Claims Submission

Most medical claims are submitted to MedCost Benefit Services from a network after repricing. We encourage providers to submit claims electronically to the appropriate network, since the electronic claims interface typically reduces payment turnaround cycles by 5 – 10 working days. EDI numbers can be located on the claims submission instructions on the patient identification card.

We enjoy a seamless data transfer on claims from most of the affiliated networks, including claims from the MedCost Preferred network. We can offer providers the convenience of Electronic Remittance Advice (ERA) in coordination with payment.

Dental Providers: Claims for all D-series HCPCS or ADA codes should be filed
directly with MedCost Benefit Services since they do not require repricing.
Please use the Payer ID 56205.

Here are some successful filing tips for prompt payment:

• Submit claims to the network indicated on the patients ID card to avoid delays to to misdirection.
• Be sure that all services are correctly coded according to the most current editions of CPT, ICD, HCPCS, ASA, and ADA Manuals.
• Include with claim all critical data elements for identification, including member ID number, policy number, and employer name.
• If possible, include information regarding any other coverage a member may have, and if filing secondary, you can submit the other carrier payment amount in the appropriate electronic field.
• Submit claims as quickly as possible after services are rendered. (Self-funded plans have filing time limits that can affect whether a claim is payable if filed after the designated timeframe.)
• File all claims in the appropriate current electronic format or on the current CMS-approved paper form.

If a claim is denied, MedCost is obligated to provide notice of the adverse determination within 30 days of the receipt of the original claim. Following notification of an adverse determination, the claimant or provider has 180 days in which to appeal the decision. Any formal appeal should be submitted in writing to the MedCost Appeals Coordinator along with supporting documentation.

If the appeal results in a reversal of the original determination, the 30-day time period for processing the claim will begin from the date of the appeal decision. All decisions will be delivered to the party initiating the appeal.