1. Probable liability is established at the
time claim is filed.
a. When the Title XIX
agency has established the probable existence of third party liability at the
time the claim is filed, the agency rejects the claim and returns it to the
provider for a determination of the amount of liability. The establishment of
third party liability takes place when the agency receives confirmation from
the provider or a third party resource indicating the extent of third party
liability. When the amount of liability is determined, the agency pays the
claim to the extent that maximum payment allowed under the agency's payment
schedule exceeds the amount of the third party payment.
b. Exhausting all available third party
resources is the responsibility of the providers. The Medicaid Management
Information System (MMIS) does not allow payments to be made by Virginia
Medicaid unless the invoice indicates that the third party has either paid or
denied the claim.
c. There are
certain circumstances in which cost avoidance may not be utilized:
1. Medical support enforcement. In the case
of any service covered under Medicaid provided to an individual on whose behalf
child support enforcement is being carried out by the IV-D agency, Medicaid
makes payment for such service in accordance with the usual payments schedule.
These payments are made without regard to any third party liability, if such
third party liability is derived, through insurance or otherwise, from the
parent whose obligation to pay support is being enforced by the IV-D agency.
Medicaid shall make these payments providing that they have not been made by
such third party within 30 days after such service is furnished.
Providers shall not be required to bill the third party in
this situation. When the provider does bill Medicaid, he must certify
either:
(a) That he has not billed the
third party documented on the claim due to medical support enforcement,
or
(b) That he has billed the third
party documented on the claim but that he has not received payment or denial
for the service from the third party within 30 days after the service was
furnished. In this case, 30 days must elapse from the date of service to the
date of provider certification.
2. Prenatal Care. When the claim is for
prenatal, labor and delivery, or postpartum care that is covered under the
State Plan, the Commonwealth makes payment for such services in accordance with
the usual payment schedule without regard to the liability of a third party for
payment for such services.
3.
Preventive Pediatric Care. When the claim is for preventive pediatric care,
including Early and Periodic Screening, Diagnosis and Treatment (EPSDT)
services that are covered under the State Plan, the Commonwealth makes payment
for such services in accordance with the usual payment schedule without regard
to the liability of a third party for payment for such services.
4. In order to accomplish this pay and chase
activity, in accordance with 42 CFR 433.139, (once the claims
have been processed for payment), a report is generated advising the third
party unit so that recovery of funds can be made.
