Medicaid providers: Make sure your Primary Specialty is entered in CHAMPS

To align with MDHHS, we’re updating our Medicaid edit 5169 to more accurately validate claims from providers enrolled in CHAMPS as “individual/sole proprietor.” The edit will reference the CHAMPS provider enrollment form’s Primary Specialty field to determine whether a provider is an approved provider type.

If the Primary Specialty field isn’t filled in when the edit logic is updated, providers will see an increase in front-end rejected claims.

We’re aiming to have the edit’s logic updated in the next 90 days and will send a follow-up communication with the exact date.

Fewer requests for providers to reimburse inaccurate payments Medicaid edit 5169 rejects claims for "non-approved provider types” found in the Attending, Ordering or Referring fields for claims submitted by those registered in CHAMPS as individual/sole proprietors.

The state’s 5169 edit validates provider type using CHAMPS Primary Specialty field. This data was recently made available to health plans. Aligning our data sources for this edit with the state’s will lead to:

  • More accurate validation of Medicaid-approved provider types on the claims
  • Fewer claim rejections from the state
  • Fewer requests for providers to reimburse inaccurate payments

What do you need to do?

If you're enrolled in CHAMPS as “Individual / Sole Proprietor”, verify the following before submitting claims for Medicaid members. Make sure:

  1. You're active in CHAMPS on the date of service.
  2. Your Primary Specialty in CHAMPS is complete and an approved provider type.

If you see an increase in 5169 front-end rejected claims after the edit’s logic is updated, you should verify the above and then resubmit your claims.

Note: Medical necessity review doesn’t verify provider type

Providers with approved authorization requests for Medicaid members may still see claim denials if their CHAMPS Primary Specialty isn’t filled out or isn’t an approved provider type.