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Claims Information
Claims Overview
Ped-I-Care claims are paid by the Third Party Administrator, MED3000. Ped-I-Care pays for services at the prevailing Medicaid rate and will follow Medicaid guidelines for service limits. Payments are made according to the Utilization Management policies described in this manual.
Ped-I-Care only pays for services to children who are enrolled in Ped-I-Care during the month in which the service is provided. If a child loses eligibility for Ped-I-Care, the provider should contact the CMS Office for consultation on payment options.
Physician extenders (ARNPs and Physician Assistants) may bill “incident to” an enrolled provider in accordance with Medicaid guidelines. They must be currently licensed, operating within the scope of their profession and in accordance with the protocols established by the provider under whose authority they practice. The physician must be on-site during the visit/service provided and must sign the chart.
Payment Criteria
In order to be paid, a claim must meet the following criteria:
- Member must have been enrolled in the month service was delivered
- Service is a covered and authorized benefit
- Provider must be enrolled in the Ped-I-Care network (unless out-of-network services are authorized)
- Uses HIPAA and Florida law compliant format for claims submission
- Claim must be complete and accurate
- Claims for specialty services and procedures need to include the referral/authorization number
- Procedure must be consistent with the diagnosis code listed on the claim
- Claims must be submitted within 90 days of the date of service
Claims Submission:
Electronic claims are the preferred method of claims submission. This can be arranged directly with MED3000 by completing the set-up sheet included in this section (p. 4) and faxing it as requested or by calling the MED3000 Help Desk at 1-866-703-1444.
Paper claims forms may also be used. Hospital facilities should be billed using the standard UB92 form. Professional claims should be filed using a CMS1500 form.
Send paper claims to:
University of Florida ICS
PO Box 10887
Pensacola, FL 32524
Claim payment will be made in accordance with state and regulatory guidelines, within 40 days if submitted on paper and within 20 days if submitted electronically.
Ped-I-Care providers must accept the payment made by the ICS through its fiscal agent (MED3000) as payment in full and may not request payment from Ped-I-Care enrollees or family members. If your claim cannot be paid as submitted, MED3000 will give the reason on the Explanation of Benefits (EOB) that will accompany every payment to your office.
If you have questions about the payment or the EOB, please contact MED3000 Customer Service at 1-800-664-0146. They will respond to your questions or concerns. If, after talking with them you wish to appeal a claim, you should follow the procedures described in this manual (see Section VIII).
Online Claims Status:
MED3000 offers INFOsource, a web-based application that will allow providers to check on the status of claims, to verify eligibility and to obtain referral numbers and authorization and referral information. This will provide accurate and timely information, while decreasing time spent on the phone.
To use INFOsource, you will need access to the Internet or dial-up connection with the following: Pentium Processor (preferably 200 MHz or better), Windows 95, 98 or NT (including dial-up connection; 16 Meg RAM (preferably 64 Megs), Internet Explorer 4.0 (or greater) and a 14.4K (56K for best performance) modem.
The internet address is: https://infosource.pensacola.med3000.com. For more information or to establish a login for your office, please contact the MED3000 Help Desk at 1-866-703-1444.
