Midwest Health Plan EDI Claims

Midwest Health Plan EDI Claims Department endeavors to assure prompt and accurate claim and encounter review, processing, adjudication and payment. This is accomplished through the development of Midwest Health Plan EDI claims processing systems, pre-payment and post-payment audits, policies, and procedures that are consistently and appropriately applied.

Midwest Health Plan EDI Claims Definition

Midwest Health Plan defines a “claim” as a properly completed claim form (CMS1500, UB04 or electronic version), submitted by a valid provider, for service(s) rendered to an eligible member. Services for-fee-for service and capitation may be billed together on the same form. Capitated procedure codes are reviewed and updated annually. For more information partners can contact Provider Services Representative.

Midwest Health Plan EDI Clean Claims Submission Requirements

HAP Midwest Health Plan accepts claims submitted in the following formats: First time submitters please check with your clearing house for the correct payor ID to use when sending claims to HAP Midwest Health Plan. Also please use the link on the providers home page “Verify Vendor” to make sure the provider payment address is exactly the way you are submitting on your 837. Questions may be directed to Webadmin@midwesthealthplan.com.

In general, HAP Midwest Health Plan follows Michigan Medicaid Uniform Billing Guidelines. Indicate the appropriate HAP Midwest Health Plan product name on the claim (upper right corner on a CMS 1500 form and FL61 on a UB-04 form) and on the outside of the mailing envelope. E.g. Midwest Health Plan, Midwest AKM – Health Choice, Macomb Heath Plan, Med- Basic plan, and Midwest Advantage etc.

Member ID numbers

When billing on CMS 1500 field 1A and UB04 field FL60, please provide the member ID as follows:

• Midwest Health Plan Medicaid: Use the 10 digit Recipient ID number on the HAP Midwest Health Plan ID card
• AKM Health Choice members: Use the 9 digit ID number from your Health Choice ID card
• Macomb Connect and BasiCare: Use the 7-8 digit number beginning with letter B
• MIChild Card: Use 10 digit Recipient or CIN ID number on the HAP Midwest Health Plan MIChild card
• Medicare Advantage members: Use HAP Midwest Health Plan Assigned 11 digit ID number from the HAP Midwest Health Plan Medicare Advantage ID card.

Providers must verify member’s Medicaid eligibility and effective dates of health plan enrollment before rendering covered Medicaid services.