What is MedCost?
MedCost is a provider network in North Carolina and Virginia. As a company, they also offer TPA and health plan services, but this article talks only about working with them in their capacity as a network.
What is MedCost’s Role in This Health Plan?
MedCost is responsible for receiving claims, pricing them to their contractual amounts, and sending the priced claims to Yuzu, the TPA. You can read more about this flow in a great blog post by Stedi.
MedCost: Two Networks, One Brand
The Two Different Networks.
MedCost is a network that originally started in North Carolina. They acquired a Virginia network “Virginia Health Network Inc” several years ago, and are in the process of rebranding it to “MedCost”. They are working on integrating the backend claims processing behind the two networks (moving to one PO Box and one electronic PayerID). Right now, though, it is better to think of these two networks as separate for the purposes of submitting claims.
Consult the following table for information on how these networks are differentiated:
MedCost VA | MedCost NC | |
|---|---|---|
Alternate names | Virginia Health Network Inc | MedCost (default) |
Mail Address | P.O. Box 26314 Winston-Salem, NC 27114-6314 | P.O. Box 25307 Winston-Salem, NC 27114-6314 |
Electronic PayerID | 54138 | 56162 |
Transactions Supported | 837I, 837P | 837I, 837P / 270, 271 |
Logo |  |  |
Repricing ID in EDI Spec | 541389446 | 561629757 |
Stedi Payer Network Link | Link here | Link here |
Advantage of Electronic Submissions
HIPAA was passed 30 years ago and requires that health plans accept electronic claims submissions. There is no converse to this requirement: plans do not legally have to accept paper CMS 1500 submissions. Please check out this blog from Stedi to understand more about how important it is for providers to be able to submit electronically.
Although networks like MedCost do their best to support paper claims flows, it is always better to figure out how to submit claims electronically. There are not different validation rules applied to electronic claims versus paper claims, and electronic claims can be received within a day.
Yuzu and MedCost will have a really hard time helping providers get information about claims that don’t show up that were sent paper. Meanwhile, we can dive right into recent electronic claims submissions.
Common MedCost Issues
We’re going to walk through each of these issues.
I cannot electronically submit my claim to MedCost. It does not show up in my system.
I am getting my claim denied by the payer because it says I am sending the claim to the wrong network. I don’t know why.
I submitted my claim, but don’t know where it is. Some (or even all) of my claims are not being received.
Issue 1: I cannot electronically submit my claim to MedCost. It does not show up in my system.
There are two reasons for this:
If you are looking for the MedCost Virginia network, you may need to search for “Virginia Health Network” or similar. See the table above for an explanation.
Keep in mind that MedCost Virginia can still receive claims even if you cannot electronically verify eligibility (through 270/271 transactions). See here for a list of supported transactions with MedCost Virginia.
Summary: It is not true that you cannot submit to these networks electronically, you may just have to adjust how you are searching for these networks within your clearinghouse / EHR.
The network is receiving claims, and Yuzu and MedCost have successfully helped many providers fix their configuration to submit claims correctly.
Issue 2: I am getting my claim denied by the payer because it says I am sending the claim to the wrong network. I don’t know why.
MedCost’s contract with TPAs requires that TPAs enforce that claims are sent to the correct place or denied and returned to the provider. Most TPAs also have auto-deny logic set up to deny claims that were submitted to the wrong place.
In all instances we have looked at, the provider has been mistakenly or unknowingly submitting claims to the wrong place. Here are some common reasons why:
They may not realize that there are two networks with different addresses and PayerIds in place.
Their Payer Record for one of the networks may have the right physical address for the specific sub-MedCost network they are trying to reach, but the wrong electronic PayerId for that network. Providers may think that their claims are being submitted via paper, but they are actually being submitted electronically.
Issue 3: I submitted my claim, but don’t know where it is. Some (or even all) of my claims are not being received.
This issue is almost always caused by providers submitting paper claims. Please submit claims electronically if you expect help tracking down a claim.
Additional Contacts:
If you're unable to locate the correct payer ID, please contact your clearinghouse first, as they can assist with identifying the appropriate payer ID and claim routing.
If the payer information is not available or appears incorrect within your billing software, your EMR or practice management system vendor can help update or configure your payer settings to help with filing the claim correctly.
If you have filed several claims to MedCost Virginia and you have not received payment or you are unsure of the status of your claim, and you have already contacted your clearinghouse to confirm that your claims are being routed to the correct Payer ID (54138), you should reach out to networkservicesspecialist@medcost.com for assistance.
The team at MedCost will respond to networkservicesspecialist@medcost.com. within 16 business hours.