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


THIRD PARTY COVERAGE

Identification of Third Party Resources

Providers must always identify third party resources and report third party payments in the appropriate item(s) on the claim. Third party resources must be identified even when the payer does not cover the services.

Medicare Services Medicare covered services must be submitted on one claim and any excluded services must be submitted on a separate claim. Do not mix covered and excluded services on the same claim.

Providers must indicate Medicare’s allowable amount as the charge (item 24F) and report the actual payment and/or deductible as instructed.

If the beneficiary is in a Medicare risk HMO, the fixed copay must be entered in item 24F.


If the beneficiary is in a commercial plan with fixed copays, the copay must be entered in item 24F.


If payments are made by a commercial insurance, the EOB must be submitted with the claim.


Medicaid Deductible If the beneficiary's Medicaid deductible amount is met in the middle of a service so that part of the charge is the beneficiary's responsibility and part is Medicaid's responsibility, enter the remaining Medicaid liability for the service in item 24F of the service line. Spend-down See Medicaid Deductible.

Evidence of Other Insurance Response

When billing on the CMS 1500 paper claim form, providers must submit evidence of other insurance responses (EOBs, denials, etc.) when billing MDHHS for covered services.

If billing electronically, no EOB is necessary, as all required data are part of the electronic format. However, in all cases where a provider is billing on the CMS 1500 claim form, a copy of the Medicare EOB must be submitted with the claim.

Beneficiaries in a MHP or PIHP

MDHHS cannot be billed for copays, deductibles, or any other fee for services provided to beneficiaries enrolled in a MHP or who are receiving services under PIHP/CMHSP capitation. Payment for services must be obtained from the MHP/PIHP/CMHSP.
For detailed information related to third party billing, including Medicare and commercial insurance, refer to the Coordination of Benefits Chapter of this manual.


Injectable Drugs

Covered as a Pharmacy Benefit by Third Party Payors

When billing for injectable drugs that are covered as a pharmacy benefit by a third party payor but covered as a physician service by Medicaid, the provider must reflect the payment from the carrier on the claim. The fixed copay/coinsurance/deductible must be reported in the appropriate field on the electronic claim form and in Item 24F on the CMS 1500 paper form.

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