Federal 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.

The 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:

  1. Effective 04/01/2021 prenatal care claims will no longer be paid under pay and chase.
  2. 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.
  3. EPSDT medical, vision, and hearing screening services.
  4. EPSDT dental services.
  5. EPSDT services to children with special needs (formerly referred to as school health services) which result from screening and are rendered by school boards.
  6. 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).
  7. 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:
https://ldh.la.gov/index.cfm/page/1734

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).

Medicaid Provider No. 
(7 digits)
(Optional Control Number)

Services have been provided under Louisiana's
Medicaid Program and are
payable under R.S. 46:446:1 to:
 
DHH Bureau of Health Services Financing
P. O. Box 91030
Baton Rouge, LA 70821-9030
ATTN: Third Party Liability Unit

Any additional authorization needed may be obtained from DHH/BHSF's TPL Unit at (225) 342-8662.   

TRAUMA DIAGNOSIS CODES

Providers 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) 342-1376.

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) 342-1376.

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 rights.

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.

Providers 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

Many 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:

  • If 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.
  • If 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.