BadgerCare Plus & Medicaid SSI Provider Manual - Group Health ...

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BadgerCare Plus & Medicaid SSI Provider Manual - GHC of Eau Claire June 2012 ELECTRONIC CLAIM SUBMISSION - QUICKCLAIM GHC has made an online claim submission software program available to contracted providers; QuickClaim is a claims submission program powered by Smart Data Solutions (SDS). This program combines direct online data entry and automation, allowing providers to submit HIPAA complaint claims directly to GHC at no cost to the provider. This solution eliminates paper claims, reduces costs and shortens claims processing turnaround time. To access QuickClaim: https://quickclaim.smart-datasolutions.com:8443/quickclaim/servlet/quickclaim/template/CustomerLogin.vm/c/GRH BALANCE BILLING / COPAYMENT INFORMATION Provider (with the exception of collecting co-payments) may not bill, charge, collect a deposit from, seek remuneration from, or have any recourse against a GHC Member for covered benefits. Under state and federal laws, if a provider inappropriately collects payment from an enrolled member, or authorized person acting on behalf of the member, that provider may be subject to program sanctions, termination of Medicaid certification, and/or be fined, imprisoned or both. However, a member may request a non-covered service, a covered service for which authorization was denied (or modified), or a service that is not covered under the member’s limited benefit category. The charge for these services may be collected from the member if the following conditions are met prior to the delivery of that service: The member accepts responsibility for payment. The provider and member make payment arrangements for the service. Providers are strongly encouraged to obtain a written statement in advance, documenting that the member has accepted responsibility for the payment of the service. Furthermore, the service must be separate or distinct from a related, covered service. PAYER OF LAST RESORT Following Wisconsin Fee-For-Service Medicaid guidelines, BadgerCare Plus and Medicaid SSI HMOs are the payer of last resort for any covered services. Therefore, the provider is required to make a reasonable effort to exhaust all of the member’s other health insurance sources before submitting claims to GHC. SUBROGATION AND RECOUPMENT General Information All liability insurer medical coverage benefits are considered primary to GHC payment of Medicaid claims as per Wisconsin Statutes, Medicaid is payer of last resort. GHC reserves the legal right to process claims accordingly. Wisconsin Statutes Chapter 49 and Administrative Code DHS §106 govern how providers should submit liability claims and how GHC reviews these claims for processing. Wisconsin law also protects GHC’s right of subrogation. GHC reserves all legal, statutory and contractual subrogation and recoupment rights related to paid claims and will enforce its right in all cases, unless waived in writing by GHC. [8]
BadgerCare Plus & Medicaid SSI Provider Manual - GHC of Eau Claire June 2012 Claims submissions Unless the provider wants to relinquish on liability claims (see below), the provider must submit claims to the primary liability insurance before submitting to GHC. Following the liability carrier’s payment/denial determination, a copy of the original liability insurer EOB must be submitted to GHC, along with the original claim, for GHC’s review and/or payment determination (regardless of balance due). If liability claims are submitted to GHC without the liability carrier’s payment determination via the original EOB, the claims will be denied using the appropriate ANSI codes. The denial reason will be printed on GHC’s EOB to the provider. All claims should be submitted with accident relatedness and/or appropriate E-Codes when a liability carrier may be involved (i.e.: initial treatment and all subsequent related treatment). In the event a provider fails to submit claims with the appropriate liability coding information, and/or the claims are adjudicated and the provider accepts the Medicaid payment, these claims become the property of GHC to pursue any subrogation interest. Once a provider accepts the Medicaid payment from GHC, even where liability of another party/payor exists, the provider can no longer pursue or accept a payment from the liability carrier or Medicaid recipient, pursuant to Wisconsin Administrative Code DHS §106.03(8). This applies to all liability-related GHC payments, even if claims had not been coded to indicate liability as stated above. Relinquishments Relinquishments are available for claims denied by a liability insurer. All relinquishments must be in writing to ensure compliance with Wisconsin Administrative Code DHS §106.03(8). The subsection language is included on the relinquishment form, which can be found at the link below. If a provider chooses to accept the Medicaid payment in lieu of pursuing payment from the liability carrier, the provider may complete a relinquishment form and attach the same to the claim submission. The relinquishment form can be found at www.group-health.com under Provider Login/Provider Tools. Send the completed relinquishment requests to GHC, Attention: Subrogation Department. Relinquishments are provider-, date- and claim-specific. If the form does not match the submitted claims, it will be returned to the provider for correction. This policy protects the provider’s right to choose which claims they wish to pursue liability payments on. Claims not specifically mentioned on a relinquishment form will not be reversed for processing. After accepting the Medicaid/relinquishment-payment on a claim, the provider can no longer pursue liability payments and/or accept any other payment or settlement on the relinquished claim. Relinquishment decisions are final. No recoupments, reprocessing or refunds will be allowed on relinquished claims. Recoupments/Refunds ALL recoupment and refund requests MUST comply with Wisconsin Administrative Code DHS §106. Requests should be reviewed for compliance prior to submission to GHC. Requests found to be in violation of Wis. Adm. Code will be denied and returned to the provider. Violations will be reported as required under GHC’s contract with the Department of Health Services. [9]
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