ACCESSING PROVIDER MASTER LIST
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- Annice Hardy
- 8 years ago
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1 AHCA requires that all providers who render services in the state of Florida are registered to ensure reimbursement. AHCA maintains a Provider Master List (PML) on their Managed Care site ( for providers and MCOs to download and view. This list includes detailed information about a provider's type, specialty, NPI, and Medicaid status. This information is pertinent for various reasons; to include: a provider s eligibility to provide services, claim/encounter reimbursement, and increased payments. AHCA requires that provider's records on the Provider Master List (PML) have a unique cross-reference between their NPI and each Medicaid identification number to create a one-to-one relationship. Based on provider validation our system is unable to identify a unique record for accurate claim/encounter processing. Claims/encounters submitted to AHCA are subject to a hierarchical waterfall logic that performs matching validation between what was submitted on a claim/encounter and what AHCA has document on their Provider Master List (PML). The logic is as follows: 1. Are there any rows for the submitted NPI if not, a match cannot be made 2. Is there a single match on NPI 3. Is there a single match on NPI + Taxonomy 4. Is there a single match on NPI + Zip 5 5. Is there a single match on NPI + Zip 5 + Zip 4 6. Is there a single match on NPI + taxonomy + Zip 5 7. Is there a single match on NPI + taxonomy + Zip 5 + Zip 4 ACCESSING PROVIDER MASTER LIST 1. Access the PML on AHCA s Managed Care site at: 2. Scroll to the bottom of the page until Provider Master List is visible. 3. Click the link for the spreadsheet unless the delimited text file is preferred 4. A file download pop-up will appear. Depending on preference either save or open the zip file. a. This document will show the open selection.
2 5. After selecting Open a download will begin and a WinZip pop-up will open containing a csv. file typically with the naming convention prw19000.csv. 6. The file can either be opened or saved and opened depending on preference. 7. An opened file should look like this (Columns A-X): PREP FOR SEARCH 1. Highlight all data contained in file by clicking the left corner. 2. Select the Data tab. 3. Select Filter and drop downs will appear on all columns with text.
3 4. I. Reject Code 320: Billing Provider NPI Not Found on the State Roster 1. A search by NPI can be performed to see if a valid and active record appears on AHCAs Provider Master List (PML). a. If the provider s information is not found on AHCA's PML then a WellCare Health Plans, Inc. representative should be notified to perform additional research pertaining to the rejection. If it is concluded that a record cannot be located then the provider can decide to do one of two things: i. WellCare Health Plans can obtain a Medicaid ID on his or her behalf. Registrations performed by WellCare are not fully enrolled (Not FFS); and, when applicable, are subject to the required Level 2 background screening. WellCare can register a provider in one of two ways: Mass Registration and Manual Registration. Mass Registration is an automated process with a one business day turnaround. This is the most common method; however, there are certain requirements that a provider must meet in order to be registered using this method. Manual Registration: A twopage form is prepared and mailed to AHCA. This process takes business days to be processed by AHCA. This method is used when a provider does not meet the Mass Registration requirements.
4 ii. The providers who wish to fully enroll with AHCA can register electronically using the online enrollment wizard. The wizard is available at: The provider can also access enrollment forms for manual submission at lmentforms/tabid/129/default.aspx. Providers who need to register but do not wish to fully enroll with AHCA can access the necessary form at: 20Files/MCO%20Treat%20Prov%20Reg%20Rev% pdf *Please note: Any provider that is not fully enrolled with AHCA is subject to a Level 2 background screening. II. Reject Code 321: Unable to Obtain a unique Medicaid-ID for Billing Provider NPI or Zip-5 on the State Roster. 1. This error indicates a unique match was not identified based on step following through steps 1-5 in the hierarchical process discussed previously. b. The example shows that neither record has a taxonomy documented, so the validation would be based on NPI+Zip 5. c. One of the records in the example does have an exact match by NPI + Zip 5 but the second record counteracts this because the zip code field is null. i. Nulls on the PML are supposed to work as a wildcard to allow any entry to pass. Unfortunately because of that basically the system sees the supplied zip code in both fields and supplies a warning because it is unable to find a match. 4. If a unique or matching record does not exist a provider has a few options for resolution: Option 4.
5 iii. Both fully enrolled and mass registered providers may correct the data recorded on their given Medicaid record by downloading the NPI Registration Form and faxing any revisions to AHCA. The form is located at: 20Files/AHCA_Form_ _NPI_Reg_Form_ pdf III. Reject Code 322: Unable to obtain a unique Medicaid-ID for Billing Provider NPI or Zip-9 on the State Roster 1. This error indicates a unique match was not identified based on step following through steps 1-4 in the hierarchical process discussed previously. b. The example shows that all records have the same taxonomy. c. Two of the records in the example do have an exact match by NPI + Zip 5 but (Should but be in uppercase?) there is not a distinct record based on NPI + Taxonomy + Zip Code. 5. If a unique or matching record does not exist a provider has a few options for resolution: Option 4.
6 iii. Both fully enrolled and mass registered providers may correct the data recorded on their given Medicaid record by downloading the NPI Registration Form and faxing any revisions to AHCA. The form is located at: 20Files/AHCA_Form_ _NPI_Reg_Form_ pdf IV. Reject Code 323: Unable to obtain a unique Medicaid-ID for Billing Provider NPI, Taxonomy AND Zip-5 on the State Roster 1. This error indicates a unique match was not identified based on step following through steps 1-6 in the hierarchical process discussed previously. b. The example shows that both records have the same taxonomy. c. Both records have a distinct zip-code but (Should but be in uppercase?) neither matches the zip code(should be 2 separate words) submitted to WellCare. 4. If a unique or matching record does not exist a provider has a few options for resolution:
7 iii. Both fully enrolled and mass registered providers may correct the data recorded on their given Medicaid record by downloading the NPI Registration Form and faxing any revisions to AHCA. The form is located at: 20Files/AHCA_Form_ _NPI_Reg_Form_ pdf V. Reject Code 324: Unable to obtain a unique Medicaid-ID for Billing Provider NPI, Taxonomy and Zip-9 on the State Roster 1. This error indicates a unique match was not identified based on step following through steps 1-7 in the hierarchical process discussed previously. b. The example shows that two of the records have the same taxonomy. c. Both records have a distinct zip-code but neither matches the zip code submitted to WellCare. 4. If a unique or matching record does not exist a provider has a few options for resolution:
8 VI. Reject Code 325: Multiple Medicaid ID's found for Billing Provider NPI and Zip- 9 on the State Roster. 1. This error indicates a unique match was not identified based on step following through steps 1-5 in the hierarchical process discussed previously. b. The example shows that all three records have a distinct taxonomy but since the provider did not supply a taxonomy, the logic moves to trying to match NPI + Zip5. c. All three records have the same zip code so the system is unable to identify a unique match. 4. If a unique or matching record does not exist a provider has a few options for resolution: VII. Reject Code 326: Multiple Medicaid ID's found for Billing Provider NPI, Taxonomy and Zip- 9 on the State Roster. 1. This error indicates a unique match was not identified based on step following through steps 1-7 in the hierarchical process discussed previously. b. The example shows that both records have the same taxonomy.
9 c. Both records have the same zip code so the system is unable to identify a unique match. 4. If a unique or matching record does not exist a provider has a few options for resolution: VIII. Reject Code 333: Provider type enrolled with FL Medicaid not allowed to bill Institutional for the services rendered. 1. This error indicates that while a unique match was obtained using steps 1-7, the claim type submitted does not align with the provider type of the record. a. Based on AHCA s Provider Types and Specialty Codes detailed in the Managed Care Organization Provider Mass Registration Enrollment Guide (P. 7-11) the following provider types and specialties would meet the criteria for submitting a UB-04. PROV TYPE PROV DESCRIPTION SPEC CODE SPECIALTY DESCRIPTION 01 General Hospital 200 Hospital with Birth/Delivery Services 01 General Hospital 201 Emergency Services 01 General Hospital 210 Psychiatric Community Hospital/CSU 01 General Hospital 211 CAP Only Adult Psychiatric Community Hospital/CSU CAP Only Child 01 General Hospital 901 General Hospital 04 State Mental Hospital 904 State Mental Hospital 09 Skilled Nursing Unit Hospital Based 909 Skilled Nursing Unit Hospital Based 11 State ICF/DD Facility 911 State ICF/DD Facility 12 Private ICF/DD Facility 912 Private ICF/DD Facility 13 Swing Bed Facility 913 Swing Bed Facility 15 Hospice 915 Hospice 16 Statewide Inpatient Psychiatric Services (SIPP) 916 SIPP 66 Rural Health Clinic 966 Rural Health Clinic 68 Federally Qualified Health Center 968 Federally Qualified Health Center
10 89 Dialysis Center 989 Dialysis Center ACCEPTABLE CROSSOVER FOR MEDICARE-MEDICAID PROV TYPE PROV DESCRIPTION SPEC CODE SPECIALTY DESCRIPTION 68 Federally Qualified Health Center 968 Federally Qualified Health Center 66 Rural Health Clinic 966 Rural Health Clinic 83 Therapist (PT, OT, ST, RT) 983 Therapy Group (PT, OT, ST, RT) 83 Therapist (PT, OT, ST, RT) 090 Occupational Therapist 83 Therapist (PT, OT, ST, RT) 091 Physical Therapist 83 Therapist (PT, OT, ST, RT) 092 Speech Therapist 83 Therapist (PT, OT, ST, RT) 093 Respiratory Therapist b. The example shows two records have the same taxonomy as the one submitted on the encounter. c. Of the two records one matches the zip code supplied on the encounter. d. The key to this rejection is the provider type. In this instance the provider type is a 20 = Pharmacy. i. A pharmacy claim is not submitted on a UB-04 which is the claim type for this encounter. ii. Also review of the procedure codes indicate emergency services which does not align with a pharmacy provider type but instead the Provider Type Code 01 = Hospital. 4. If the provider type determined after identifying a distinct match is inaccurate the provider has a few options: a. The provider can correct the claim/encounter with data elements that coordinate with the correct record on the PML. Resubmission of the encounter will require a resubmission code of 7
11 IX. Reject Code 407: Rendering Provider NPI Not Found on the State Roster. 1. This error indicates the NPI submitted for the Rendering NPI is not registered with AHCA and therefore cannot be found on the Provider Master List. 2. All providers who render services to Medicaid members must be registered with the state and can use the following methods for registration: a. Providers who wish to fully enroll with AHCA can register electronically using the online enrollment wizard. i. The wizard is available at: b. Providers who need to register but do not wish to fully enroll with AHCA can access the necessary form at: MCO%20Treat%20Prov%20Reg%20Rev% pdf c. In addition if the provider would like WellCare s assistance with the registration process we would be happy to advise or assist as much as we are able. Please contact WellCare at: X. Reject Code 408: Rendering Provider NPI and Taxonomy Not found on the State Roster. 1. Rendering provider verification only passes through NPI + Taxonomy validation. This error indicates the provider has more than one matching record so a unique match is not attainable. 2. A rendering provider must have and Individual/Group designation of I = Individual. 3. When reviewing the eligible records there are two with and I designation; one of which has the correct taxonomy. Unfortunately the blank taxonomy record acts as a wildcard so a matching taxonomy makes the system believe this is a duplicate record. 4. If a unique or matching record does not exist a provider has a few options for resolution: a. The provider can correct his or her registration information:
12 XI. Reject Code 409: Rendering Provider NPI and Taxonomy Not found on the State Roster. 1. Rendering provider verification only passes through NPI + Taxonomy validation. This error indicates the provider has more than one matching record so a unique match is not attainable. 2. A rendering provider must have and Individual/Group designation of I = Individual. 3. When reviewing the eligible records there are two with and I designation. 4. In this case the taxonomy for the Rendering provider is null which acts as a wildcard; and able to match to any record. Unfortunately there are two records and the system is unable to determine a distinct match. 5. If a unique or matching record does not exist a provider has a few options for resolution:
13 XII. Reject Code 410: Multiple Medicaid-ID's found for Rendering Provider NPI and Taxonomy on the State Roster. 1. Rendering provider verification only passes through NPI + Taxonomy validation. This error indicates the provider has more than one matching record so a unique match is not attainable. 2. A rendering provider must have and Individual/Group designation of I = Individual. 3. When reviewing the eligible records there are three with and I designation. Two of the records have a matching taxonomy and the third record has a blank. 4. All records in this case are considered duplicates causing inability for the system to identify a unique record. 5. If a unique or matching record does not exist a provider has a few options for resolution: a. The provider can correct his or her registration information:
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