How claim are processed by insurance - paid or denied

Level of Claims Processing

Paper Claim Handling

When the Medicaid fiscal agent receives a paper claim, it is screened for missing information and necessary attachments. If information or documentation is missing, the claim will not be entered into the Florida Medicaid Management Information System (FMMIS). It will be returned to the

provider with a Return to Provider (RTP) letter that will state the reason the claim is being returned. The provider needs to correct the error, attach any missing documentation, and return the claim to the fiscal agent for processing.

Claim Entry 

Data entry operators image and key into FMMIS each paper claim that passes initial screening. Electronic claims are loaded by batch into FMMIS by the fiscal agent’s data processing staff.

Claim Adjudication 

FMMIS analyzes the claim information and determines the status or disposition of the claim. This process is known as claim adjudication.

Disposition of Claim

A claim disposition can be:

·  Paid: payment is approved in accordance with program criteria.

·  Suspended: the claim is put on “hold” so it can be analyzed in more detail by the fiscal agent or AHCA Medicaid.

·  Denied: payment cannot be made because the information supplied indicates the claim does not meet program criteria, or information necessary for payment was either erroneous or missing.

Processing Time Frames Claims are processed daily. Payments are made on a weekly basis. Under

normal conditions a claim can be processed from receipt to payment within 7 to 30 days.