Denied Claims (Oklahoma Medicaid Management Information System)
Claims can be denied at either the header or detail levels. The header level contains information about the member and provider, but not about the services performed. This is where the OKMMIS will verify member’s eligibility and provider’s contract information. Denials at this level will cause the entire claim to be denied. The detail level of the claim contains information specific to the services performed. The detail level verifies coverage of services, policy limitations or program restrictions. Denials at this level will deny specific service lines and not the entire claim. Once a claim has been denied, providers have two ways to research their denials: via the SoonerCare Provider Portal or the RA.
When researching using the RA, locate the denied claims section. Once you have found a denied claim, view the header information. Any edits applying to the header information will be listed as Header EOBs. These codes are the HIPAA Adjustment Codes and contain general information about the claim. For further description of these codes, see the EOB Code Descriptions page of the RA. You may find several edits listed. Please note that not every edit listed is a denial edit. If there are no header denials, look at each detail line for edits specific to that service. These edits will be listed at the end of each detail line as Detail EOBs.
To learn more about EDI and become a certified EDI Professional, please visit our course schedule page.