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November 29, 2006
TO:                 ALL PROVIDERS
FROM:           Leslie m. Clement
SUBJECT:     Cancellation of Claim Cutback Policy
Effective February 1, 2007, Medicaid will deny services/claims which are billed in excess of the remaining Prior Authorized (PA) amounts. Amounts are defined as units, total dollars, or occurrences. These claims currently pend for manual processing for edit 806 “No Prior Authorization on File”. This change is being made in response to requests from providers seeking quicker turn around times on processing of their claims.
Currently, as a courtesy to providers, claims are manually “cutback” in order to process the claim and provide payment to the provider. Depending on the number of claims requiring manual processing in the system, a claim has the potential of waiting up to 120 days for processing to occur. Cutback is a process where the amounts billed on the claim are manually compared against the amounts remaining on the prior authorization, and the amounts on the claim are reduced to match the number of remaining amounts in the prior authorization. By eliminating this process, a claim will generally be processed and denied within the same week of receipt. This will allow providers to research and re-bill with the proper amounts and receive payment in a timelier manner.
Providers wanting to verify whether a Prior Authorization will cover the intended amounts prior to billing can call the MAVIS line at (800) 685-3757 and use the PA feature for verification or request to speak with an EDS agent, or they can contact the authorizing agency at the phone number listed at the bottom of the Prior Authorization notice.
Thank you for your continued participation in the Idaho Medicaid Program.