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MACSIS Guideline Summary for Claims and Claims Payment

(Updated on 9/10/2004)

As stated in the board/State agreement, boards must comply with MACSIS guidelines for the submission and payment of claims. Since the guidelines pertain to all aspects of board operations, the finance-related matters have been consolidated and highlighted below:

Guidelines Supporting Reference
100% Payment for Medicaid Services

Boards are required to pay providers 100% of their Medicaid contracted rate at the time the service is billed by the provider minus amounts of actual payments received from other carriers as reported on the electronic claim file. 

Guidelines Pertaining to MACSIS under HIPAA, Topic 43
Timeliness of Claim File Processing

Boards or MACSIS Administrators may not choose to process files only monthly or semi-monthly. If files have been submitted, they must be processed weekly unless there are MACSIS system problems preventing the State or Board/MACSIS Administrator from processing files. 

All Boards or MACSIS Administrators are required to notify their providers within seven business days of receiving a claim file if the file was accepted and processed into MACSIS and the corresponding MACSIS batch number under which it was processed or if the file was rejected. If the file was rejected, the Board or MACSIS Administrator must indicate the generic reason why and what action the provider is expected to take accordingly. 

Guidelines Pertaining to MACSIS under HIPAA, Topic 42

Claims EDI File Processing For the 837P in MHHIPAA

Timeliness of Payment

Boards must remit 100% payment from non-Federal funds to the provider for Medicaid services before state department(s) receive FFP reimbursement from ODHS.  Remit payment means actually disbursing the check, not just the remittance advice.   Boards should check every Monday for 835/ERA files in their Unix directory because they may have claims they are responsible for paying which came into the system via another Board.  For claims submitted to a particular Board, the reimbursement of the FFP is estimated to be 90 calendar days from the date of a provider submitting a billing file to the Board.  An 835/ERA for the majority of those claims submitted would be produced and available approximately 30 days from the date of submission.  Providers must be paid prior to the FFP being received by the Departments (CMIA requirement).  This is within four weeks of the creation of the 835/ERA. It is approximately 45 days from the date the department(s) receive the ODHS pay/reject file to the FFP being available to a Board.

Any non-Medicaid services paid for with Federal funds are also covered by the CMIA.  These services should be paid within 30 days of creation of the 835/ERA or the federal interest penalties of the CMIA may be applicable.

Guidelines Pertaining to MACSIS under HIPAA, Topic 43

Medicaid Agreement Item 12

Claims EDI File Processing for the 837P in MHHIPAA

Inter-Agency Agreements between the Departments and ODHS

MACSIS Claims Timeline Documents

Other Agency Match Guides Pertaining to
Boards, not providers, are responsible for receiving any matching funds from CSB/CDHS. Payment of valid claims can not be made contingent upon receipt of such matching funds.  
Out-of-County

Boards MUST pay providers for Medicaid Eligible Services rendered to Medicaid Eligible Clients enrolled in that Board’s group and plan in MACSIS irregardless of the County of Service, as long as the servicing Provider holds a valid Medicaid contract with at least one Board.

Boards cannot withhold payment to a provider on behalf of a client receiving eligible out-of-county services during the time when a residency dispute between boards is being settled.

Once the dispute is settled, boards may seek reimbursement outside of MACSIS for paid services from the responsible board as determined by the settlement.

Eligible out-of-county services include Medicaid eligible services, non-Medicaid crisis intervention MH service within three days, Level 1 ADAS services within 3 days or Level III-IV detoxification services within three days or until the appropriate linkage of services with the home county occurs.

Guidelines Pertaining to MACSIS under HIPAA, Topic 16 

Guidelines and Operating Principles for Residency, bullet 16 

Medicaid Agreements (for Medicaid Clients)