MANAGED CARE
How do we find out which network provider to call?
If you check eligibility through the web portal, look for this information in the Managed Care section of the recipient’s eligibility screen. You will find the name, type and phone number of the HMO, PSN or other managed care plan.
Is the network provider the one who is going to give us the authorization for the services?
No, you would get the authorization from the Health Plan. The only time you will get authorization from a provider is for a person managed under MediPass.
Referring to Slide 50: If recipients don’t have managed care, will it be blank or will it state FL Medicaid? If the recipient does not have managed care, the Web Portal screen will show ***No rows found***.
A patient will come in with a Medicare managed plan yet also show us a Medicaid card. The Medicaid eligibility will show full Medicaid benefits but does not show the Medicare Advantage plan yet we do call and verify eligibility with the Medicare HMO. Does Medicaid pay as a secondary in this case?
Medicaid is not currently paying crossover claims for beneficiaries in Medicare HMOs (Part C plans), but there are changes in the works that may take place as soon as the end of the year. Please watch for any upcoming provider alerts on this subject. You may also contact your Local Medicaid Area Office for questions on this topic. You can find a list of the Medicaid Area Offices and contact information on the Medicaid fiscal agent’s Web Portal at: http://mymedicaid-florida.com/
If I have a situation where our claims are being underpaid with our HMO contract and we have sent several requests, spreadsheets and calls to get this rectified; what other recourse do we have as a provider?
The Medicaid contract requires that the provider address any claims/billing disputes through the provider complaint system of the individual Health Plan. Language from the contract is provided below. If the provider is unable to resolve this with the Health Plan, they are able to access an outside claims arbitrator, Maximus, which deals with claims disputes between Health Plans and providers. Application forms and instructions on how to file claims are available from Maximus.
How can I check for eligibility for a specific service by a managed care plan?
You may ask the recipient’s managed care plan when you contact them for authorization.
If you do not have a specific recipient, you may contact the managed care plan for general information. Your Area Medicaid office may be able to provide the contact telephone numbers for the managed care plans in your county.
