May 5, 2020

State of Alabama
Press Release: Medicaid

Enhancement to Third Party Denial (TPL) Claims Process

PDF Version

TO:  All Providers

Effective 05/06/2020, claims which have other commercial insurance primary (not Medicare) that have denied the services can be submitted electronically. The list of denial codes that may be submitted electronically can be found here:
https://medicaid.alabama.gov/content/7.0_Providers/7.1_Third_Party.aspx. Providers will complete a simple form, attach TPL Explanation of Benefits and upload electronically. Once the form has been completed an electronic claim can then be submitted for review. 

First, upload supporting documentation and receive an ACN (Attachment Control Number) to be used in claims submission. Please follow these steps:

Accessing the Medicaid Interactive Web Portal

A secure logon to the Medicaid Interactive Web Portal is required to access the new TPL Claims Form. TPL Claims supporting documentation may be submitted in two different ways:

         Medicaid Interactive Web portal (preferred)

https://www.medicaid.alabamaservices.org/ALPortal/.

         Fax information using barcode cover sheet received after submitting the form in the web portal.

 

Browser Compatibility

Follow the below instructions to set their browser compatibility settings:

         Navigate to the Medicaid Interactive Web Portal using the URL provided above.

         Select Tools from upper right-hand corner of browser. The feature is displayed as a wheel.

         Choose Compatibility View Settings.

         Click Add.

         Click Close.

         Refresh Browser to apply setting.

 

Documents must be in a Portable Document Format (PDF)

Documents must be in a PDF for upload through the Web Portal. If you do not currently have the ability to create PDF versions of supporting documentation, you may perform an internet search and find free downloadable utilities that can be installed to create a PDF. For your convenience, DXC is including a list of three PDF creation utilities that can be installed to create PDF documents at no charge:

         PrimoPDF - http://www.primopdf.com/

         Solid PDF Creator - http://www.freepdfcreator.org/

         PDF24 - http://pdf24-pdf-creator.en.softonic.com/

 

Steps to Upload Documentation

Once a PDF utility has been successfully downloaded and the PDF document created, providers should follow these steps to upload documentation for review:

  1. Log on to Medical Interactive Web portal by going to the following link and selecting Secure Site: https://www.medicaid.alabamaservices.org/ALPortal/.
  2. Select Trade Files/Forms.
  3. Select the “TPL Claims Attachment Supporting Doco” form from the drop-down list and click on Search.
  4. Complete all fields on the form (Record ID and Attachment Control Number fields will auto populate). Required fields are indicated with an asterisk (*).
  5. Click Browse and select the required TPL Explanation of Benefits documentation from your network drive or PC.
  6. Review all the values entered for completion and accuracy as no further updates will be allowed once the Submit button is pressed. Note: If any error messages are presented, resolution of the identified errors is required to complete submission.
  7. Press Submit.
  8. A message will be generated at the top of the page that states “Your form was submitted successfully."
  9. A barcode cover sheet is generated and will be displayed. It is imperative that you save a copy of this cover sheet should you be requested to submit additional documentation for this packet.
  10. Select the Print Friendly View button to print the barcode cover sheet.

  Steps to FAX Documentation

Information can also be faxed in for review. Providers should follow the instructions below to fax documentation:

  1. Follow steps 1-10 documented above.
  2. Include the barcode cover sheet as page one of the fax transmission for the corresponding attachment control number.
  3. Fax the required documentation with the barcode cover sheet on top to (334) 215-7416. Important: Barcode cover sheets are unique to each TPL Claims form submission. DO NOT use it for another TPL Claims form submission.
  1. DO NOT place anything over the barcode on the cover sheet or alter it in any manner.
  2. DO NOT fax double sided pages.
  3. DO NOT fax multiple sets of records at the same time, each fax should be sent separately.

NOTE:

A fax submission cannot be processed without the barcode cover sheet.

Forms using the fax method will be kept for 30 days to allow a provider to upload the supporting documentation. If the supporting documentation is not received, the forms will be purged. 

Once a TPL form is completed and supporting documentation is received, it will be used in the claims review process to determine claims payment or denial. The claims submission for this process is detailed below.

The next step is to submit an electronic claim that will be suspended for review.

How can a provider submit a claim?

You can continue to submit claims as you do today. If you use a software vendor, consult with your software vendor prior to submitting claims to ensure they are populating the proper loops and segments. When submitting claims with a TPL denial, you include the appropriate primary payer information (most importantly the adjustment information with corresponding denial reason from the payer) and an ACN (Attachment Control Number). These items are required for claims to process correctly and not deny for TPL edits. The ACN must be obtained from the AL Medicaid Interactive Web Portal by completing the new TPL Attachment form as described above. 

 

  For claims submitted through 5010 X12:

1.    In either Loop 2320 (Header) or Loop 2430 (Detail) a CAS segment corresponding to the Primary Payers Adjustment amount (for these claims it should equal the billed amount) and denial reason (CARC) must be submitted.

       Example - CAS*OA*59*124.01~

2.    In either Loop 2300 (Header) or Loop 2400 (Detail) a PWK Segment must be submitted with the below values:

       PWK01 = EB

       PWK02 = FT or FX

       PWK05 = AC
PWK06 = Your Provided Attachment Control Number

       Example - PWK*EB*FX***AC*123456789

   For claims submitted on the Medicaid Interactive Web Portal:

New panels have been added to the TPL Information Section of the claim forms to allow for submission of data elements necessary to process these denied claims correctly.

                               1.    The new supplemental information panel is now available to add the appropriate                                                          ACN to your claim. 
   

       By clicking add, the panel will create a record and auto-populate the Report Type as EB and Transmission type as FT (valid values for the TPL Denial Process).

       Populate the Control number field with the ACN provided by the TPL Attachment form.

2.    The New TPL Denial subpanel is now available to provide the amount denied by the Primary Insurance and the appropriate denial reason (CARC) provided by the primary payer.


 

   For claims submitted through PES:

1.    PES does not currently allow claims to be submitted with this information, but a software upgrade (3.11) will be available in the near future.

 

Medicaid Claim Denials:

If all the required elements for a TPL Denied claim are not correctly submitted, and/or the information (Dates, Providers, and Recipients) on the claim does not match that of the corresponding ACN, then appropriate error responses will be returned.

 

Some examples of what a provider can expect to see on the denied claim include:

      2570 TPL DENIAL CAS CODE NOT SUBMITTED

      2572 ATTACHMENT CONTROL NUMBER NOT SUBMITTED

      2573 ATTACHMENT NUMBER NOT ON FILE

      2574 ATTACHMENT STATUS IS REJECTED

      2575 ATTACHMENT PROVIDER MISMATCH

      2576 ATTACHMENT RECIPIENT MISMATCH

      2577 ATTACHMENT DATE MISMATCH

 


 
If all the required elements for a TPL Denied claim are correctly submitted and the information on the claim matches the documentation which corresponds to the submitted ACN, then the claim will be suspended for internal review. The claim along with the supporting documentation will be used to determine if the claim should Pay, Deny, or if additional documentation is required.


The Current Procedural Terminology (CPT) and Current Dental Terminology (CDT) codes descriptors, and other data are copyright © 2020 American Medical Association and © 2020 American Dental Association (or such other date publication of CPT and CDT). All rights reserved. Applicable FARS/DFARS apply.

 

 

 

 

 

 

 

 

 

 

 



  • For more information, visit http://medicaid.alabama.gov
  • For more state-wide press releases, click here