2013 Practitioner and Provider Manual - Presbyterian Healthcare ...

Claims and PaymentCentennial Care COBPresbyterian Centennial Care is, by law, the payerof last resort for Presbyterian Centennial Caremembers. Therefore, if a Presbyterian CentennialCare member is eligible for benefits under anotherinsurance plan, you must file a claim and obtain anEOB/EOP from the other insurance plan, asrequired by your contract. Coverage requirementsof the other insurance plan must be satisfied.In coordinating benefits between the primaryinsurance carrier and Presbyterian CentennialCare, Presbyterian Centennial Care still acts in thesame capacity that the HSD Medical AssistanceDivision has in the past as the payer of last resort.Presbyterian Centennial Care’s normal priorauthorization guidelines and plan requirementsapply when Presbyterian is acting as the primarycarrier if the other carrier denied the services.Presbyterian Centennial Care does not makepayment for services denied by another carrierwhen the provider or member did not follow therequirements of the primary plan.Presbyterian Centennial Care does not require aprior authorization or referral in the followingcircumstances:When the member’s primary insurance does notinclude a benefit that is covered by PresbyterianCentennial CareWhen the member’s primary insurance hasreached annual plan maximums, or maximums onspecific benefits that are covered by PresbyterianCentennial CareCentennial Care Third-Party LiabilityPresbyterian Centennial Care is responsible foridentification of third-party coverage of membersand coordination of benefits with applicable thirdparties.Presbyterian Centennial Care is required to informHSD within 20 calendar days of receivinginformation regarding any member who has otherhealth coverage and must provide documentationwithin 20 calendar days to the HSD Third PartyLiability Unit, enabling HSD to pursue its right underfederal and state law, regulations, and rules.Presbyterian Centennial Care has the sole right ofcollection to recover from a third-party resource orfrom a provider who has been overpaid because ofa third-party resource for 12 months from the datePresbyterian Centennial Care first pays the claim toinitiate recovery and attempt to recover any thirdpartyresources available to Medicaid members, forall services provided by Presbyterian CentennialCare.Without mitigating any rights the PresbyterianCentennial Care provider has pursuant to federaland state law and regulations, HSD has the soleright ofCollection from a third-party resource whichPresbyterian Centennial Care has failed to identifywithin 12 months from the date PresbyterianCentennial Care first pays the claim.Recovery from Presbyterian Centennial Care or aPresbyterian Centennial Care provider who hasbeen overpaid because of the combined paymentsof Presbyterian Centennial Care and a third-partyresource when Presbyterian Centennial Care has18-122014 Practitioner and Provider Manual - Ver. 3