Current through March 20, 2024
005.01
THIRD PARTY RESOURCE PAYMENT. All third party
resources available to a Medicaid client must be utilized for all or part of
their medical costs before Medicaid. Medicaid payment is made only after all
third party resources have been exhausted or met their legal contractual or
legal obligations to pay. Medicaid is the payor of last resort.
005.01(A)
EXCEPTIONS. The Nebraska Chronic Renal Disease Program
and the Medically Handicapped Children's Program are not included as a third
party resource.
005.02
AVAILABILITY OF THIRD PARTY RESOURCE INFORMATION. The
Coordination of Benefits and Third Party Liability Unit of the Department
maintains all known current health insurance, casualty insurance, and Medicare
coverage on the Nebraska Medicaid Eligibility System (NMES). Providers may also
obtain this information using the standard electronic Health Care Eligibility
Benefit Inquiry and Response transaction. If the provider becomes aware of any
additional third party resources, the provider must contact the Department and
report the new sources.
005.02(A)
REQUEST FOR RELEASE OF PATIENT ACCOUNT INFORMATION. To
alert the Department to a potential third party resource, the provider must
notify the Department when a provider receives a request for an itemized bill
or a request for the balance of a bill from the client, an attorney, an
insurance company, or employer. This does not include routine billing
information requests to process insurance or Medicare. The provider may release
the information in accordance with the provider's standard office
practice.
005.03
PAYOR OF LAST RESORT. Medicaid clients who have third
party resources must exhaust these resources before Medicaid considers payment
for services. Medicaid will not pay for medical services as a primary payor if
a third party resource is contractually or legally obligated to pay for the
service.
005.03(A)
BILLING THIRD
PARTY RESOURCES. Providers must bill all third party resources and
the client, when there is a share of cost obligation, for services provided to
the client, except for waiver claims. Providers must submit all charges and
Medicare covered services provided to Medicare and Medicaid dually eligible
individuals to Medicare plus any Medicare supplement plans for resolution prior
to billing Medicaid.
005.03(B)
WAIVER CLAIMS. Certain services, defined as waiver claims, are an
exception to the requirements of this chapter. Providers may
submit these claims to Medicaid before submitting to a third party resource.
Nebraska Medicaid pays these claims and Department staff initiate recovery
activities for any third party resource. This does not prohibit the provider
from billing the third party resource before billing Medicaid. In these
situations, the provider does not bill Medicaid until the claim is
resolved.
005.03(C)
SERVICES NOT COVERED BY MEDICARE. Nebraska Medicaid
may cover services within the scope of Nebraska Medicaid which are not covered
by Medicare. Nebraska Medicaid does not cover any Medicare Part D Drug or
Medicare Part D covered supply or equipment, even if coverage is denied by the
Medicare Part D Plan. For services not covered by Medicare, documentation of
the Medicare denial is not required.
005.04
MEDICARE PART A AND B
DEDUCTIBLE AND COINSURANCE. In some cases, Medicaid pays the
deductible and coinsurance for Medicare-covered services. The Department
accepts Medicare's utilization review and payment decisions for Medicare
allowable fees, except after crediting any amount received from Medicare for
Medicare-covered services and crediting any amount received from any third
party resource, Medicaid will pay the lesser of the Medicare or Medicaid
allowable amount of any remaining amount due.
005.04(A)
MEDICARE PART D MONTHLY
PREMIUM, DEDUCTIBLE, CO-INSURANCE, AND COVERAGE GAPS. Medicaid
does not pay the premium, deductible, co-insurance, copays, or coverage gaps
for Medicare Part D.
005.04(B)
MEDICARE PART A COINSURANCE FOR NURSING FACILITY
SERVICES. For nursing facility services covered under Medicare
Part A, Medicaid payments are limited to rates and payments according to the
following method:
(i) If the Medicare payment
amount for a claim exceeds or equals the Medicaid rate or payment for the
claim, Medicaid reimbursement will be zero.
(ii) If the Medicaid rate and payment for a
claim exceeds the Medicare payment amount for the claim, Medicaid reimbursement
is the lesser of:
(1) The difference between
the Medicaid rate and payment minus the Medicare payment amount; or
(2) The Medicare coinsurance and deductible,
if any, for the claim.
005.05
PROVIDER PAYMENT IN
FULL. Medicaid payment is the lower of the provider's usual and
customary charge or the Medicaid allowable less all third party payment. When a
claim is submitted to Medicaid with a payment from a third party resource, the
provider is considered paid in full when payment from the third parties and
Medicaid equals or exceeds the Medicaid allowable amount. The provider may only
bill the client for services not covered by Nebraska Medicaid, for Nebraska
Medicaid copayment fees, where applicable, or if the client has received
payment from the third party resource.
005.05(A)
MEDICARE PART A AND
PART B. Department payment of Medicare coinsurance and deductible
constitutes payment in full. The provider will not balance bill.
005.05(B)
MEDICARE
ADVANTAGE. Department payment of Medicare Advantage coinsurance
and deductible constitutes payment in full to the provider. The provider will
not balance bill.
005.05(C)
MEDICARE PART D. Nebraska Medicaid does not pay
premiums, deductibles, co-insurance, copays, or coverage gaps for Medicare Part
D.
005.05(D)
MEDICARE
WAIVER OF LIABILITY. When a Medicare and Medicaid dually eligible
individual signs a Medicare Waiver of Liability and Medicare denies the claim
as not reasonable and necessary, Nebraska Medicaid will not pay the
claim.
005.05(E)
USE OF
CONTRACTS BY MEDICARE AND MEDICAID DUALLY ELIGIBLE INDIVIDUALS. If
providers negotiate private contracts with Medicare and Medicaid dually
eligible individuals for which no claim is to be submitted to Medicare and for
which the provider receives no reimbursement from Medicare directly, neither
Medicare nor Medicaid would cover the services provided under the private
contract.
005.05(F)
CASUALTY SETTLEMENTS WITH A THIRD PARTY RESOURCE. When a provider
enters into an agreement with a Medicaid client or a representative of the
client to accept less than billed charges, the provider is considered paid in
full. No further payment is due from either the client or Nebraska
Medicaid.
005.05(G)
PROVIDER'S FAILURE TO COOPERATE IN SECURING THIRD PARTY PAYMENT.
The provider's failure to file necessary claims for third party resources,
except waiver claims, or to cooperate in securing payments by other third party
resources is grounds for denial of the claims. If Nebraska Medicaid denies
claims for these services, the client cannot be billed unless the payment went
to the client.
005.06
FILING CLAIMS WITH THIRD PARTY RESOURCES
005.06(A)
WAIVER OF COOPERATION
FOR GOOD CAUSE. With respect to obtaining medical care support and
payments or identifying and providing information to assist the State in
pursuing liable third parties for a child for whom the individual can legally
assign rights, the Department must find cooperation is not in the best
interests of the individual or the person to whom Medicaid is being furnished
because it is anticipated cooperation will result in reprisal against, and
cause physical or emotional harm to, the individual or other person as
described in chapter one of this title.
005.06(B)
TIMELY FILING OF CLAIMS
WITH HEALTH INSURANCE. Providers must first submit all claims to
third party resources. To secure a provider's right to Medicaid consideration
for payment, a claim must be filed within 12 months from service date even if
the third party resource has not been resolved. If the provider fails to submit
a claim or fails to contact the Department within 12 months from the date of
service, Nebraska Medicaid will not pay the claim.
005.06(B)(i)
DENIAL DUE TO THIRD
PARTY RESOURCE. If the provider files a claim with Nebraska
Medicaid within 12 months of the date of service and receives a Medicaid denial
due to the existence of a third party resource, the provider is allowed up to
12 months from the original receipt date of the Medicaid claim to resolve the
third party resource. The provider must submit the claim adjustment to Nebraska
Medicaid within six months of the date on the insurance or Medicare remittance
advice no later than 12 months from the original receipt date of the Medicaid
claim.
005.06(C)
TIMELY FILING OF CLAIMS WITH CASUALTY INSURANCE.
Providers must submit claims within 24 months of the date of service.
005.06(C)(i)
EXCEPTION. The Department can make payment beyond 24
months if the provider can document action was taken to obtain payment from the
third party. If a provider has received a denial from the Department due to the
existence of casualty insurance coverage, the provider has sought payment from
the third party, and the provider has waited 24 months without receiving
payment from the third party, the provider can request the Department
reconsider payment. If the provider has filed a lien, the provider must release
the lien upon receipt of payment from the Department. These situations are
reviewed on a case by case basis.
005.06(D)
FILING MEDICAID CLAIMS
AFTER RESOLVING THIRD PARTY RESOURCES. Providers will bill
Nebraska Medicaid only when all third party resources have failed to cover the
service or when a portion of the cost of the service has been paid. The
provider must submit the third party documentation with each claim submitted to
the Department. The dates of service on the third party documentation must
match the dates of service on each claim.
005.06(D)(i)
BILLING THE USUAL
AND CUSTOMARY CHARGE. When billing Nebraska Medicaid, the provider
must bill the usual and customary charge for each service. The provider cannot
submit a claim showing only the Medicaid allowable amount or the difference
between the Medicaid allowable amount and the amount of the third party
payment.
005.06(D)(ii)
ADJUSTMENT REQUEST. After the provider has submitted a
claim with third party resource documentation and the Department has
adjudicated the claim for payment, if the provider wishes to request an
adjustment, the provider must submit the adjustment request within 90 days from
the payment date on the Remittance Advice.
005.07
THIRD PARTY RESOURCE
DENIALS.
005.07(A)
HEALTH INSURANCE DENIALS. Nebraska Medicaid will
recognize and consider payment on claims the health insurance has denied with a
valid health insurance denial.
005.07(B)
MEDICARE
DENIALS. Nebraska Medicaid will recognize and consider payment on
claims Medicare has denied when the claim is submitted with a valid Medicare
denial.
005.07(B)(i)
EXCEPTION. The Department will not consider payment
for services which have been denied by Medicare for lack of medical
necessity.
005.07(C)
CASUALTY INSURANCE DENIALS. Nebraska Medicaid will
recognize and consider payment on claims involving casualty coverage denial
when the claim is submitted with a valid casualty denial.
005.07(C)(i)
PAYMENT PENDING
LIABILITY DETERMINATION. The insurer's statement indicating
payment cannot be made at this time due to a pending liability determination or
litigation is not a valid denial.
005.08
FILING ELECTRONIC CLAIMS
WITH THIRD PARTY RESOURCES. Medicaid will accept electronic claims
when third party resources are available. The health insurance and Medicare
documentation is required.
005.08(A)
AUTOMATIC TRANSFER OF CLAIMS FROM MEDICARE. Nebraska
Medicaid accepts Medicare crossover claims directly from Medicare's fiscal
intermediaries and will pay the deductible and coinsurance when no additional
third party resource is identified. Claims received from Medicare must include
Medicare supplemental insurance coordination of benefits and remittance advice
documentation, if applicable.
005.09
THIRD PARTY RESOURCE
REVERSAL OF PAYMENT TO PROVIDER. If a provider filed a claim with
a third party resource and received payment in full, and thus did not bill
Medicaid, and the third party resource reverses its determination after 12
months from the date of service, the provider may bill Nebraska Medicaid for
the services. The provider must bill Nebraska Medicaid within 60 days from the
date on the third party reversal document and refund. The provider must submit
documentation of the reversal with the claim. The claim may be considered for
payment by Nebraska Medicaid only if the date of service is no more than 24
months from the date of receipt of claim.
005.10
PRIOR AUTHORIZATION AND
THIRD PARTY RESOURCES. The provider must resolve all third party
resources before Nebraska Medicaid can consider paying a claim regardless of
whether Medicaid prior authorization has been given.
005.11
MEDICAID ELIGIBILITY AND
THIRD PARTY RESOURCES. The provider must resolve all third party
resources before Nebraska Medicaid can consider paying a claim, regardless of
whether the client is eligible for Medicaid, with the exception of waiver
claims. A client's eligibility for Nebraska Medicaid does not guarantee payment
of a claim.
005.12
LONG-TERM CARE INSURANCE POLICIES. A long-term care
indemnity policy is considered a health insurance policy when the policy allows
assignment of benefits and covers medical care based on specified criteria.
Long-Term Care insurance which meets this criteria is not considered income for
eligibility determination.
005.12(A)
NURSING FACILITY CLAIMS. Because nursing facility
claims are included in the category of "waiver claims," Nebraska Medicaid will
pay these claims at the specific per diem for the client, less any excess
income or share of cost the client is obligated to pay the provider for the
monthly services. The Coordination of Benefits Unit will seek recovery on all
of these policies. Because the claims have been paid, the provider will not
bill the insurer. The provider must assist the Coordination of Benefits Unit in
obtaining reimbursement from these policies by furnishing any medical
documentation the insurer requests.
005.12(B)
BILLING LONG-TERM CARE
INSURANCE. A provider may choose to bill the long term care
insurance; in these situations, the provider does not bill Medicaid. If the
provider or the client receives a payment directly from the insurer, the
payment must be sent to the Coordination of Benefits and Third Party Liability
Unit.
005.12(C)
PAYMENT
RECEIVED BY THE DEPARTMENT. Whenever the Department receives any
payments from long-term care insurance which exceed what Medicaid has paid
toward the care of the client, the Department will apply the excess to any
Medicaid expenditure for the Medicaid client regardless of whether the
expenditure was covered by the third party. The application of the excess third
party liability payment is not limited to a particular Medicaid service and can
be applied to any claims paid by Medicaid. After the excess payment has been
applied to all claims, any remaining amount will be paid to the client or the
client's authorized representative.
005.13
MEDICAL SUPPORT FROM
NON-CUSTODIAL PARENTS. When children with a non-custodial parent
become Medicaid eligible, medical support is court ordered in compliance with
Omnibus Budget Reconciliation Act 1993. The County Attorney's staff or Child
Support Enforcement staff will notify the Coordination of Benefits and Third
Party Liability Unit of any health insurance coverage and medical support court
orders obtained for a child who is eligible for Nebraska Medicaid. When a
non-custodial parent is ordered by the court to furnish health insurance or
make payment for medical services, the provider may bill Medicaid for the
services if the provider has not received payment from the health insurer or
non-custodial parent within 30 days of the date of service. Medicaid will pay
the claims and the Department will seek recovery from the health insurer or
non-custodial parent.
005.13(A)
BILLING WHEN A COURT ORDER EXISTS. To determine whether a court
order exists, the provider may contact the Coordination of Benefits and Third
Party Liability Unit. The provider is not required to continue to seek payment
from the health insurer or non-custodial parent before billing Medicaid when
there is court-ordered medical support.
005.13(B)
SEEKING PAYMENT FROM
THE NON-CUSTODIAL PARENT. Non-custodial parent medical support
court orders may include an obligation by the non-custodial parent to pay a
percentage of medical expenses after the health insurer has made payment. The
provider is not required to seek payment from the non-custodial parent in these
cases. If the provider receives a payment from a non-custodial parent, the
provider will indicate this amount and the amount received from the health
insurer as a prior payment or amount paid on the claim submitted to Medicaid.
The provider must submit with the claim a copy of the documentation showing the
non-custodial parent made the payment. If the provider receives payment from
the non-custodial parent after Medicaid has paid the claim, the provider must
refund Medicaid according to the requirements of this chapter.
005.13(C)
HEALTH INSURER
OBLIGATION WHEN THE NON-CUSTODIAL PARENT HAS A MEDICAL SUPPORT COURT
ORDER. A health insurer cannot deny a child insurance coverage if
the non-custodial parent has a court or administrative order for medical
support. An insurer must provide the custodial parent information to file
claims, allow the custodial parent or provider to file claims, and pay claims
to the custodial parent, provider, or the Department, as required by
Neb.Rev.Stat. Section
44-3,149.
If the provider receives a denial of insurance coverage for any of these
reasons from an insurer and the client is a child, the provider must contact
the Department.
005.14
PROVIDER REFUNDS TO THE DEPARTMENT. When a provider
receives payment from a third party resource on a claim previously paid by
Nebraska Medicaid, the provider must submit a refund to the Department. The
provider must include the third party documentation with the refund. If the
payment from the third party resource equals or exceeds the Nebraska Medicaid
payment on the claim, the total payment must be refunded to the Department. If
the payment from the third party resource is less than the Nebraska Medicaid
payment on the claim, the total third party payment must be refunded to the
Department.
005.15
BILLING THIRD PARTY RESOURCES AFTER NEBRASKA MEDICAID
PAYMENT. If, after Nebraska Medicaid has paid, a provider learns
of a third party resource which would have paid more for the service than
Nebraska Medicaid, in cases where health insurance is the third party resource,
the provider must supply the Department with the third party resource
information, refund the Department the full Nebraska Medicaid payment, and then
seek recovery from the third party resource. If a Medicaid client becomes
retroactively eligible for Medicare, the provider must refund the Department
the full Nebraska Medicaid payment and seek reimbursement from Medicare for
payment unless Medicare filing time limits for dates of service on the claims
have been exhausted. In cases where casualty insurance is the third party
resource, the provider will not refund Nebraska Medicaid's payment and then
seek recovery from a third party resource, unless the refund is requested by
the Department.
005.15(A)
DEPARTMENT REQUESTS FOR REFUNDS. When the Department
receives information indicating the provider has received a third party
resource payment on a Medicaid paid claim, the Department will request a refund
from the provider. The provider has 30 days to submit a refund check, show the
refund has already been made, document the refund request is in error, or
appeal. Failure to comply with this request within 30 days is cause for the
Department to withhold future provider payments until the situation is resolved
or impose sanctions on the provider. The refund request constitutes notice of
sanction.
005.16
CLIENT RIGHTS AND RESPONSIBILITIES
005.16(A)
CLIENT
RIGHTS. A provider cannot refuse to furnish services to an
individual who is eligible for Nebraska Medicaid because of a third party's
potential liability for payment of service.
005.16(B)
FAILURE TO
COOPERATE. A Nebraska Medicaid client has the obligation to assist
the provider and the Department in obtaining payment from all available third
party resources. This may include complying with any requests from the insurer
for additional information, ensuring the provider or the Department receives
remittance advice, coordination of benefits, and payments from the insurer, or
appearing in court in litigation situations. If the client fails to cooperate
with the provider in securing third party resources, the provider may contact
the Department. Failure by the client to cooperate may cause the client to lose
Nebraska Medicaid eligibility. The client will be responsible for payment of
the denied services.
005.16(C)
CLIENT RESPONSIBILITY WHEN ENROLLED IN A HEALTH MAINTENANCE
ORGANIZATION OR PREFERRED PROVIDER ORGANIZATION PLAN. Clients are
required to utilize the services provided through and obtain all necessary
prerequisites as set out by the health maintenance organization or preferred
provider organization. Failure to do so is considered lack of cooperation and
may result in loss of Medicaid eligibility. The client is responsible for the
payment of the denied services.
005.16(D)
CLIENT RESPONSIBILITY
WHEN HEALTH INSURANCE PREMIUMS ARE PAID BY THE DEPARTMENT. If the
Department determines it is cost effective to pay the premiums for a Medicaid
eligible client to maintain his or her current commercial insurance coverage,
the client must follow any preauthorization or referral provisions of the plan
or utilization of specific providers in the network. Claims denied by third
party resources because client did not utilize a network provider or obtain
necessary authorizations or referrals will not be paid by Medicaid. The client
will be responsible for payment of the denied services.
005.16(E)
CLIENT RESPONSIBILITY
WHEN CHOOSING TO ENROLL IN MEDICARE ADVANTAGE PLANS. Nebraska
Medicaid will not pay claims denied by Medicare for Medicaid clients enrolled
in Medicare Advantage plans who move out of the service area without complying
with notification requirements or who do not utilize a network provider or
obtain necessary authorizations and referrals. The client will be responsible
for payment of the denied services.
005.17
COVERAGE INFORMATION
REQUESTS. The Department may request coverage information from a
licensed insurer or a self-funded insurer about a specific individual without
the individual's authorization to determine eligibility for state benefit
programs or coordinate benefits with state benefit programs. The Department
will specify the individual recipients for whom information is being requested.
005.17(A)
RESPONSE TO
REQUESTS. Self-funded insurers and licensed insurers must respond
within 30 days of receipt of any request for coverage information from the
Department. The information must be provided within thirty days after the date
of the request unless good cause is shown.
005.17(B)
FAILURE TO ACKNOWLEDGE
AND RESPOND TO COVERAGE INFORMATION REQUESTS. If a self-funded
insurer fails to acknowledge and respond to a request from the Department for
coverage information about an individual, the Department may find this a
violation of the requirements of this chapter and impose a civil money
penalty.
005.17(C)
CIVIL MONEY PENALTY. The Department may impose a civil
money penalty of no more than $1,000 for each violation, not to exceed an
aggregate penalty of $30,000, unless the violation by the self-funded insurer
was committed flagrantly and in conscious disregard of the requirements of this
chapter in which case the penalty will not be more than $15,000 for each
violation, not to exceed an aggregate penalty of $150,000.
005.17(D)
HEARING. A
licensed insurer or a self-funded insurer's request for a hearing to appeal an
action by the Department must comply with Department regulations.
005.18
SERVICES
REQUIRING PRIOR AUTHORIZATION. Services which require prior
authorization for payment of claims, prior authorization requirements, and
methods are listed in the chapter of the Nebraska Department of Health and
Human Services Finance and Support Manual related to the specific type of
service.
005.18(A)
LIMITATIONS OF
PRIOR AUTHORIZATION. Prior authorization is issued only if the
client is eligible for Nebraska Medicaid for the period for which services are
authorized. If the client becomes ineligible for Nebraska Medicaid during the
authorization period, the authorization is invalid in the period of
ineligibility. The authorizing agent will not submit a prior authorization
request until eligibility for Nebraska Medicaid has been determined. Prior
authorization is not transferable to other clients or other
providers.
005.18(B)
DUAL MEDICARE AND MEDICAID ELIGIBILITY. If the client
is eligible for Medicare as well as Medicaid and the requested services are
covered by Medicare, prior authorization is not issued. In some cases, as
defined in the specific service policy, the provider must receive a denial of
coverage from Medicare before a prior authorization is issued. The provider
must submit a copy of the denial with the claim form to receive
payment.
005.18(C)
NOTIFICATION OF THE CLIENT. The provider or Department
will notify the client of approval or denial of prior authorization according
to the prior authorization procedures under the individual chapters of this
Title.
