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Medicaid billing

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Jdmontee:
Need some additional clarification regarding billing Medicaid in the state of Pa.  Have done research regarding state and federal regulations and want to be sure I am understanding them correctly. This is in regards to psych evals (90801) only. If there is a primary insurance in place Medicaid is to be the payor of last resort correct?  Is there anything that I might be missing in regards to this?

Thanks!

Joanne

PMRNC:
If they have a primary to Medicaid it most likely is Medicare. If there is a group plan primary, there is something not right  :o

Jdmontee:
In the state of Pennsylvania you can have a private individual or group plan of insurance in addition to Medicaid. Most of this provider's patients are children and have special needs and medicaid pays for these evals for determining wrap around and TSS services. What I need to know is if anyone is familiar with PA regs and know if there is anything I am missing in regards to Medicaid being the payor of last resort. If they have a private/group plan in addition to Medicaid does the private ins have to be billed first or is there an exclusion to this that I may not know about.

Thanks.

Joanne

PMRNC:

--- Quote ---In the state of Pennsylvania you can have a private individual or group plan of insurance in addition to Medicaid. Most of this provider's patients are children and have special needs and medicaid pays for these evals for determining wrap around and TSS services. What I need to know is if anyone is familiar with PA regs and know if there is anything I am missing in regards to Medicaid being the payor of last resort. If they have a private/group plan in addition to Medicaid does the private ins have to be billed first or is there an exclusion to this that I may not know about.
--- End quote ---

Yes, you can have Medicaid, under certain circumstances however PA has always had a big problem with their eligibility checks..anyway to answer your question..Medicaid would be the last payor.  You would follow COB rules where group plans are in place. If there is an individual policy however you will want to check with Medicaid, that could be iffy depending on the person paying the premium and circumstances, regardless if you are submitting a private/group plan primary to Medicaid it's always a good idea to let each one know about the other to avoid problems.

Pay_My_Claims:
Even if its an individual policy, it would be primary regardless of who pays the premiums. The one thing that is true no matter what state you are in, is that Medicaid is ALWAYS the payor of last resort. In NC, once you bill the primary and send the claims to medicaid, they will place a code on the medicaid card, that will alert you of other insurance. The issue in NC is when the client no longer has the policy, and they haven't notified medicaid to update it. You have to get documentation from the insurance company to send to medicaid along with the claim to update and process (grrrr).

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