Current through all regulations passed and filed through September 16, 2024
(A)
Definitions.
(1)
"Coordination of benefits" (COB) means the process of
determining which health plan or insurance policy will pay first or determining
the payment obligations of each health plan, medical insurance policy, or third
party resource when two or more health plans, insurance policies or third party
resources cover the same benefits for a medicaid covered
individual.
(2)
"Coordination of benefits claim" (COB claim) means any
claim that meets either the definition of third party claim as described in
paragraph (A)(7) of this rule or the definition of medicare crossover claim as
described in rule
5160-1-05 of the Administrative
Code.
(3)
"Explanation of benefits" (EOB) or "remittance advice"
means the information sent to providers or plan beneficiaries (covered
individuals) by any other third party payer, medicare, or medicaid to explain
the adjudication of the claim.
(4)
"Medicare
benefits" has the same meaning as in rule
5160-1-05 of the Administrative
Code.
(5)
"Third party" (TP) has the same meaning as in section
5160.35 of the Revised
Code.
(6)
"Third party benefit" means any health care service
available to individuals through any medical insurance policy or through some
other resource that covers medical benefits and the payment for those services
is either completely the obligation of the third party payer (TPP) or in part
the obligation of the individual, the third party payer, or medicaid (examples
of a third party benefit include private health or accidental insurance,
medicare, CHAMPUS or worker's compensation).
(7)
"Third party
claim" means any claim submitted to the Ohio department of medicaid (ODM) for
reimbursement after all TPPs have met their payment obligations. In addition,
the following will be considered third party claims by ODM:
(a)
Any claim
received by ODM that shows no prior payment by a TPP, but, ODM's records
indicate the medicaid covered individual has third party
benefits.
(b)
Any claim received by ODM that shows no prior payment
by a TPP but the provider's records indicate the medicaid covered individual
has third party benefits.
(8)
"Third party
liability" (TPL) means the payment obligations of the third party payer for
health care services rendered to eligible medicaid covered individuals when the
individual also has third party benefits as described in paragraph (A) (6) of
this rule.
(9)
"Third party payer" (TPP) means an entity, other than
the medicaid or medicare programs, responsible for adjudicating and paying
claims for third party benefits rendered to an eligible medicaid covered
individual.
(B)
If the existence of a third party benefit is known to
ODM, a code number that represents the name of the third party payer covering
the individual will be indicated on the individual's medicaid card. The
provider shall obtain from the medicaid covered individual the name and address
of the insurance company, and any other necessary information, and bill the
insurance company prior to billing ODM.
(C)
The provider must
always review the individual's Ohio medicaid card for evidence of third party
benefits. Whether there is or is not an indication of a TPP on the medicaid
card, the provider must always request from the medicaid covered individual, or
the individual's representative, information about any third party benefit(s).
If the medicaid covered individual specifies no TP coverage and the medicaid
card does not indicate TP coverage, the provider may submit a claim to medicaid
(and the claim for the service is not considered a TP claim). If, as a result
of this process, the provider or ODM determines that TP liability exists, the
provider may only submit a claim for reimbursement if it first takes reasonable
measures to obtain TP payments as set forth in paragraph (E) of this
rule.
(D)
The medicaid program must be the last payer to receive
and adjudicate the claim except for the following:
(1)
Medicaid pays
after any TPL and medicare but before:
(a)
The children with
medical handicaps program under sections
3701.021 to
3701.0210 of the Revised
Code.
(b)
The state sponsored program awarding reparations to
victims of crime under sections
2743.51 to
2743.72 of the Revised
Code.
(2)
Medicaid pays before any TPL and medicare for
preventive pediatric services identified in
42 C.F.R.
433.139 (as in effect October 1,
2018).
(E)
ODM reimburses for medically necessary covered services
only after the provider takes reasonable measures to obtain all third party
payments and file claims with all TPPs prior to billing ODM. Providers who have
gone through reasonable measures to obtain all third party payments, but who
have not received payment from a TPP, or have gone through reasonable measures
and received partial payment, may use an appropriate code on the claim to
obtain payment and submit a claim to ODM requesting reimbursement for the
rendered service.
(1)
Providers are considered by ODM to have taken
reasonable measures to obtain all third party payments if they comply with one
of the following requirements:
(a)
The provider submits a claim first to the TPP and
receives a remittance advice indicating that a valid reason for non-payment
applies for the service as described in paragraph (E)(2) of this
rule.
(b)
The provider submits a claim first to the TPP for the
rendered service no less than three times within a ninety-day period and does
not receive a remittance advice or other communication from the TPP within
ninety days of the last submission to the TPP. Providers must be able to
document each claim submission and the date of the submission.
(c)
The provider
followed the process described in paragraph (C) of this rule for the billed
service and meets the following requirements:
(i)
The provider did
not find a change in third party coverage;
(ii)
The billed
service was previously rendered to the medicaid covered individual by the
provider within the last three hundred sixty-five days; and
(iii)
The claim for
the previously rendered service met the requirements of paragraph (E)(1)(a) or
paragraph (E)(1)(d) of this rule.
(d)
The provider did
not send a claim to the TPP, but has received and retained at least one of the
following types of documentation that indicates a valid reason for non-payment
for the service(s) as set forth in paragraph (E) (2) of this rule:
(i)
Written
documentation from the TPP;
(ii)
Written
documentation from the TPP's automated eligibility and claim verification
system;
(iii)
Written documentation from the TPP's member benefits
reference guide or manual; or
(iv)
Any other
reliable method for obtaining information or documentation from the TPP that
there is no third party benefit coverage for the rendered
service(s).
(e)
The provider submits a claim first to the TPP and
receives a partial payment along with a remittance advice documenting the
allocation of the billed charges.
(2)
Valid reasons for
non-payment from a third party payer to the provider for a third party benefit
claim include, but are not limited to, the following:
(a)
The service is
not covered under the medicaid covered individual's third party
benefits.
(b)
The medical expenses for the medicaid covered
individual were incurred prior to the third party benefit's coverage
dates.
(c)
The medical expenses for the medicaid covered
individual were incurred after the third party benefits coverage was
terminated.
(d)
The medicaid covered individual does not have third
party benefits through the TPP for the date of service.
(e)
All of the
provider's billed charges or the TPP's approved rate was applied to the
medicaid covered individual's third party benefit deductible
amount.
(f)
All of the provider's billed charges or the TPP's
approved rate was applied in total across the medicaid covered individual's
deductible, coinsurance, or co-payment for the third party
benefit.
(g)
The medicaid covered individual has not met eligibility
requirements, out-of-pocket expenses, required waiting periods, or residency
requirements for the third party benefits.
(h)
The medicaid
covered individual is a dependent of the individual with third party benefits,
but the benefits do not cover the individual's dependents.
(i)
The medicaid
covered individual has reached the lifetime benefit maximum for the medical
service being billed to the third party payer.
(j)
The medicaid
covered individual has reached the benefit maximum of the third party
benefits.
(k)
The TPP is disputing or contesting its liability to pay
the claim or cover the service.
(l)
The claim was
submitted timely and with the correct information to the TPP but the claim was
rejected by the TPP.
(F)
Providers who
have gone through reasonable measures as described in paragraph (E) of this
rule to obtain all third party payments, but who have not received payment from
a TPP, or received a partial payment, may submit a claim to ODM requesting
reimbursement for the rendered service. If payment from the TPP is received
after ODM has made payment, the provider is required to repay ODM any overpaid
amount. The provider must not reimburse any overpaid amounts to the medicaid
covered individual.
(G)
Providers who have billed the TPP and the TPP submits
payment directly to the medicaid covered individual should contact the
individual to request the payment be remitted to the provider. If the
individual is uncooperative with the request, the provider should contact the
county department of job and family services (CDJFS).
(H)
Third party
claims must meet the claim submission guidelines in accordance with rule
5160-1-19 of the Administrative
Code.
(I)
Medicaid reimbursement for third party claims will not
exceed the medicaid maximum payment for the service, determined in accordance
with applicable rules for the service, less all third party payments for the
service. If the result is less than or equal to zero dollars, there will be no
further medicaid payment for the service.
(J)
ODM will reject a
TP claim when a third party claim indicates coverage by a TPP, or when the
existence of third party benefits is known to ODM, and the submitted claim does
not indicate collection of the third party payment or does not indicate
compliance with paragraph (E) of this rule. Providers should complete their
investigation of available third party benefits before submitting a TP claim to
ODM for payment.
(K)
The provider is prohibited from billing the medicaid
covered individual any charges in accordance with rule
5160-1-60 of the Administrative
Code.
(L)
If the medicaid covered individual states his or her
private health insurance has changed or been terminated, the provider should
advise the individual to contact his or her county caseworker to correct the
case record. If the individual is not cooperative in pursuing third party
liability as required by rule
5160:1-2-10 of the
Administrative Code, the provider should contact the CDJFS. Once the case
record has been corrected, the provider may bill ODM directly.
(M)
ODM has right of
recovery pursuant to section
5160.37 of the Revised Code
(medicaid, or any federal or state funded public health program) against the
liability of a third party for the cost of medical services paid by ODM, or
billable to ODM for payment at a later date. Section
5160.37 of the Revised Code
requires that a medicaid covered individual provide notice to ODM prior to
initiating any action against a liable third party. ODM will take steps to
protect its rights of recovery if that notice is not provided. If any person,
whether the medicaid covered individual or an individual acting on the behalf
of a medicaid covered individual requests a financial statement from a medicaid
provider for services paid by ODM or to be billed to ODM on behalf of the
medicaid covered individual, the provider shall meet all of the following
requirements:
(1)
Require that the medicaid covered individual or the
individual's representative make a request for access to financial statements
in writing.
(2)
Notify ODM immediately upon receipt of the medicaid
covered individual's written request and forward a copy of the request to ODM,
bureau of claims operations, coordination of benefits section.
(3)
Release the
financial statement to the medicaid covered individual or the individual's
representative no later than thirty days after the date the request is
received.
(4)
Stamp or type on each page of the financial statement
in bold font "SUBJECT TO RIGHT OF RECOVERY PURSUANT TO SECTION
5160.37 OF THE OHIO REVISED
CODE. FAILURE TO COMPLY MAY RESULT IN PERSONAL LIABILITY."
(5)
This rule applies
to financial statements whether or not the provider has received reimbursement
from ODM. This rule is not intended to prevent or restrict the provider from
furnishing records of medical treatment and condition to the medicaid covered
individual.
(N)
Except as otherwise provided in paragraph (D)(2) of
this rule, when the medicaid covered individual is covered by medicare, in
addition to other third party payers, medicaid is the payer of last resort.
Whether or not a TPP is the primary payer, providers must bill all other third
party payers and medicare prior to submitting a claim to ODM in accordance with
rule 5160-1-05 of the Administrative
Code.
Replaces: 5160-1-08
