Code 35 Payment Dispute Guidance

The Department of Health (DOH) Bureau of Early Intervention (BEI) has approved the State Fiscal Agent (SFA) to reimburse providers for open service coordination services claims denied by Medicaid due to the “Code 35” restriction. Claims selected for reimbursement must have been received by the SFA before July 1, 2014 and remain unpaid. Payments are subject to recoupment of previous overpayments.

Upon receipt of a payment, if the provider believes the payment was not correct, the SFA asks the provider to take the following steps to review the billing information they have before moving to the next step in the process.

·         Reimbursed claims are based on the date the claim was received in EIBilling, not date of service

·         Ensure the claim was received before July 1, 2014 – payment is only being made on claims received in the system prior to this date

·         Check to make sure that the claim remains unpaid and in a Medicaid denial status of Code 35

·         Compare the provider’s billing records with those in EIBilling for the time period prior to 7/1/14

·         Note any negative balance that the EIBilling records show in that time period, as they will be subtracted from the payment amount

Once the provider has reviewed the billing data and still believes they received an incorrect payment, they should contact the PCG Customer Services Center at 1-866-315-3747 and speak with a representative to review the data. If after that step is taken the provider still believes they have received an incorrect payment, they can fill out a Code 35 Payment Dispute Form (Code 35 Payment Dispute Form) and return it along with supporting billing data to the Secure Fax listed below. Disputes will be reviewed in the order they are received and providers may be asked to provide additional billing and claiming information if more information is needed to complete the process.