How to verify insurance eligibility - effective dates

Confirming Eligibility

Whenever possible, providers should verify eligibility prior to providing service. To verify eligibility, providers should perform the following:

Step 1  Request to see the recipient’s plastic card, or a copy of the eligibility notification letter.

Step 2  Ask to see a driver’s license or other picture identification for adult recipients.

Step 3  Perform eligibility verification using one of the methods described in Section 3.2, Confirming Eligibility.

Step 4 Review the entire eligibility response, as applicable, to ensure the recipient is eligible for the service(s) in question. Please note that the eligibility response provides lock-in, third party, managed care and dental information. You need all the available information to determine whether the recipient is eligible for Medicaid.

Step 5 Maintain a paper copy of the eligibility response in the patient’s file to reference, should the claim deny for eligibility.

If the claim denies for ineligibility, the provider may contact the HP Provider Assistance Center to review the eligibility verification receipt and discuss the reasons the claim denied.

Providers may use various resources to verify recipient eligibility:

• Provider Electronic Solutions software
• Software developed by the provider’s billing service, using specifications provided by HP
• Automated Voice Response System (AVRS) at 1 (800) 727-7848
• Contacting the HP Provider Assistance Center at 1 (800) 688-7989


DETERMINATION OF ELIGIBILITY - Medicaid Guideline

LOCAL MICHIGAN DEPARTMENT OF HEALTH AND HUMAN SERVICES OFFICE DETERMINATION

Eligibility for Medicaid and most other health programs is determined at the local Michigan Department of Health and Human Services (MDHHS) office. MDHHS reviews the beneficiary's financial and nonfinancial (e.g., disability, age) factors and determines the types of assistance for which the beneficiary is eligible.

Once eligibility is established, data from MDHHS is available via the CHAMPS Eligibility Inquiry. CHAMPS will also issue a mihealth card for new beneficiaries.


Some Medicaid beneficiaries are in a deductible situation. This means the beneficiary has met all Medicaid eligibility criteria except he has excess income. (Refer to the Medicaid Deductible Beneficiaries Section of this chapter for additional information.)

Migrant agricultural workers may also be eligible for health care benefits. However, due to the transient nature of the migrant population, they might not receive their mihealth card. The provider must verify eligibility using the CHAMPS Eligibility Inquiry and/or vendor that receives eligibility data from CHAMPS.

(Refer to the Verifying Beneficiary Eligibility Section of this chapter for additional information.) 1.2 ELIGIBILITY BEGIN DATE

Coverage is usually effective the first day of the month that the beneficiary becomes eligible.

** Not all beneficiaries, however, are eligible beginning the first day of the month. Coverage may become effective the actual day the beneficiary becomes eligible.

** In some instances, the beneficiary's eligibility may be retroactive up to three months prior to the month of application. This may occur if, during the retroactive period:

** All eligibility requirements for the specific health care program were met; and

** Medical services were rendered.

The provider may submit claims to the Michigan Department of Health and Human Services (MDHHS) for payment of any covered services rendered during the beneficiary's eligibility period. If the beneficiary has previously paid for services and the provider has billed MDHHS for the same services, the provider must refund to the beneficiary the portion of payment the beneficiary is responsible for, regardless of the amount MDHHS pays. (Refer to the Medicaid Deductible Beneficiaries Section of this chapter for additional information).


REDETERMINATIONS

Beneficiary eligibility is redetermined annually but may occur more often as case circumstances dictate.

Beneficiaries are notified of the need to have their cases redetermined and the process to be followed to accomplish this.

BENEFICIARY APPEALS

Beneficiaries may appeal their eligibility determination/redetermination by contacting their local MDHHS office.


CORRECTIVE ACTION

Beneficiaries that have been denied Medicaid eligibility and have filed a hearing request may be entitled to a reimbursement if they paid for Medicaid covered services during a corrective action period. The corrective action period begins on the date the hearing request is received by MDHHS and ends on the date that eligibility is established. The services received must have been provided during the established eligibility period, including any months of established retroactive eligibility.

The provider has the option to reimburse the beneficiary in full and bill Medicaid for services rendered.

MDHHS encourages the provider to return the amount the beneficiary paid and bill Medicaid for the service. If the provider chooses not to reimburse the beneficiary, the beneficiary can request a direct reimbursement from the State.

In order to be eligible for a direct reimbursement from the State, the beneficiary, or someone legally responsible for the beneficiary's bills, must have paid for a Medicaid covered service during the corrective action period. The beneficiary cannot receive reimbursement for any required copays, patient pay amounts, amounts used to meet a Medicaid deductible, or care or services paid for through private insurance, Medicare, or any other form of government-sponsored or private health care coverage.


To request a refund of medical expenses, the beneficiary must provide a copy of all bills for medical services received on or after February 2, 2004 for which the beneficiary, or someone legally responsible for the beneficiary's bills, paid during the corrective action period to MDHHS.

Bills must include or contain:

** Beneficiary name

** Date the care or service was received

** Amount charged for the care or service

** Amount paid by the beneficiary or legally responsible party

** Date the bill was paid

** Procedure code(s) for the care or service

** Description of each care or service, e.g., office visit, physical therapy, etc. The drug name, quantity dispensed, and the name of the prescribing physician must be included for prescriptions.

** Proof of any payment made by a third party, such as an insurance company

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