Process for Handling Medicaid Claim Denials / Other Insurance Found

Introduction

This process provides step-by-step instructions for CSRs when Medicaid denies client claims or when another insurance is identified in the Medicaid system. The goal is to ensure accurate billing, timely communication with clients, and proper documentation so that services are not provided without confirmed coverage.

Step 1: Review Case Details

Review the email/text sent by Leigh for client and claim information.

Open the client’s account in Therapy Notes.

Note the number of sessions Medicaid did not cover.

Step 2: Cancel Sessions & Record

Cancel all scheduled sessions for the client.

Add the reason for cancellation to both:

Emmanuel’s Tracker

Appointment Alerts in Therapy Notes

Step 3: Contact the Client

Call the client and explain:

Medicaid has not covered their sessions.

Another insurance is showing in the Medicaid system.

If client confirms they have other insurance:

Collect the insurance details.

Run eligibility/verification on the new insurance.

Inform client that claims will be submitted to the other insurance going forward.

Update billing settings with new information accordingly and notify Leigh

If client states they do NOT have other insurance:

Instruct them to call Carelon Behavioral Health at 1-800-888-1965 and request that an expiration date be added to the other insurance showing in the system.

Remind them that the expiration date must be prior to their session dates for Medicaid to process claims correctly. If the client states that they were informed their insurance was removed, but our records indicate otherwise, we may initiate a three-way call with Carelon Behavioral Health. This will allow them to hear the information directly from the source and ensure the issue is escalated to the appropriate department or supervisor. Clients may also call Maryland Health Connection at [phone] for support.

Important Note (from Carelon): The entire process to update COB can take a week or longer, depending on how long it takes Medicaid to confirm with the other insurance company. Until the expiration date is updated in Provider Connect, claims will continue to be denied — even if the client says the other insurance has been removed. Always follow what is currently listed in Provider Connect.

Step 4: Document in Therapy Notes

Create a Contact Note including:

Patient information

Summary of the interaction with client

Add Billing comment: “No further sessions to be scheduled until the COB is updated.”

Step 5: Notify Clinician(s)

Send an email to the treating clinician(s) and CC the Admin Team.

Note the issue and confirm sessions have been canceled until insurance/COB is resolved.