Alabama Administrative Code
Title 560 - ALABAMA MEDICAID AGENCY
Chapter 560-X-20 - THIRD PARTY
Section 560-X-20-.02 - Third Party Cost Avoidance And Recovery
Universal Citation: AL Admin Code R 560-X-20-.02
Current through Register Vol. 43, No. 02, November 27, 2024
(1) General.
(a) All providers must file claims with a
third party as specified by this rule.
(b) Providers should not file with Medicaid
until the third party responds with a payment or denial. Exceptions: Providers
may file Medicaid and Medicare simultaneously if the Medicare intermediary
crosses over claims to the Medicaid fiscal agent. Providers may also file
Medicaid prior to actual payment being received from a third party when the
benefit is paid on a "set fee per day basis"; however, the provider must
indicate the amount to be paid by the third party on the Medicaid claim.
(c) Providers must file claims
with a primary third party within sufficient time for the third party to make
payment. If the provider has difficulty obtaining a response from the third
party or with the processing of Medicaid claims due to third party procedures,
the provider should contact the Third Party Division, Alabama Medicaid
Agency.
(d) An aged, outdated claim
which is timely submitted to Medicare or another third party must be received
by the fiscal agent within one hundred twenty (120) days of the notice of the
disposition of such claim to the provider.
(2) Health Insurance Resources
(a) Cost Avoidance - Medicaid requires all
providers (except as excluded through CMS - approved cost avoidance waivers or
those excluded from cost avoidance requirements by federal regulations) to file
for and obtain available third party health insurance benefits or a valid
denial for all services. Cost avoidance is a way to ensure that Medicaid is the
payer of last resort.
(b) Pay and
Chase - Pay-and-Chase occurs when the Alabama Medicaid Agency pays providers
for submitted claims and then attempts to recover payments. This may be done
through post payment billing to the third party insurance or through recoupment
of Medicaid payment from the provider who must then file with the primary
payer. Medicaid recoups certain claims from the provider when the insurance
carrier requires additional medical information that Medicaid cannot provide or
when Medicaid pays for medical services under a managed care/global rate, for
example: Maternity Waiver services. Alabama Medicaid will pay and chase claims
when TPL insurance is identified after payment of claims.
(3) Casualty and Other Third Party Resources
(a) All providers are required to file for
liability insurance and other third party benefits when the recipient is
insured with the plan and/or the recipient is eligible for worker's
compensation benefits.
(b) The
Third Party Division, Alabama Medicaid Agency, will file for third party
benefits in situations where there is a third party other than the recipient's
Health insurance and an injury is involved. Medicaid will file for casualty
related resources to insure that all related medical care paid by Medicaid will
be considered in a settlement. Therefore, once a provider has filed a claim
with Medicaid on a casualty/litigation case, the provider cannot submit an
adjustment request to Medicaid's fiscal agent in order to bill the liability
insurance. Once a claim has been paid by Medicaid, Medicaid has a subrogation
interest with the liable third party.
(c) In the case of a recipient who receives
medical assistance through a managed care organization, the amount used in
Medicaid's subrogation claim shall be the amount the managed care organization
pays (if available) for medical assistance rendered to the recipient or the
amount captured through encounter data that represents the amount Medicaid
would have paid if fee for service.
(d) If a provider files with a third party
resource other than the recipient's own insurance, the provider must notify the
Third Party Division, Alabama Medicaid Agency, within five days of filing with
the third party.
(4) Credit Balances
(a) Credit balances owed to
Alabama Medicaid occur when a provider's reimbursement for services exceeds the
allowable amount or when the provider receives payments from multiple parties
for the same service. Any credit balance resulting from an excess payment, as a
result of patient billing or claims processing error, must be conveyed to the
Alabama Medicaid Agency.
(b) A
provider must refund to Alabama Medicaid any overpayments, duplicate payments,
and erroneous payments which are paid to a provider by Medicaid as soon as the
payment error is discovered.
Author: Wanda Wright, Administrator, Third Party Liability
Statutory Authority: Code of Ala. 1975, § 22-6-6, 42 CFR §§432 and 433; Section 1902(a)(25), Social Security Act; 42 CFR § 447.45; Title XIX, Social Security Act.
Disclaimer: These regulations may not be the most recent version. Alabama may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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