Claims and Billing

EFT and ERA

Troubleshooting Frequent Claims Questions/Issues

  • Confirm that the Taxonomy on the claim matches what is in NCTracks.
  • Review the Claims Submission Reminder Guide (PDF) and please also advise your Clearinghouse to make sure the changes made to taxonomy placement are permanent on your account going forward. 

Taxonomy Placement:

CMS 1500 Paper Submission

  • Rendering – Box 24i should contain the qualifier “ZZ”. Box 24j (shaded area) should contain the taxonomy code.
  • Billing – Box 33b should contain the qualifier “ZZ” along with the taxonomy code.
  • Referring – If a referring provider is indicated in Box 17 on the claim, Box 17a should contain the qualifier of “ZZ” along with the taxonomy code in the next column.

837 Professional Submission

  • Billing –Loop 2000A PRV01=“BI” PRV02 = “PXC” qualifier PRV03 = 10 character taxonomy.
  • Rendering – Loop 2310B PRV01=“PE” PRV02 = “PXC” qualifier PRV03 = 10 character taxonomy code002E.
  • Please note that “PXC” is the correct qualifier and that there is no taxonomy number needed for referring physician.

UB-04 Paper Submission

  • Billing – Box 81CCa should contain the qualifier of “B3” in the left column and the taxonomy code in the middle column. 

837I Electronic Submission

  • Billing - Loop 2000A PRV01 = “BI” PRV02 = “PXC” qualifier; PRV03 = 10 character taxonomy code.

Review the Billing Manual (PDF) for guidance.

  • NCTracks is the “system of record” for provider enrollment data, which is then shared with health plans to inform contracting and provider directories. If provider information is not current, then the data that flows forward to the health plans and the enrollment broker will not be accurate.
  • Refer to the Provider Data and Enrollment Guide (PDF) and the Claims Submission Reminder Guide (PDF)
  • Refer to page 22 (see below) of the Billing Manual (PDF). Best practice is to submit corrected claims rather than new claims to avoid this denial. 
  • Duplicate Edits: Code auditing will evaluate prospective claims to determine if there is a previously paid claim for the same enrollee and provider in history that is a duplicate to the prospective claim. The software will also look across different providers to determine if another provider was paid for the same procedure, for the same enrollee on the same date of service. Finally, the software will analyze multiple services within the same range of services performed on the same day. For example a nurse practitioner and physician bill for office visits for the same enrollee on the same day.
  • This comprehensive guide (PDF) walks you through how to submit COB information on a professional claim submitted via the Provider Portal. When following these instructions, it is not a requirement to include a copy of the explanation of Benefits received from the primary payer when submitting a claim via the Secure Provider Portal. We offer this as an optional feature. For claims submitted outside the portal, the EOB is required.

Definitions

  • Paid in Full - The claim has been adjudicated, processed and reimbursed in accordance and with the executed provider contract on file including the coordination of benefits, as applicable per claim.

Provider Claims Payment Schedule

Claim Type

First Claims Payment

First Claims DOS

Future Forward

Envolve Vision

July 8, 2021

July 1 – 7, 2021

Weekly,  Wednesday

NIA

July 13, 2021

July 1 – 9, 2021

Weekly, Tuesday and Friday

Medical

July 13, 2021

July 1 – 9, 2021

Weekly, Monday and Thursday

Pharmacy

July 14, 2021

July 1 – 7, 2021

Weekly,  Wednesday