When a provider inquires about why they were denied on any claim for eligibility reasons, Medical Services can verify that the provider had checked on the member's eligibility and got a YES confirmation for a particular service date.
A provider normally logs into North Dakota MMIS Web Portal to check the eligibility on a member for a particular service date prior to providing the service to that member to ensure that they will be paid when the claim is submitted. The member eligibility function provides a confirmation to the provider indicating whether the member is eligible or not.
This situation occurs when a retroactive change is received from the member eligibility interface that changed the member's eligibility dates.
After Medical Services verifies that the provider did in fact check on the member's eligibility and received a Yes confirmation before performing the service, then the claim can be forced paid.
The detail information for member eligibility confirmation provides the category of eligibility, the type of eligibility, their beginning and ending dates, as well as the benefit plan that the member is assigned to. This information is useful when force paying the claim that was denied.
How to Search for Member Eligibility Confirmation
How to View a Member's Eligibility Confirmation Details
Eligibility Confirmation Search Page
Version as of 5/16/14.
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