Claims Processing FAQ

Yes. Your claims will be received and processing will begin immediately. Electronic claim submission benefits both providers and payers. For more information, see Electronic Data Interchange Frequently Asked Questions.

Here are some basic steps to help you get started with billing.

Familiarize yourself with the DHHS website and sign up for email notifications

Sign up for direct deposit of your Medicaid payments

As the provider, it is your responsibility to appropriately and accurately code your claims.  Nebraska uses national code sets for procedures, procedure code modifiers, diagnosis and most other claim information. The specific code sets used are outlined in billing instructions.

For help with coding medical equipment and supplies, use the Centers for Medicare and Medicaid Services (CMS) website at: https://www.cms.gov/medicare-coverage-database/view/ncd.aspx?NCDId=190​.

If you have questions about billing requirements, contact your Medicaid program specialist.

Claims that have been entered into the Medicaid claims processing system go through a series of edits and reviews to determine if the claim is payable. During this time, they are referred to as “instream," “pending" or “not finalized."

To check status of processing claims, review your “Medicaid claims in process over 30 days report" or contact Medicaid claims customer service at (877) 255-3092.

To help us process your claims as quickly as possible:

• While a claim is processing, do not submit a duplicate or replacement claim. Receipt of a duplicate claim delays processing of both the original and duplicate claim and results in denial of the duplicate claim.
• Submit a new claim only after notice has been received that the original claim was returned, rejected or deleted.
• Do not submit a new/duplicate claim if you received a notice of denial on your Medicaid remittance advice. Send an adjustment request for review of the denied claim.

After Medicare processes claims, they are electronically “crossed over" to Medicaid. Your remittance advice from Medicare will include a remark telling you the claim was forwarded to Medicaid. If it has been forwarded, please do not send another claim.

Medicaid will process the electronic claim and pay the Medicare coinsurance and deductible amounts due. If Medicare denied a service, Medicaid will not pay for it on the “Medicare crossover" claim. In some cases, you may submit the service on a separate paper or electronic claim. See your provider handbook (471-000-70) for details.

If you do not receive payment of coinsurance and deductible within 45 days of the Medicare payment, contact Medicaid claims customer service at (877) 255-3092 to determine status.

Some claims processing requirements do not allow a claim to be finalized. These claims must be deleted from the Medicaid claims processing system. If the deleted claim was submitted on paper, you will receive notice on a deleted Medicaid claims report. Deleted electronic claims are reported on the electronic claim activity report sent to your electronic submitter/clearinghouse. The reason for deletion is listed on the reports.

If your claim was deleted, it does not mean it was denied. Instead, your claim had certain problems that need to be addressed before it can be processed. A new, corrected claim must be submitted within six months from the date of service. If your deleted claim had attachments, be sure to send the attachments with your new claim. The attachments to the deleted claim cannot be used to process the new claim.

First, look at the type of notice you received.

• If your claim was reported on your Medicaid remittance advice and one or more lines were paid at $0.00, then your claim was denied. You must submit a claim adjustment request within 90 days from the date of the Medicaid remittance advice. In this case, please do not submit a new claim. (See “What is an adjustment request? How do I submit one?")
• If your claim was not reported on your Medicaid remittance advice, it was not 'denied.' Your claim was either returned, rejected or deleted. In these cases, you will need to submit a new claim.

Nebraska Medicaid uses national codes for reporting on the electronic remittance advice and other reports. Go to the Washington Publishing Company (WPC) HIPAA Code List to connect to the website where the national codes are maintained.

• Medicaid remittance advice uses “claim adjustment reason codes" and “remittance advice remark codes."
• Medicaid deleted claims and Medicaid electronic claim activity (ECA) reports use “claim status codes" and “claim status category codes."

An explanation of the remittance advice can be found in the Title 471 appendix, 471-000-85.

If you need to change the information on a paid claim or request reconsideration on a denied claim, you must submit an adjustment request. The request must be received within 90 days of the date on the Medicaid remittance advice.  There are certain exceptions to this time limit, such as for claim denials related to third-party resources.

Adjustment requests must be clearly marked and contain the following information: Client ID, provider ID, date of service, Medicaid claim number and the reason the adjustment is being requested. A copy of the Medicaid remittance advice is preferred. A new claim should never be submitted as an 'adjustment request' or to correct a claim that has been reported on your remittance advice.  For complete instructions, see 471-000-99.

Approved claim adjustment requests that result in payment changes are reported on the Medicaid remittance advice. Denied claim adjustment requests are reported on a paper “Medicaid claim adjustment denial notice" sent to your pay-to address.

To make sure we received your adjustment, you may call Medicaid claims customer service at (877) 255-3092. Remember to check before the 90-day time limit expires.

This report is your notice of paper claims deleted from the Medicaid claims processing system. The reason(s) each claim was deleted is printed on the report. The report is mailed each week if you have claims that were deleted the previous week. The report is mailed to your 'pay-to' address, the same address used for your Medicaid remittance advice.

If the Medicaid provider number on your claim is incorrect, the claim will not be listed on the report. A notice of these deleted claims will be mailed to the address on your claim.

Review the report weekly and submit a new, corrected claim if needed. If the deleted claim had attachments and you will be sending in a new, corrected claim, make sure all the original attachments are sent with the new claim.

For an example and explanation of this report, see 471-000-127 (for CMS1500, dental and nursing home turnaround claims) and 471-000-129 (for CMS1450 and electronic 837 Institutional claims).

This report lists your paper and electronic claims in process that were received at least 30 days prior to the report date. The report mailed to your payment address and is sent only if you have claims in process over 30 days. The report is mailed weekly for institutional claims and monthly (on the last Saturday of each month) for professional claims.

If your claim does not appear on the report as expected, or if your claim was listed on a prior report and is no longer on the report, the claim either completed processing (check your Medicaid remittance advice) or was deleted (check your deleted Medicaid claims report). Remember, if your claim was returned, rejected or deleted, and you submitted a new claim, the 30-day timeframe starts again with receipt of the new claim. If you are unable to locate a claim on the report, contact Medicaid claims customer service at (877) 255-3092.

For an example and explanation of this report, see 471-000-128 (for CMS1500, dental, nursing facility turnaround and electronic 837 practitioner and dental claims) and 471-000-129 (for CMS1450 and electronic 837 institutional claims).

This report shows processed/finalized claims, refunds and processed claim adjustments. The remittance advice may be sent on paper or electronically. For an example and explanation of the report, see 471-000-85.

Electronic claims are initially processed through software that verifies the claim data is in the correct format. Claims that do not meet these requirements are rejected before entry into the Medicaid claims processing system. Rejected claims are reported on the “electronic claim activity report" sent to your electronic submitter/clearinghouse. If a claim is rejected, a new claim must be submitted within six months from the date of service.

Paper claims are screened as soon as they are received. Claims are returned if they are missing information required for entry into the Medicaid claims processing system. The original claim is returned to the provider address printed on the claim. A “Medicaid claim return notice" is attached explaining the reason the claim could not be accepted. You should correct the claim or submit a new claim within six months from the date of service.