FAQ for Physicians

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MIPAnet

How do I get access to MIPAnet?
Please follow this link to register.
I’m having technical problems with MIPAnet, how can I reach technical support?

They can be reached by

Claim Status

I’d like to check on the status of my claim(s)

Information regarding your claim(s) can be accessed via our MIPAnet portal.

Or- You can contact our dedicated Call Center at 415 884-1840, option 4.

 

Please note that we do not accept calls-nor give any information regarding claims to any outsourced collection agency, or to third party callers.

If a corrected claim needs to be submitted, what information, aside from the corrected information, is needed?

Meritage no longer asks providers to stamp or write the word “corrected” on CMS-1500 paper form, corrected claim submissions. However, claims do need to contain the correct billing code to help us identify when a claim is being submitted to correct or void a claim that we’ve previously processed. Additional information about the CMS-1500 claim form is available by visiting the National Uniform Claim Committee website at www.nucc.org. Please share this information with your practice management software vendor, as well as your billing service or clearinghouse, if applicable.

Correcting or Voiding Electronic CMS-1500 Claims:

  • Enter Claim Frequency Type code (billing code) 7 for a replacement/correction, or 8 to void a prior claim, in the 2300 loop in the CLM*05 03.
  • Enter the original claim number in the 2300 loop in the REF*F8*.

Correcting or Voiding Paper CMS-1500 Claims

  • Indicate your submission is a Corrected Claim in Box 22 and Box 22A
    • Box 22- Value 7 For Corrected and 8 For Void.
    • 22A- You will need to reference Meritage Medical Network’s original claim number.
What is the time frame for processing a claim?

Claims are typically resolved within 36 calendar days.

How to request a copy of the Explanation of Benefits?

MIPAnet will provide you with all the pertinent information contained in an EOP/EOB. You can also call us to request another copy. Please note that copies will only be delivered to the “pay to” address that we have on file.

How do I go about requesting a check tracer?

Contact our Call Center at 415-884-1840 option 4, or email us at callcenter@meritagemed.com

Can you provide me with information regarding when and who deposited this check?

Yes. The Call Center is here to assist. Please call our office and we will initiate the check tracer and replacement process.

How long does a Check Tracer take?

The process of voiding and replacing checks can take up to 10 business days.

Not sure if I’m Contracted/Associated with Meritage Medical Network?

Physicians can call our Call Center at 415-884-1840 for NorCal, 833-446-1758 for Central Valley, or call their liaisons at:

NorCal Liaisons:

Central Valley Liaisons:

How do I notify Meritage of a change to my billing or other information?

Contact our Network Relations Department at 415-475-4821 or via email at:

I need to add a physician on MIPAnet or the website? How do I get added?

A W9 form must be submitted and sent to Meritage’s Network Relations Department.

 

I received an overpayment notification from Meritage – What do I need to do?

Overpayments are initiated and followed up by the Claims department. Each letter will contain a brief summary of how the error occurred and how to contact us should the you wish to contest the overpayment notification.

Explanation of Benefits and Check Status

How to request a copy of the Explanation of Benefits?

MIPAnet will provide you with all the pertinent information contained in an EOP/EOB. You can also call us to request another copy. Please note that copies will only be delivered to the “pay to” address that we have on file.

How do I go about requesting a check tracer?

Contact our Call Center at 415-884-1840 option 4, or email us at callcenter@meritagemed.com

Can you provide me with information regarding when and who deposited this check?

Yes. The Call Center is here to assist. Please call our office and we will initiate the check tracer and replacement process.

How long does a Check Tracer take?

The process of voiding and replacing checks can take up to 10 business days.

Contract Status

Not sure if I’m Contracted/Associated with Meritage Medical Network?

Physicians can call our Call Center at 415-884-1840 for NorCal, 833-446-1758 for Central Valley, or call their liaisons at:

NorCal Liaisons:

Central Valley Liaisons:

How do I notify Meritage of a change to my billing or other information?

Contact our Network Relations Department at 415-475-4821 or via email at:

I need to add a physician on MIPAnet or the website? How do I get added?

A W9 form must be submitted and sent to Meritage’s Network Relations Department.

 

Overpayments

I received an overpayment notification from Meritage – What do I need to do?

Overpayments are initiated and followed up by the Claims department. Each letter will contain a brief summary of how the error occurred and how to contact us should the you wish to contest the overpayment notification.

Utilization Review

How do I submit a referral or authorization request?

Both referral and authorization requests should be submitted via our MIPAnet* Portal.  If your office does not have an account, please follow this link to register.

On the rare occasion in which you cannot submit to our Utilization Review Department electronically, requests can be faxed to these numbers: 415-884-3505, 415-475-4558.

How do I find out which providers (doctors, hospitals, etc.) are in my network?

Information as to providers and facilities are available on the Meritage website.

The facility information is here.

Or you may call our Call Center directly for assistance at 415-884-1840 or 800-874-0840 (TTY 415-884-1801)

What happens if a member presents to a specialist without a referral?

Referrals can be verified through MIPAnet or by calling the Primary Care Physician’s office. If the PCP did not issue a referral and the member wants to be seen, they must sign a waiver and are then responsible for the services provided.  Providers cannot bill members if they do not have a signed waiver.

We will accept retroactive authorization requests for Commercial plans only. We will not process retro requests for Medicare plans. Instead, providers can submit the claim and all pertinent clinical records to us for a Post Service Review where Julie Gersh will review the request with our Medical Director.  If Dr. Andrews approves the claim, we will pay it. If not, the claim is denied citing “Denied per Medical Review”.

What in office procedures require authorization?

Services that are potentially cosmetic in nature, e.g. skin tags, vascular procedures, certain ENT services, and pain management procedures require authorizations.  Also, any in-office single surgical procedure in which the Medicare allowed amount is greater than, or equal to  $1500.00

Where can I call for questions or additional information regarding the authorization/referral process?

Our Call Center is here to assist you. Please call 415-884-1840 or 800-874-0840 (TTY 415-884-1801).

Are members covered if they obtain medical care outside the network?

If a member receives routine care from out-of-network providers, neither the member’s health plan nor Meritage will pay for the costs.

In a medical emergency, members can go straight to the nearest hospital – It does not have to be in your plan’s provider network. If they are admitted to a hospital because of an injury or life-threatening medical emergency, they should notify their PCP/Health Plan as soon as reasonably possible.

What happens to a member’s coverage when they are in college or out of area?

A dependent child is eligible for coverage until their 26th birthday, regardless of whether or not they are in college.  If your patient’s location is outside of the Meritage Service area, benefits are only provided for urgent/emergent services.   Please contact the health plan directly (e.g. Blue Shield) regarding care needs for out of area medical services.

What is a referral?

A referral is when a primary care physician (PCP) authorizes a covered person to see a specialist for diagnosis or treatment of a medical condition.  Most often, that means they have to call or be seen by the doctor before seeing a specialist.  If you don’t know whether your patient needs a referral contact Meritage Cal Center at 415-884-1840 for assistance.

What is prior authorization?

Prior authorization means getting formal approval from Meritage before your patient can get access to medication or services.  The PCP or treating physician will submit a request to Meritage for review.  A letter of approval or denial will be sent to the requesting physician and patient.  Coverage for approved services is also based on insurance eligibility at the time services are performed.

How long is a referral valid?

Once the PCP or treating specialist approves the referral, a member has 90 days from the time a referral is provided to start care with the specialist.  Once care is initiated, the specialist can continue to treat the member for that diagnosis until the problem is resolved and he/she is discharged from care.

Do I need to submit chart notes for every referral/authorization?

It is not necessary to submit chart notes when referring to providers within Meritage. Please provide current CPT, service and diagnosis code information.

Notes ARE required for the following services:

  • Advanced imaging requests
  • Procedures or surgeries
  • Infertility services
  • Requests for providers outside of Meritage
  • Therapy extensions
  • Specialty Injectable Medication requests
  • Certain DME services, e.g. (Oxygen, CPAP, Hospital Beds)
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