Ala. Admin. Code r. 560-X-20-.06

Current through Register Vol. 43, No. 1, October 31, 2024

Section 560-X-20-.06 - Fiscal Agent Responsibility

(1) Medicaid's fiscal agent is responsible for monitoring all claims for possible third party liability and utilizing information on the claim to identify potential Third Party liability. The fiscal agent will utilize Medicare coverage dates, the Commercial TPL policy file and Medicare Advantage enrollment dates to ensure that Medicaid properly processes claims as the payer of last resort.

(2) The fiscal agent is responsible for editing claims for third party coverage in accordance with State requirements to ensure that claims are either cost avoided, recouped from the provider, or identified for post payment billing to third party payers.

(3) The fiscal agent is responsible for retroactively identifying third party liability, including Medicare, and either cost avoiding covered claims, recouping Medicaid payment from the provider or producing post payment billings to an insurance carrier to obtain reimbursement for Medicaid paid claims in accordance with State and Federal requirements.

Ala. Admin. Code r. 560-X-20-.06

Amended by Alabama Administrative Monthly Volume XXXIII, Issue No. 04, January 30, 2015, eff. 2/13/2015.

Author: Wanda Wright, Administrator, Third Party Liability

Statutory Authority:Code of Ala. 1975, § 22-6-6, 42 CFR §§432 and 433; Section 1902(a)(25), Social Security Act.