Third party insurance denial the claim

Providers may not bill a recipient when a Medicaid claim is denied due to third party liability.

TPL Denied Claims 

If the third party insurer does not reimburse the provider for the service, the provider must attach a copy of the third party’s explanation of benefits that indicates the reason for the denial to the Medicaid paper claim and resubmit it for processing.

Canceled or Expired Third Party Coverage

If the provider contacts the third party insurer by phone to confirm coverage and finds that the coverage has expired or is not applicable, even though the Medicaid computer shows the recipient is insured, the provider must request that the company or government agency send proof that the recipient’s insurance has been
terminated, does not exist, or does not cover the procedure. The provider must attach this proof to the Medicaid paper claim and resubmit it for processing to the Medicaid fiscal agent.

If Proof is Not Available

If the provider has billed the third party insurer and the third party insurer refuses to send the provider an explanation of benefits (EOB) or proof that the coverage has been terminated or the service is not covered, the provider must attach a letter on official letterhead stationery to the Medicaid paper claim that
details his attempts to obtain information. The provider must resubmit the claim with the letter attached for processing.
The letter must include:
• Recipient’s name, Medicaid number, and date of service;
• Date of telephone conversation or letter to the third party;
• Name of person(s) contacted;
• Telephone number, if available, for the third party insurer;
• Patient’s policy number;
• Any pertinent information obtained from the third party insurer; and
• A detailed explanation of the attempts made to obtain an EOB from the
third party source.

Requesting Help 

Providers who have questions on third party insurance can contact the Medicaid third party contractor by phone at (850) 656-8870, fax at
(850) 656-9271, or in writing to:

Health Management Systems, Inc.
2002 Old St. Augustine Road, Suite B-16
Building B, Room 720
Tallahassee, Florida 32301