Billing and Claims
Claims will be considered for reimbursement only if they are appropriately authorized by MPC, are a covered benefit and the enrollee is eligible at the time of service.
If prior authorization is required, the prior authorization number must be entered on the appropriate billing form. However, authorizations in themselves are not guarantees of payment.
Claims/Encounter Data Reporting Requirements
Providers shall utilize the most current diagnostic and procedure coding guidelines, including but not limited to International Classification of Diseases (ICD), American Medical Association Current Procedural Terminology (AMA CPT), Health Care Financing Administration Common Procedural Coding System (HCPCS), Diagnostic Statistical Manual (DSM), Current Dental Terminology (CDT), Uniform Billing Data Elements (UB-04) Specification Manual.
Providers may contact MPC’s Claims Inquiry/Claims Research Department (CI/CR), to check the status of claims submitted for reimbursement, clarify any denials or other claim processing actions. CI/CR can be reached at 1-800-953-8854, and then follow the prompts. Registered network providers may also perform claims inquiry through the employment of MPC’s HIPAA-compliant web portal, My MPC Source.
Timely Filing Limitations
Providers are required to submit electronic or paper claims to MPC for reimbursement within one hundred eighty (180) days from the date of service. For a claim on a CMS 1500 claim form, one hundred eighty (180) days is counted from the day that the service was performed. For a claim on a UB 04 claim form, one hundred eighty (180) days is counted from the date of discharge for the hospital or nursing home stay. Claims that are not initially received within one hundred eighty (180) days of the date of service may be denied for payment. Please mail medical claims to:
Maryland Physicians Care
P.O. Box 5080
Farmington, MO 63640-5080
MPC prefers to receive electronic claims via a MPC-approved Electronic Data Interchange (EDI) vendor. Please contact your Provider Relations Representative for further information on electronic claims or for a list of approved EDI vendors.
After MPC has adjudicated a claim, you will receive a Remittance Advice with thereimbursement, which will provide details about the submitted claim and its status.