Billing > Billing
Medicaid billing
Pay_My_Claims:
Medicaid of PA has a policy whereas they seek providers in helping to recoup money from COB issues where recipients are not giving them information regarding other insurance. Again, this enforces the policy of Medicaid being the last payor.
April 27, 2009 Third Party Liability Recovery
On April 27, 2009, the Department of Public Welfare's (DPW) Division of Third Party Liability (TPL) issued a Commercial TPL/Coordination of Benefits (COB) recoupment project related to claims originally paid by Medical Assistance (MA) through its TPL contractor, Health Management Systems, Inc. (HMS). The April 27 recovery was sent to provider type 01 (inpatient facility).
* This TPL/COB Recoupment Project encompasses recipients having Commercial coverage.
* TPL is seeking assistance from medical providers in recouping funds associated with recipients who had both commercial and MA coverage at the time the service was delivered. DPW was not aware of the coverage at the time of service delivery.
* TPL and its contractor, HMS, are continually identifying resources via eligibility data exchanges with commercial carriers. These are often identified after a claim is paid. It is a Federal requirement that TPL recoup payments when a third party is identified. MA is to be the payer of last resort.
* The claims in this project cover dates of service associated with Commercial resources (excluding Medicare Advantage plans) from March 2006 through October 2008.
* The letter to providers related to this recoupment project includes the following: two listings of the claims being considered for recoupment; instructions for responding to the TPL/COB Recoupment Project; and HMS contact information should the provider have questions.
* The letter also explains our expectation that the provider attempt to bill the commercial carrier. After the deadline date (60 days from the date of the letter), TPL will recoup the money electronically. Providers are asked not to submit checks or payments as a result of any payments they receive from the commercial carrier for the claims in this recoupment project, but they should supply documentation as explained in the project instructions to HMS to confirm receipt of denial from the commercial carrier.
* Since these are MA reclamation claims, the commercial carriers must honor the timely filing limits imposed by the Public Welfare Code under §1413(b)(c)(1)(2) related to MA claims presented for payment within five years of the date of service for claims with dates prior to July 1, 2007, and within three years for claims with a date of service on or after July 1, 2007. DPW recommends using the Timely Filing letter available on the DPW web site when filing these claims to the commercial carriers.
* The commercial carriers must also honor claims regardless of the type or format of the claim or a failure to present proper documentation at the point of sale (this includes obtaining prior authorization from the commercial carriers.
* If co-insurance and deductible amounts are due, the providers should submit a new claim for these payments to HMS according to the instructions included in the project. The new claim forms should be submitted only after the recovery has been completed. Providers will need to supply the ICN associated with the voided/retracted claim (ICN begins with Region Code '54') and the original ICN of the claim. Please send new billing forms only as the old forms will not be accepted.
* It is recommended that providers contact HMS at the toll-free number supplied in the instructions if there are questions regarding this project.
Jdmontee:
Thanks for the input! I was pretty sure of what I knew just wanted to be certain I wasn't missing anything in what I had researched.
Joanne
PMRNC:
I was trying to be "delicate" One of my clients in PA was pediatric group and I can tell you we had a ton of cases where the patient had either an individual plan and then would ask us for itemized bill and low and behold we would get an inquiry as they tried to collect from Medicaid.
PA and NJ both have a LOT of this. Many of the times you don't even know they have Medicaid (they withold it on purpose)
Pay_My_Claims:
ROFLMAO!! Our itemized statements show payment by other payors, so none from any office I work will work for medicaid. Unless patient has proof of payment, they won't pay. *Im moving to PA*
Michele:
I'm not that familiar with PA Medicaid but I have seen several in NY (my nephew and my office manager's son) where they have a commercial insurance prime thru mom or dad, but they are eligible for Medicaid due to their disability. It isn't based on income.
Michele
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