The purpose of rule 59G-1.052 is to specify provider responsibilities when a Florida Medicaid recipient has coverage through an individual, entity, insurance, or program that is liable to pay for health care services, and where to submit notices ...

 

AGENCY FOR HEALTH CARE ADMINISTRATION

Medicaid

RULE NO.:RULE TITLE:

59G-1.052Third-Party Liability Requirements

PURPOSE AND EFFECT: The purpose of rule 59G-1.052 is to specify provider responsibilities when a Florida Medicaid recipient has coverage through an individual, entity, insurance, or program that is liable to pay for health care services, and where to submit notices informing Florida Medicaid that a recipient has third-party coverage.

SUBJECT AREA TO BE ADDRESSED: Rules 59G-1.052, Third-Party Liability Requirements; 59G-1.054, Recordkeeping and Documentation Requirements; and 59G-1.056, Copayments and Coinsurance.

An additional area to be addressed during the workshop will be the potential regulatory impact Rules 59G-1.052, 59G-1.054, and 59G-1.056, F. A. C., will have as provided for under sections 120.54 and 120.541, FS.

RULEMAKING AUTHORITY: 409.919 FS.

LAW IMPLEMENTED: 409.910 FS.

A RULE DEVELOPMENT WORKSHOP WILL BE HELD AT THE DATE, TIME AND PLACE SHOWN BELOW:

DATE AND TIME: November 16, 2015, 2:00 ‒ 4:00 p.m.

PLACE: Agency for Health Care Administration, 2727 Mahan Drive, Building 3, Conference Room B, Tallahassee, Florida 32308-5407

Pursuant to the provisions of the Americans with Disabilities Act, any person requiring special accommodations to participate in this workshop/meeting is asked to advise the agency at least 48 hours before the workshop/meeting by contacting: Ray Aldridge. If you are hearing or speech impaired, please contact the agency using the Florida Relay Service, 1(800)955-8771 (TDD) or 1(800)955-8770 (Voice).

THE PERSON TO BE CONTACTED REGARDING THE PROPOSED RULE DEVELOPMENT AND A COPY OF THE PRELIMINARY DRAFT, IF AVAILABLE, IS: Ray Aldridge, Bureau of Medicaid Policy, 2727 Mahan Drive, Mail Stop 20, Tallahassee, Florida 32308-5407, telephone: [phone], e-mail: [e-mail].

Comments will be received until 5:00 p.m., on November 17, 2015.

 

THE PRELIMINARY TEXT OF THE PROPOSED RULE DEVELOPMENT IS:

 

 

59G-1.052 Third-Party Liability Requirements.

(1) This policy applies to all providers enrolled or registered under the Florida Medicaid program and to all persons who are required to notify Florida Medicaid of any third-party benefit a recipient has.

(2) Purpose: Third-Party Liability (TPL) refers to the legal obligation of third parties (e.g., certain individuals, entities, insurers, or programs to pay part or all of the expenditures for medical assistance furnished under the Florida Medicaid Program. In accordance with Title 42, Code of Federal Regulations, section 433, Subpart D, all other available third-party resources must meet their legal obligation to pay claims before the Florida Medicaid program pays for a recipient’s care.

(3) Exhausting third-party resources.

(a) Florida Medicaid is the payer of last resort. Providers must exhaust all TPL sources of payment, such as Medicare, TRICARE, private health insurance, AARP plans, or automobile coverage, prior to submitting or resubmitting a claim for reimbursement to Florida Medicaid.

(b) The following programs are exceptions to Florida Medicaid being the payer of last resort:

1. Federal funds for the Individuals with Disabilities Education Act, Part B or C.

2. Indian Health Services, according to 42 CFR 136.61.

3. Programs funded through state and county funds, including:

a. Acquired Immune Deficiency Syndrome (AIDS) drug assistance programs.

b. County health departments.

c. Department of Health indigent drug programs.

d. Substance abuse, mental health, and developmental disabilities programs funded by the Department of Children and Families and the Agency for Persons with Disabilities.

e. Victim’s compensation funds.

f. Vocational rehabilitation programs.

(4) Refusal of services to recipients. Providers may not refuse to furnish a covered Florida Medicaid service to a recipient solely because of the presence of other insurance, including Medicare, in accordance with 42 CFR 447.20(b).

(5) Florida Medicaid reimbursement.

(a) Florida Medicaid reimburses the difference between the rate specified on the applicable Florida Medicaid fee schedule and the third-party payment, minus any Florida Medicaid copayment or coinsurance.

(b) Florida Medicaid does not reimburse for services when:

1. The amount of the third-party payment is equal to, or exceeds, the fee for the service specified on the applicable Florida Medicaid fee schedule.

2. The provider’s TPL claim is denied for failing to obtain the appropriate authorizations from the third-party.

(6) Third-party liability resources.

(a) Third-party liability information for each recipient is available when the provider verifies recipient eligibility on the Florida Medicaid fiscal agent’s Web site at http://portal.flmmis.com/flpublic.

(b) Providers must determine if the insurance on the Florida Medicaid file is applicable to the services being provided. Florida Medicaid uses the following two-digit numeric codes when veryfying recipient eligibility and for claims processing purposes:

CODE	INSURANCE COVERAGE TYPE
03	BASIC SURGICAL
04	BASIC HOSPITAL/MEDICAL/SURGICAL
05	PHARMACY ADMINISTRATOR (TPA)
06	MAJOR MEDICAL
07	ACCIDENT ONLY (NON AUTO)
08	VEHICLE ALL INCLUSIVE
09	MAJOR MEDICAL WITH TPA OR NO PHARMACY
10	CANCER
11	MEDICARE SPECIAL NEED PLAN
12	MEDICARE SUPPLEMENT
13	NURSING HOME SUPPLEMENT
14	HEALTH MAINTENANCE ORGANIZATION
15	DENTAL
16	TRICARE
17	HMO WITHOUT PHARMACY
18	CONTINUOUS CARE/LIFE CARE
19	MEDICARE HMO UNLIMITED PHARMACY
20	MEDICARE HMO LIMITED PHARMACY
21	PHARMACY CARD SERVICE
22	HOSPITAL ROOM – BOARD/INDEMNITY
23	BASIC MEDICAL

 

(7) Claim instructions.

(a) Providers must adjust or void a Florida Medicaid claim if they receive payment from a third-party after the Florida Medicaid claim is paid.

(b) Discounted contracts.

1. Florida Medicaid reimburses providers participating in plans with a third-party, in which the provider agrees to accept as full payment an amount less than its customary charges for any remaining recipient liability under the plan, such as a copayment or deductible.

2. If the discount contract’s allowable fee is less than Florida Medicaid’s maximum allowable fee and there remains a recipient liability under the plan, providers must:

a. Compute the amount of patient responsibility (deductible, coinsurance, etc.).

b. Deduct the result of sub-subparagraph a. from the Florida Medicaid rate.

c. Include the result of sub-subparagraph b. as the third-party payment on the claim.

Providers must prorate the discount contract’s allowable, third-party liability payment, and the recipient responsibility for each line item, if the Explanation of Benefits (EOB) from the insurance company is not itemized.

(c) Canceled, expired, non-payment, or no proof of third-party coverage.

1. Providers must obtain proof from the third-party insurer that a recipient is not covered by the third- party when Florida Medicaid’s eligibility verification information indicates the recipient has TPL coverage.

a. If the provider has billed the third-party insurer and the third-party insurer refuses to send an EOB, proof that the coverage has been terminated, or proof that the service is not covered, providers must submit a letter on letterhead with a claim for reimbursement to the Florida Medicaid fiscal agent, including:

(I). A detailed explanation of the attempts made to obtain an EOB or other proof of non-coverage from the third-party.

(II). Any pertinent information obtained from the third-party.

(III). Date of correspondence or other communication with the third-party.

(IV). Name of person(s) contacted.

(V). Recipient’s name, Florida Medicaid number, and date of service.

(VI). Recipient’s third-party policy number.

(VII). Telephone number, if available, for the third-party.

b. Providers must submit a written explanation certifying there has not been a response from an absent non-custodial parent’s third-party for at least 30 days.

(d) Contributions to a facility.

1. Providers must treat any contribution made to a facility on behalf of a specific recipient as a third-party payment.

2. Providers do not have to report a contribution made to a facility to Florida Medicaid, when it is not for a specific recipient, but for the benefit of all residents.

(e) Crossover with TPL Claim and Adjustment Form.

1. Providers must submit the following with the claim for reimbursement when Florida Medicaid is liable for all, or a portion of, the claim after the third-party has settled or denied its claim:

a. Crossover with TPL Claim and/or Adjustment Form, ______, incorporated by reference in Rule 59G-1.045, F.A.C.

b. Proof of third-party liability payment or denial.

c. Explanation of Medicare Benefits (EOMB)

2. Providers must submit one of the following forms, as applicable, with Medicare Advantage Plan (Part C) claims:

a. State of Florida Medicare Part C – Florida Medicaid CMS-1500 Crossover Invoice Form, ________, incorporated by reference in Rule 59G-1.045, F.A.C.

b. State of Florida Medicare Part C – Florida Medicaid UB-04 Crossover Invoice Form, ______, incorporated by reference in Rule 59G-1.045, F.A.C.

(8) Third-party liability vendor. Florida Medicaid contracts with a TPL contractor to identify, manage, and recover Florida Medicaid funds paid on behalf of recipients when another party is or was responsible. For more information, visit https://www.flmedicaidtplrecovery.com.

(9) Third-party liability notices.

(a). In accordance with sections 409.910 (Medicaid Third-Party Liability Act) and 409.9101, F.S., notices informing Florida Medicaid of any third party benefit must be submitted in writing, by United States mail, private carrier, or hand, to the  Agency for Health Care Administration’s designated third-party liability contractor or the following address:

Office of Florida Medicaid Third-Party Liability

Agency for Health Care Administration

2727 Mahan Drive

Tallahassee, Florida 32308-5403

(b). Notice provided to any other office of the Florida Medicaid Program or delivered to any other address is not effective to fulfill notice requirements of section 409.910, F.S.

Rulemaking Authority 409.919 FS. Law Implemented 409.910 FS. History-New ________.