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January 01, 2023

New York Medicaid: Claim denials for non-enrolled providers

As of Oct. 1, 2022, we have begun to deny claims submitted to the UnitedHealthcare Community Plan of New York by providers who are not enrolled with the state Medicaid program. All NPI’s on the claim must be enrolled in order for the claim to process for payment including:

Professional claims Hospital claims
Billing NPI Billing NPI
Attending NPI Rendering NPI
Rendering NPI Referring NPI
Operating NPI Ordering NPI
Referring NPI Servicing NPI

If your claim is denied due to a non-enrolled status, you will see a denial code of Q3V or Q7J.

This policy aligns with the 21st Century Cures Act, which requires all Medicaid Managed Care (MMC) and Children's Health Insurance Program network providers to be enrolled with state Medicaid programs no later than Jan. 1, 2018.

What to do if your claim is denied

If your claim is denied, you must begin the process to enroll with NY State Medicaid.

You will not need to resubmit claims once the enrollment process has started. Automated reprocessing projects will occur monthly to adjust claims for providers who have become enrolled with NY State Department of Health.

Resources and supporting information

For more information, view the following resources:

Questions?

Contact your UnitedHealthcare Community Plan representative.

PCA-1-22-04042-C&S-News_12122022
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