holder ID
In Individual Relationship field - select recipients relationship with insured
In Release of Medical Data field – make a selection from the drop-down box
In Benefit Assignment field – make a selection from the drop-down box
In Claim Filling Code field - select MB- Medicare Part B
Scroll to the SERVICE ADJUSTMENTS for Service Line 1 Section
In Adjustment field - from drop-down select why MA is being billed
In Amount field - enter the amount being billed
In Adjustment Group Code field - from drop-down select PR-Patient Responsibility
In Paid Date field - enter the date of Medicare EOB or check
In Paid Amount field - enter how much Medicare Paid. If Medicare did not pay, leave blank
In Carrier Code field - select 100-Medicare Part B
In Medicare Approved Amount field - enter the Medicare Approved amount
To bill MA secondary charges via the UB-04 paper claim form, follow these steps:
Example: If billing for deductible
Form Locators 39-41 A1 – deductible Payer A
Form Locator 54 Report the Medicare-approved If Medicare applied the entire
payment to the recipient's deductible,
Example: When there is Medicare Coinsurance/copayment
If Medicare applied part of the payment to the Deductible and assessed coinsurance or copayment towards the same service or assessed co-insurance or copayment only
Form Locators 39 though 41 list the following value codes:
Locator 54 Report the Medicare Paid
Form Locators 50 through 65