Ohio Claims Validation: Handling Claims Denials

If you receive claim denials, there are steps you can take. This video provides an overview of claims validation and offers essential steps to prevent claim denials.

If you are using the Sandata EVV system, it is essential that you make sure each visit is in verified status before billing for those visits. To learn more about using the Visit Maintenance module to resolve visit exceptions, see Managing Exceptions.

Check out the webinar recording of "Get Ready for Claims Matching".  This training session covers the top 4 EVV claim errors and how to fix them so you can get paid on time.

This chart provides steps to take upon receiving claims denials based on the ODM EVV Claims Validation Process.

Remittance Advice	What does this mean?	Steps to take in Sandata EVV
Provider ID does not match:  The Provider Medicaid ID is not in Sandata’s system.	This indicates the plan either sent a claim for a Provider Medicaid ID that is not subject to EVV, or the Provider has not registered with Sandata’s Provider Portal to obtain an EVV account.	Register in the Sandata Provider Portal. Already registered? Make sure the provider ID you used to register is the same as the one you are using to submit claims.
Recipient ID does not match:  The Recipient’s Medicaid ID is not in Sandata’s system. The recipient on the claim does not exist in the provider’s Sandata EVV account.	This indicates the provider has not added the Recipient to their EVV account or the Recipient is missing the correct Medicaid ID.	Go to the Recipient profile in the Sandata portal and add/update the Medicaid ID.
Procedure Code does not match:  There is no matching visit in the EVV account with both the Provider Medicaid ID and Recipient ID for this service.	This could mean: There is no visit in Sandata EVV. The visit is not in Verified status in Sandata EVV. The visit does not have the correct payer and/or service in Sandata EVV.	Go to the Recipient Management screen and ensure the correct program, authorization, and services are in scope. Navigate back to Visit Maintenance module and edit the visit details to make sure the visit has the correct information for the claim. If there is no visit, use the Create Visit button.
Unmatched Units:  Electronic Visit Verification System units do not meet the requirements of visit. The units on the claim line are not “equal to or less than units on the visit.”	This means there is a visit in a Verified status that would match to a claim request, except there are not enough units on the visit.	Go to the Visit Maintenance module and edit Visit Details to update the call times. Make sure to add reason code for adjusting visit.

This table provides a description of the error codes and the resources that will help you reduce claims denials.

Error Code and Description	Sandata EVV Guide
Provider ID does not match:  Mismatch between the submitted provider information and the provider information stored in the system. The provider on the claim does not exist in EVV Aggregator.	Provider Identification (ID) Does Not Match
Recipient ID does not match:  Patient not enrolled in Electronic Visit Verification System. The recipient on the claim does not exist in the provider’s EVV account.	Creating a New Recipient Record
	Updating an Unknown Recipient
Procedure Code does not match:  Procedure code billed is not correct/valid for the services billed or date of service billed. The date of service, payer, and procedure code on the claim line do not match visit information.	Creating Recipient Authorizations
	Viewing Service Details
	Fixing an Incorrect or Missing Service
	Correcting an Unauthorized Service Exception
Unmatched Units:  Electronic Visit Verification System units do not meet the requirements of visit. The units on the claim line are not “equal to or less than units on the visit.”	Creating a Call
	Creating a Visit
	Adjusting Visit Times and Dates