AlphaMCS Claims

AlphaMCS Claims And Secondary Claims Processing

AlphaMCS Claims can be submitted via a web-based provider portal that allows providers to submit claims to the LME/MCO. Claims can be submitted via a CMS 1500/UB04 or via an 837P/I. The daily cutoff for nightly adjudication is 5pm. The claims are adjudicated nightly. For claims submitted via CMS1500/UB04, the claims status is updated in the provider portal (download queue) the next business day. The Remittance Advice is available the following week (see Checkwrite Schedule). Claims submitted via 837s will have adjudication information on the 835s which will be available according to the standardized checkwrite schedule. The Claim Specialists and Claim Analysts review the claims processed on a daily basis to ensure claims are approving correctly, to review denials for possible system errors, and to review any claims that pended for manual review. The reviews are performed to ensure that claims are processed efficiently so that payment can be made timely.

Alliance requires all Network providers to either submit claims through the AlphaMCS Portal or to file claims electronically through an 837. All paper claims submitted to Alliance by Network providers will be returned unprocessed to the provider.

Submitting Secondary Claims

Submission of secondary claims will require that the related EOBs are uploaded into AlphaMCS. Providers should upload the EOBs at the time of claim submission. When keying secondary claims you must enter the information needed from the primary EOB as highlighted below. “COB amount” refers to the value paid by primary insurer and “COB Allowable Amount” refers to the value the primary insurance allows for the service billed. You must also include a “COB Reason” in order for the claim to be recognized as a secondary claim.

COB Payment Amount

For approved Secondary claims, Alliance will either:

  1. Pay the difference up to the Medicaid amount, or
  2. Not pay any additional amount if primary pays more than Medicaid allowed amount.

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