regulations and applicable state laws require that third party resources be used
before Medicaid is billed. Third party
refers to those payment resources available from both private and public health
insurance and from other liable sources, such as liability and casualty
insurance, that can be applied toward the Medicaid recipient's medical and
health expenses. Providers should
check the recipient's TPL segment to verify that the third party liability (TPL)
codes are accurate according to the TPL listing and the name of the third party insurance carrier. (Gainwell Technologies
conducts a full mailing of the TPL carrier codes at the beginning of every year.
Updates to the full listings are completed in June or July.) If
this code is not correct, the provider should instruct the recipient to contact
his/her parish worker to correct the file, especially if the insurance has been
canceled. Claims submitted for
payment will deny unless the insurance coverage is noted on the claim with the
appropriate TPL code or unless a letter explaining the cancellation of the
insurance from the carrier is attached to the claim.
NOTE: The lack of a third party TPL code segment does not negate the provider's
responsibility for asking the recipient if he/she has insurance coverage.
In most cases it is the provider's responsibility to bill the third party carrier
prior to billing Medicaid. In those situations where the insurance payment is received
after Medicaid has been billed and has made payment, the provider must reimburse
Medicaid, not the recipient. Reimbursement
must be made immediately to comply
with federal regulations.
TPL BILLING PROCEDURES
When billing Medicaid after receiving payment from a TPL (except Medicare), the
provider must bill a hard copy claim. The
six-digit carrier code from the TPL segment must be entered in the appropriate
block and any payments received must also be entered as prior payments.
NOTE: The six-digit carrier code for Medicare (060100) is not needed to process
Medicare crossover claims. In fact,
including the Medicare carrier code on these claims may cause processing errors.
In addition, providers should not indicate the amount paid by Medicare on
their claim forms. The Medicare EOB
should be attached to each claim form.
EOB from the other insurance should be attached to the claim form and the dates
of service, procedure codes and total charges must match, or the
claim will deny. All Medicaid
requirements, such as pre-certification or prior authorization, must be met before
payment will be considered.
NOTE: Claims submitted where the billing information does not match the EOB
should be sent to Provider Relations with a cover letter explaining the
discrepancy. Such instances would include payment for dates not pre-certified by Medicaid and
privately assigned procedure codes not recognized by Medicaid.
PAY AND CHASE
Louisiana Medicaid uses the "pay and chase" method of payment for preventive pediatric care services and prescription drug services for individuals with health insurance coverage. This means that most providers are not required to file health insurance claims with private carriers when the service meets the pay and chase criteria. The Bureau of Health Services Financing (BHSF) seeks recovery of insurance benefits from the carrier within 60 days after claim adjudication when the provider chooses not to pursue health insurance payments.
Service classes which do not require private health insurance claim filing by most providers are:
- Effective 04/01/2021 prenatal care claims will no longer be paid under pay and chase.
- Primary preventive pediatric care diagnoses are confined to those listed here: Diagnosis Codes related to Preventive Pediatric Care Services. Individuals under age 21 qualify. Hospitals are not included and must continue to file claims with the health insurance carriers.
- EPSDT medical, vision, and hearing screening services.
- EPSDT dental services.
- EPSDT services to children with special needs (formerly referred to as school health services) which result from screening and are rendered by school boards.
- Services which are a result of an EPSDT referral, indicated by entering "Y" in block 24H of the HCFA-1500 claim form or "1" as a condition code on the UB-92 (form locators 24 - 30).
- Services for Medicaid eligibles whose health insurance is provided by an absent parent who is under the jurisdiction of the State Child Support Enforcement
Agency are now subject to a “wait and see period” effective 04/01/2021. Wait and see is defined as payment of a claim only after documentation is attached to a hard copy claim and submitted to the state’s Fiscal Intermediary demonstrating that 100 days have elapsed since the provider billed the responsible third party and remains to be paid.
NOTE: Documentation requirements can be found at:
VOIDING ACCIDENT-RELATED CLAIMS FOR PROFIT
A provider who accepts Medicaid payment for an accident-related service or illness
may not later void the Medicaid claim in order to pursue payment from an award
or settlement with a liable third party. Federal
regulations prohibit this practice. All
providers enrolled in Louisiana's Medicaid Program are required to accept
Medicaid payment as payment in full and not to seek additional payment for any
unpaid portion of the bill.
OUTGOING MEDICAL RECORDS STAMP
Providers who furnish medical information to attorneys, insurers, or anyone else must
obtain an ANNOTATION STAMP and must assure that all outgoing medical information
bears the stamp, which notifies the receiver that services have been provided
under Louisiana's Medicaid Program (see example below).
have been provided under Louisiana's
Medicaid Program and are
payable under R.S. 46:446:1 to:
Bureau of Health Services Financing
P. O. Box 91030
Baton Rouge, LA 70821-9030
ATTN: Third Party Liability Unit
Any additional authorization needed
be obtained from DHH/BHSF's TPL Unit at (225) 342-8662.
TRAUMA DIAGNOSIS CODES
are reminded to include the appropriate trauma diagnosis code when billing for
accident-related injuries or illnesses. Provider
cooperation is vital as trauma codes are used to help uncover instances of
unreported third party liability.
THIRD PARTY LIABILITY RECOVERY UNIT
Providers with questions about medical services to Medicaid recipients involved in
accidents with liable third parties, and providers wishing to refer information
about Medicaid recipients involved in accidents with liable third parties may
contact the DHH Third Party Liability/Medicaid Recovery Unit at (225)
342-8662 or fax information to (225) 342-2703.
HEALTH MANAGEMENT ORGANIZATION TPL CODES
Providers must determine, prior to providing a service, which HMO the recipient belongs to
and if the provider himself is approved through that particular HMO.
(If the provider is not HMO approved, the recipient should be advised
that he/she will be responsible for the bill and given the option of seeking
treatment elsewhere.) Pharmacy claims will still be handled through the "pay and chase" process;
however, claims denied by an HMO because the billing pharmacy was not HMO
approved will be voided back to the billing pharmacy.
Therefore, each pharmacist must determine to which HMO the recipient
belongs and whether or not the pharmacy is HMO approved.
Questions regarding HMOs should be referred to the DHH Third Party/Medicaid Recovery
unit, GHIPP Program at (225) 342-8662. The
fax number is (225) 342-2703.
HMO AND MEDICAID COVERAGE
Louisiana Medicaid has adopted the following policy concerning HMO/Medicaid coverage based
on HCFA clarification.
- The recipient must use the services of the HMO which they freely choose to join.
These claims must be submitted hard copy with a copy of the HMO
Explanation of Benefits from the carrier that is on file with the state;
- If the HMO denies the service because the service is not a covered service offered under the
plan, the claim will be handled as a straight Medicaid claim and processed
based on Medicaid policy and pricing;
- If the HMO denies the claim because the recipient sought medical care outside of
the HMO network and without the HMO's authorization, Medicaid will deny the
claim with a message that HMO services must be utilized, and;
- If the recipient uses out of network providers for emergency services and the HMO
does not approve the claim, Medicaid will deny the claim with a similar edit.
If the provider of the service plans to file a claim with Medicaid, co-payments or
any other payment cannot be accepted from the Medicaid recipient.
QUALIFIED MEDICARE BENEFICIARIES (QMBs)
QMBs are covered under the Medicare Catastrophic Coverage Act
of 1988. This act expands Medicaid coverage and benefits for certain persons aged 65 years and older as
well as disabled persons who are eligible for Medicare Hospital Insurance (Part
A) benefits and who:
- Have incomes less than 90 percent of the federal poverty level
- Havecountable resources worth less than twice the level allowed for Supplemental
Security Income (SSI) applicants, and;
- Have the general nonfinancial requirements or conditions of eligibility for Medical
Assistance, i.e., application filing, residency, citizenship, and assignments of
Individuals under this program are referred to as Qualified Medicare Beneficiaries (QMBs).
Two groups of Medicare/Medicaid eligibles are called "pure QMBs" and
"dual QMBs." Pure QMBs are identified by the REVS and MEVS systems
and are eligible only for Medicaid payment of deductibles and coinsurance
for all Medicare covered services. They
are not eligible for other types of Medicaid assistance.
Dual QMBs are individuals who are eligible for both Medicare and traditional types
of Medicaid coverage (SSI, etc.). Dual
QMBs are identified by the REVS and MEVS systems and are eligible
for Medicaid payment of deductibles and coinsurance for all Medicare covered
services as well as for payment for Medicaid covered services.
In addition, for those persons who are eligible for Part A premium, but must pay
for their own premiums, the State will now pay for their Part A premium, if they
qualify as a QMB. The State will
continue to also "buy-in" for Part B (medical insurance) benefits
under Medicare for this segment of the population.
MEDICARE CROSSOVER CLAIMS
If problems occur with Medicare claims crossing over electronically, please follow
the steps listed below:
If your Medicare/Medicaid claims are not crossing electronically, please call
Gainwell Technologies Provider Relations at (800) 473-2783 or
(225) 924-5040. Be very specific with your inquiry.
You should indicate whether all of your claims are not crossing over or
only claims for certain recipients. Were the claims crossing over previously and suddenly stopped
crossing, or is this an ongoing problem? The more information you can provide, the
better. The Gainwell Technologies representative will check certain pieces of information against
the provider and/or recipient files to determine if an identifiable file error exists. If a file update is
required, the Gainwell Technologies representative will route this information to Gainwell Technologies Provider Enrollment
to correct the Medicaid file. If a problem cannot be identified, you may be referred to the DHH Third Party
Liability Unit for further assistance.
If you are not certain that you have supplied your Medicare provider number(s) to
Gainwell Technologies Provider Enrollment, please contact this unit at (225) 923-8510 for
instructions to have your Medicare provider number(s) loaded correctly on your Medicaid provider file. Many Medicare providers have a primary provider number and
one or more secondary provider numbers linked to this primary number.
Claims will cross over electronically ONLY if the Medicare provider number(s) is cross-referenced to the Medicaid provider number.
If any or all of your Medicare provider numbers have not been reported to
Gainwell Technologies Provider Enrollment, please do so immediately.
Medicare adjusted claims do not automatically cross over.
Providers must submit Medicaid adjustments hard copy with the original Medicare EOB
and the Medicare adjustment EOB attached for corrected payment.
are responsible for verifying on the Medicaid Remittance Advice that all
Medicare payments have successfully crossed over.
If Medicare makes a payment which is not adjudicated by Medicaid within
30 days of the Medicare EOB date, you should submit your crossover claim hard
copy with the Medicare EOB attached. All
timely filing requirements must be met even if a claim fails to cross over.
MEDICARE HMO CROSSOVERS
The Bureau of Health Services Financing (BHSF) is working with all HMO Medicare
replacement plans to resolve outstanding and future Medicare HMO crossover
claims. All payments, both past and future, will be made directly to the Medicare HMO.
Questions and concerns should be addressed to the Medicare HMO involved.
TPL AND ELIGIBILITY REMINDERS
services covered under the Louisiana Medicaid Program require some form of prior
authorization, pre-certification, or extension request.
Please remember that authorization of services does not override any
other Medicaid Program policy and does not guarantee payment of the claim.
This includes, but is not limited to, the following examples:
a recipient is Medicare eligible, an authorization does not override the fact
that the claim must be submitted to Medicare for consideration prior to being
submitted to Medicaid. Please be aware of this fact when submitting your claims for processing.
- If a recipient is eligible for other insurance, a prior authorization or
pre-certification does not override the fact that the claim must be submitted to
the other insurance for consideration prior to being submitted to Medicaid.
- Likewise, other insurance coverage does not negate the need for prior authorization or pre-certification
if the provider intends to bill Medicaid secondary.
a recipient is not eligible for services on the specified date of service, an
authorization does not override ineligibility, and the claim will not be paid.