New York: Claim denials for non-enrolled billing providers
Last modified: Feb. 23, 2023
Added clarifying details regarding the enrollment requirement and information on automated reprocessing of incorrectly denied claims.
On Oct. 1, 2022, we began denying claims submitted to the UnitedHealthcare Community Plan of New York by providers who are not enrolled with the state Medicaid program. 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.
Our interpretation of the state’s guidance for these claims edits was that all NPI’s on the claim must be enrolled as a Fee-For-Service (FFS) provider in order for the claim to process for payment. We have recently learned that the billing provider NPI may be enrolled as an “MCO” type to be eligible for payment by UnitedHealthcare Community Plan of New York.
Automated reprocessing projects have started to reprocess claims back to October 1st that were denied for billing provider NPIs listed as “MCO” type (denial code Q3V or Q7J). Adjustments will coincide with the applicable system updates to allow for appropriate claims processing on a go forward basis.
What to do if your claim is denied
If your claim is denied due to no Medicaid Management Information System (MMIS) ID, you will see one of the following explanation codes:
| Explanation Code | Description |
|---|---|
| QSA | Billing Provider validation issue |
| QSB | Billing Provider validation issue |
| QSC | Rendering Provider validation issue |
| QSD | Rendering Provider validation issue |
| QSE | Referring Provider validation issue |
| QSF | Referring Provider validation issue |
| QSV | Ordering Provider validation issue |
| QSW | Ordering Provider validation issue |
| QSX | Supervising Provider validation issue |
| QSY | Supervising Provider validation issue |
| QSG | Service Provider validation issue |
| QSH | Service Provider validation issue |
| QSJ | Attending Provider validation issue |
| QSK | Attending Provider validation issue |
| QSL | Operating Provider validation issue |
| QSM | Operating Provider validation issue |
| QSN | Other Provider validation issue |
| QSP | Other Provider validation issue |
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:
- New York State Medicaid Update - April 2022 Volume 38 - Number 4 (ny.gov)
- New York State Medicaid Update - June 2022 Volume 38 - Number 7 (ny.gov)
- NYS Enrollable Providers List
- Medicaid Enrolled Provider Listing | State of New York (ny.gov)
- UnitedHealthcare Claims, Billing and Payments
- Medicaid Managed Care Provider Enrollment Questions
Questions?
Contact your UnitedHealthcare Community Plan representative.
