Provider FAQ

Registration is quick and easy. Go to the Secure Provider Portal, then choose the “Create an Account” button link. If you need help getting through your registration, use our step-by-step video guide or PDF available on the same page.

On the portal, you can:

• Check eligibility and view member roster
• Submit and check authorizations, claims and batch claims
• Access EOPs and capitation reports
• View care gaps for members
• Send secure messages to MHS
• And more! 

Providers’ member panel lists are available via the Secure Provider Portal. The listing can be filtered and downloaded into Excel.

The Panel Management form, along with the Member Disenrollment form, can be found within the MHS Secure Provider Portal.

In-network provider offices, practitioners, facilities, and ancillary service providers are all listed in the MHS Find a Provider search. Please remember, practitioners that are not involved in direct patient care, such as pathologists, radiologists and mid-level practitioners that are not acting as a PMP, will not be displayed on the directory even if they are contracted.

For vision providers and behavioral health providers, please follow these links:

• Vision Providers: Envolve Vision
• Behavioral Health Providers: Cenpatico

Please visit our online Provider Network Participation & Enrollment Process.

Contracted providers (A medical provider that has an agreement with MHS to accept their patients at a previously agreed upon rate of payment):

• All claims must be submitted within 90 calendar days of the date of service. The filing limit may be extended for newborn claims when the eligibility has been retroactively received by MHS, up to a maximum of 365 calendar days for services provided within the first 30 days of life.

Non-contracted providers (A medical provider that has declined an agreement with a health plan):

• Claims must be submitted within 180 calendar days of the date of service. 

The most current denial (EX) and reject codes list is available on our Guides and Manuals page.

Claims submitted before 5 p.m. EST will display status updates within 24 hours.

No, MHS is not able to display claims rejected by clearinghouses via the Secure Provider Portal.

At this time, there is no way to file a claim appeal through the Secure Provider Portal. For a full outline of claim appeal procedures, please refer to Chapter 5 of the MHS Provider Manual (pages 27-29), available on our Guides and Manuals page.

Coordination of Benefits (COB) is important for proper claims payment. We regularly look at third party liability to ensure claims are paid correctly.

If MHS overpays a claim, we may choose not to recoup the overpayment, but to reduce future claim payments to the provider until the overpayment is satisfied. The recoupments are reflected as a negative balance, and therefore will be carried over to subsequent EOPs until overpayment is satisfied. For example, Member A’s claim with a provider was overpaid by $100. The next claim processed for the provider (for any member) will reduce the payment amount until the $100 is satisfied. This could be done on one claim or over multiple claims depending upon the total dollar amount of the recoupment and the claims processed.

Example:

Member A – DOS 1/1/16, overpaid claim by $100

Member B – DOS 1/15/16, provider should be paid $60; EOB will reflect -$60.

Member C – DOS 1/18/16, provider should be paid $40; EOB will reflect – $40. (Negative balance is satisfied at this point).

The initial EOP will show the claim/claims that will be recouped. It will list the claim number along with the service line or lines that caused the take back. The provider will also receive an EX code to indicate why we are recouping along with the payment amount to be recouped. Please retain the initial negative balance EOP until the negative balance is $0, as overpaid claims information will not be repeated on future EOPs.

How should home health services be processed?

Provider Portal

• Occurrence codes billed on the portal are currently limited to 4 dates. Span dates are currently being reviewed for future use.
• Enter the 61 occurrence code with the Date of Service in the From field, then select Add.
• You may then add the next 61 with next date of service in From field and select Add (for a total at this time of 4 lines).
• If you enter the To date, you will receive an error, and it will not let you continue without removing that date.

Paper Claims

• Enter individual dates in box 31a-34b to claim overhead reimbursement (8 dates).
• Enter span dates in fields 35a-36b (up to 4 spans).
• May NOT claim more than 1 overhead per date of service billed.
• Date billed must be represented in box 45 of the UB with correct codes; this will stop a span date from being used if not listed.
• Remember if billing within 30 days of qualified IP admit, and do not have a separate authorization set up, be sure to bill occurrence code 50 and date of the hospital discharge. This will use one of the 8 dates.

Electronic Claims through a Clearinghouse:

• Enter individual dates and occurrence code 61 in loop 2300 with correct Reference Designators and other required data elements (up to 8 dates).
• Enter span dates with occurrence code 61 in loop 2300 with correct Reference Designators and other required data elements (up to 4 spans).
• May NOT claim more than 1 overhead per date of service billed.
• Date billed must be represented in line itemization of claim with correct codes; this will stop a span date from being used if not listed.
• Remember if billing within 30 days of qualified IP admit, and do not have a separate Authorization set up, be sure to bill occurrence code 50 and date of the hospital discharge. This will use one of the 8 dates. 

Pay for Performance (P4P) reports are updated monthly, and available on the Secure Provider Portal, via the Reports tab.