Current through Register Vol. 43, No. 02, November 27, 2024
(1) Third Party Payments other than Medicare
(a) Third Party payments must be applied to
the services for which the third party paid.
(b) Providers receiving a third party payment
prior to filing Medicaid must document in the appropriate field on the claim
the amount of the third party payment.
(c) Providers receiving a third party payment
after Medicaid is filed must within 60 days of receiving duplicate payment:
1. Refund the lessor of the insurance paid
amount or the Medicaid paid amount to the Third Party Division, Alabama
Medicaid Agency; or
2. Submit an
adjustment request to the Medicaid Fiscal Agent that resolves the duplicate
payment.
(d) If the
third party pays the recipient or source other than the provider, the provider
is responsible for obtaining the third party payment prior to filing Medicaid.
If the Third Party pays a source other than Medicaid, as a result of
information released by the Provider and Medicaid has paid the Provider,
Medicaid may recoup its payment.
(e) If the provider accepts a patient with a
third party resource and Medicaid, the provider cannot bill the patient for
Medicaid covered services if:
1. The third
party pays more than Medicaid allows and Medicaid zero pays the
claim.
2. Medicaid denies a claim
because a third party resource exists and recipient has provided third party
information in a timely manner.
(f) A provider may bill a Medicaid patient if
Medicaid denies a claim because of available third party benefits and the
provider cannot obtain sufficient information needed to file a third party
claim from either the recipient, AVRS, MACSAS or the Medicaid Agency.
(2) Third Party Payments -
Medicare
(a) Providers must attach a copy of
the Medicare EOB to the Medicaid claim.
(b) Within 60 days of receiving duplicate
Medicaid and Medicare payments the provider must:
1. Refund the Medicaid payment to the
Medicaid fiscal agent and state the reason for the refund; or
2. Request that the Medicaid fiscal agent
adjust the Medicaid claim.
(3) Third Party Denials
(a) Providers must attach third party denials
of benefits to their Medicaid claim when filing for Medicaid benefits. These
claims must be filed as paper claims.
(b) Providers must state on the Medicaid
claim "Denied by Third Party" if third party benefits are denied.
(c) Only true denials of benefits are
acceptable, i.e., policy has lapsed, benefits applied to deductible,
non-covered services, etc.
(d)
Denials due to the Third Party's requirement to use participating plan
providers, service requires pre-certification, etc. will not be accepted as
valid denials, unless further documentation is provided that justifies that the
third party requirement cannot be met.
(4) Recipient responsibility regarding third
party requirements - A recipient must fulfill the primary insurance's
requirement before Medicaid will pay. Claims that are denied by a third party
payer because of precertification requirements, failure to use participating
providers, etc., may be denied by Medicaid as an invalid denial reason. A
recipient cannot be billed if the failure to meet the primary plan's
requirements are due to the provider's error. If failure to meet the primary
plan's requirement is due to the recipient's failure to notify the provider of
the other insurance, then the recipient can be held responsible for the
charges.
(5) Questions regarding
third party payment/denials should be referred to the Third Party Division,
Alabama Medicaid Agency.
(6)
Balance Billing - Federal law prohibits Medicare providers from balance-billing
QMBs for Medicare cost-sharing. All Medicare physicians, providers, and
suppliers who offer services and supplies to QMBs are prohibited from billing
QMBs for Medicare cost-sharing, including deductible, coinsurance, and
copayments. QMBs have no legal obligation to make further payment to a provider
or Medicare managed care plan for Part A or Part B cost sharing. Providers who
inappropriately bill QMBs for Medicare cost-sharing are subject to
sanctions.
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; §§1902(N)(3)(b) of the
Social Security Act.
