Date: October 16, 2020
To: Enrolled Federally Qualified Health Centers; Rural Health Clinics; and Encounter Clinics
Re: C97 Rejections for Clinic Providers
This notice provides billing guidance to clinics that have received recent C97 - No Payable Service on Claim errors. This billing guidance only pertains to claims for participants covered under Medicaid fee-for-service and does not apply to claims for members covered under a managed care plan.
Due to HFS internal programming issues, two scenarios have emerged that will require action by providers for proper reimbursement of claims received by the Department on and after June 30, 2020. Both issues are the result of claims splitting during processing, resulting in the T1015 encounter code service line and subsequent detail code service lines being assigned separate document control numbers (DCNs).
If an FQHC, RHC, or ERC received C97 claim rejections on all service lines submitted, including the T1015 encounter code service line and all subsequent detail code services lines, please rebill those claims at this time. Claims should be resubmitted electronically as original claims using bill type/claim frequency ‘1’. As a reminder, paper claims may be submitted only if the claim requires an attachment.
If an FQHC, RHC, or ERC received a C97 claim rejection for the T1015 encounter code service line, but was paid under the submitted rendering NPI for any of the detail code service lines, the DCN(s) of the paid detail code service line(s) must be voided electronically using bill type/claim frequency ‘8’ and the entire claim rebilled using bill type/claim frequency ‘1’. This is true even if the detail code service line(s) paid at $0.00.
The timely filing edits have been systematically lifted for claims with dates of service beginning January 2, 2020 for all actively enrolled FQHCs, RHCs and ERCs in order to allow rebilling of claims affected by this system issue. Lifting of the timely filing edits will be in effect through claim receipt date April 15, 2021.
Questions regarding the information provided above may be directed to the Bureau of Professional and Ancillary Services at 877-782-5565.
Interim Medicaid Administrator