471 Neb. Admin. Code, ch. 3, § 005

Current through September 17, 2024

Section 471-3-005 - THIRD PARTY RESOURCES

005.01THIRD PARTY RESOURCE PAYMENT. All third party resources available to a Medicaid client must be utilized for all or part of their medical costs before Medicaid. Medicaid payment is made only after all third party resources have been exhausted or met their legal contractual or legal obligations to pay. Medicaid is the payor of last resort.

005.01(A)EXCEPTIONS. The Nebraska Chronic Renal Disease Program and the Medically Handicapped Children's Program are not included as a third party resource.

005.02AVAILABILITY OF THIRD PARTY RESOURCE INFORMATION. The Coordination of Benefits and Third Party Liability Unit of the Department maintains all known current health insurance, casualty insurance, and Medicare coverage on the Nebraska Medicaid Eligibility System (NMES). Providers may also obtain this information using the standard electronic Health Care Eligibility Benefit Inquiry and Response transaction. If the provider becomes aware of any additional third party resources, the provider must contact the Department and report the new sources.

005.02(A)REQUEST FOR RELEASE OF PATIENT ACCOUNT INFORMATION. To alert the Department to a potential third party resource, the provider must notify the Department when a provider receives a request for an itemized bill or a request for the balance of a bill from the client, an attorney, an insurance company, or employer. This does not include routine billing information requests to process insurance or Medicare. The provider may release the information in accordance with the provider's standard office practice.

005.03PAYOR OF LAST RESORT. Medicaid clients who have third party resources must exhaust these resources before Medicaid considers payment for services. Medicaid will not pay for medical services as a primary payor if a third party resource is contractually or legally obligated to pay for the service.

005.03(A)BILLING THIRD PARTY RESOURCES. Providers must bill all third party resources and the client, when there is a share of cost obligation, for services provided to the client, except for waiver claims. Providers must submit all charges and Medicare covered services provided to Medicare and Medicaid dually eligible individuals to Medicare plus any Medicare supplement plans for resolution prior to billing Medicaid.

005.03(B)WAIVER CLAIMS. Certain services, defined as waiver claims, are an exception to the requirements of this chapter. Providers may submit these claims to Medicaid before submitting to a third party resource. Nebraska Medicaid pays these claims and Department staff initiate recovery activities for any third party resource. This does not prohibit the provider from billing the third party resource before billing Medicaid. In these situations, the provider does not bill Medicaid until the claim is resolved.

005.03(C)SERVICES NOT COVERED BY MEDICARE. Nebraska Medicaid may cover services within the scope of Nebraska Medicaid which are not covered by Medicare. Nebraska Medicaid does not cover any Medicare Part D Drug or Medicare Part D covered supply or equipment, even if coverage is denied by the Medicare Part D Plan. For services not covered by Medicare, documentation of the Medicare denial is not required.

005.04MEDICARE PART A AND B DEDUCTIBLE AND COINSURANCE. In some cases, Medicaid pays the deductible and coinsurance for Medicare-covered services. The Department accepts Medicare's utilization review and payment decisions for Medicare allowable fees, except after crediting any amount received from Medicare for Medicare-covered services and crediting any amount received from any third party resource, Medicaid will pay the lesser of the Medicare or Medicaid allowable amount of any remaining amount due.

005.04(A)MEDICARE PART D MONTHLY PREMIUM, DEDUCTIBLE, CO-INSURANCE, AND COVERAGE GAPS. Medicaid does not pay the premium, deductible, co-insurance, copays, or coverage gaps for Medicare Part D.

005.04(B)MEDICARE PART A COINSURANCE FOR NURSING FACILITY SERVICES. For nursing facility services covered under Medicare Part A, Medicaid payments are limited to rates and payments according to the following method:

(i) If the Medicare payment amount for a claim exceeds or equals the Medicaid rate or payment for the claim, Medicaid reimbursement will be zero.

(ii) If the Medicaid rate and payment for a claim exceeds the Medicare payment amount for the claim, Medicaid reimbursement is the lesser of:

(1) The difference between the Medicaid rate and payment minus the Medicare payment amount; or

(2) The Medicare coinsurance and deductible, if any, for the claim.

005.05PROVIDER PAYMENT IN FULL. Medicaid payment is the lower of the provider's usual and customary charge or the Medicaid allowable less all third party payment. When a claim is submitted to Medicaid with a payment from a third party resource, the provider is considered paid in full when payment from the third parties and Medicaid equals or exceeds the Medicaid allowable amount. The provider may only bill the client for services not covered by Nebraska Medicaid, for Nebraska Medicaid copayment fees, where applicable, or if the client has received payment from the third party resource.

005.05(A)MEDICARE PART A AND PART B. Department payment of Medicare coinsurance and deductible constitutes payment in full. The provider will not balance bill.

005.05(B)MEDICARE ADVANTAGE. Department payment of Medicare Advantage coinsurance and deductible constitutes payment in full to the provider. The provider will not balance bill.

005.05(C)MEDICARE PART D. Nebraska Medicaid does not pay premiums, deductibles, co-insurance, copays, or coverage gaps for Medicare Part D.

005.05(D)MEDICARE WAIVER OF LIABILITY. When a Medicare and Medicaid dually eligible individual signs a Medicare Waiver of Liability and Medicare denies the claim as not reasonable and necessary, Nebraska Medicaid will not pay the claim.

005.05(E)USE OF CONTRACTS BY MEDICARE AND MEDICAID DUALLY ELIGIBLE INDIVIDUALS. If providers negotiate private contracts with Medicare and Medicaid dually eligible individuals for which no claim is to be submitted to Medicare and for which the provider receives no reimbursement from Medicare directly, neither Medicare nor Medicaid would cover the services provided under the private contract.

005.05(F) CASUALTY SETTLEMENTS WITH A THIRD PARTY RESOURCE. When a provider enters into an agreement with a Medicaid client or a representative of the client to accept less than billed charges, the provider is considered paid in full. No further payment is due from either the client or Nebraska Medicaid.

005.05(G) PROVIDER'S FAILURE TO COOPERATE IN SECURING THIRD PARTY PAYMENT. The provider's failure to file necessary claims for third party resources, except waiver claims, or to cooperate in securing payments by other third party resources is grounds for denial of the claims. If Nebraska Medicaid denies claims for these services, the client cannot be billed unless the payment went to the client.

005.06FILING CLAIMS WITH THIRD PARTY RESOURCES

005.06(A)WAIVER OF COOPERATION FOR GOOD CAUSE. With respect to obtaining medical care support and payments or identifying and providing information to assist the State in pursuing liable third parties for a child for whom the individual can legally assign rights, the Department must find cooperation is not in the best interests of the individual or the person to whom Medicaid is being furnished because it is anticipated cooperation will result in reprisal against, and cause physical or emotional harm to, the individual or other person as described in chapter one of this title.

005.06(B)TIMELY FILING OF CLAIMS WITH HEALTH INSURANCE. Providers must first submit all claims to third party resources. To secure a provider's right to Medicaid consideration for payment, a claim must be filed within 12 months from service date even if the third party resource has not been resolved. If the provider fails to submit a claim or fails to contact the Department within 12 months from the date of service, Nebraska Medicaid will not pay the claim.

005.06(B)(i)DENIAL DUE TO THIRD PARTY RESOURCE. If the provider files a claim with Nebraska Medicaid within 12 months of the date of service and receives a Medicaid denial due to the existence of a third party resource, the provider is allowed up to 12 months from the original receipt date of the Medicaid claim to resolve the third party resource. The provider must submit the claim adjustment to Nebraska Medicaid within six months of the date on the insurance or Medicare remittance advice no later than 12 months from the original receipt date of the Medicaid claim.

005.06(C)TIMELY FILING OF CLAIMS WITH CASUALTY INSURANCE. Providers must submit claims within 24 months of the date of service.

005.06(C)(i)EXCEPTION. The Department can make payment beyond 24 months if the provider can document action was taken to obtain payment from the third party. If a provider has received a denial from the Department due to the existence of casualty insurance coverage, the provider has sought payment from the third party, and the provider has waited 24 months without receiving payment from the third party, the provider can request the Department reconsider payment. If the provider has filed a lien, the provider must release the lien upon receipt of payment from the Department. These situations are reviewed on a case by case basis.

005.06(D)FILING MEDICAID CLAIMS AFTER RESOLVING THIRD PARTY RESOURCES. Providers will bill Nebraska Medicaid only when all third party resources have failed to cover the service or when a portion of the cost of the service has been paid. The provider must submit the third party documentation with each claim submitted to the Department. The dates of service on the third party documentation must match the dates of service on each claim.

005.06(D)(i)BILLING THE USUAL AND CUSTOMARY CHARGE. When billing Nebraska Medicaid, the provider must bill the usual and customary charge for each service. The provider cannot submit a claim showing only the Medicaid allowable amount or the difference between the Medicaid allowable amount and the amount of the third party payment.

005.06(D)(ii)ADJUSTMENT REQUEST. After the provider has submitted a claim with third party resource documentation and the Department has adjudicated the claim for payment, if the provider wishes to request an adjustment, the provider must submit the adjustment request within 90 days from the payment date on the Remittance Advice.

005.07THIRD PARTY RESOURCE DENIALS.

005.07(A)HEALTH INSURANCE DENIALS. Nebraska Medicaid will recognize and consider payment on claims the health insurance has denied with a valid health insurance denial.

005.07(B)MEDICARE DENIALS. Nebraska Medicaid will recognize and consider payment on claims Medicare has denied when the claim is submitted with a valid Medicare denial.

005.07(B)(i)EXCEPTION. The Department will not consider payment for services which have been denied by Medicare for lack of medical necessity.

005.07(C)CASUALTY INSURANCE DENIALS. Nebraska Medicaid will recognize and consider payment on claims involving casualty coverage denial when the claim is submitted with a valid casualty denial.

005.07(C)(i)PAYMENT PENDING LIABILITY DETERMINATION. The insurer's statement indicating payment cannot be made at this time due to a pending liability determination or litigation is not a valid denial.

005.08FILING ELECTRONIC CLAIMS WITH THIRD PARTY RESOURCES. Medicaid will accept electronic claims when third party resources are available. The health insurance and Medicare documentation is required.

005.08(A)AUTOMATIC TRANSFER OF CLAIMS FROM MEDICARE. Nebraska Medicaid accepts Medicare crossover claims directly from Medicare's fiscal intermediaries and will pay the deductible and coinsurance when no additional third party resource is identified. Claims received from Medicare must include Medicare supplemental insurance coordination of benefits and remittance advice documentation, if applicable.

005.09THIRD PARTY RESOURCE REVERSAL OF PAYMENT TO PROVIDER. If a provider filed a claim with a third party resource and received payment in full, and thus did not bill Medicaid, and the third party resource reverses its determination after 12 months from the date of service, the provider may bill Nebraska Medicaid for the services. The provider must bill Nebraska Medicaid within 60 days from the date on the third party reversal document and refund. The provider must submit documentation of the reversal with the claim. The claim may be considered for payment by Nebraska Medicaid only if the date of service is no more than 24 months from the date of receipt of claim.

005.10PRIOR AUTHORIZATION AND THIRD PARTY RESOURCES. The provider must resolve all third party resources before Nebraska Medicaid can consider paying a claim regardless of whether Medicaid prior authorization has been given.

005.11MEDICAID ELIGIBILITY AND THIRD PARTY RESOURCES. The provider must resolve all third party resources before Nebraska Medicaid can consider paying a claim, regardless of whether the client is eligible for Medicaid, with the exception of waiver claims. A client's eligibility for Nebraska Medicaid does not guarantee payment of a claim.

005.12LONG-TERM CARE INSURANCE POLICIES. A long-term care indemnity policy is considered a health insurance policy when the policy allows assignment of benefits and covers medical care based on specified criteria. Long-Term Care insurance which meets this criteria is not considered income for eligibility determination.

005.12(A)NURSING FACILITY CLAIMS. Because nursing facility claims are included in the category of "waiver claims," Nebraska Medicaid will pay these claims at the specific per diem for the client, less any excess income or share of cost the client is obligated to pay the provider for the monthly services. The Coordination of Benefits Unit will seek recovery on all of these policies. Because the claims have been paid, the provider will not bill the insurer. The provider must assist the Coordination of Benefits Unit in obtaining reimbursement from these policies by furnishing any medical documentation the insurer requests.

005.12(B)BILLING LONG-TERM CARE INSURANCE. A provider may choose to bill the long term care insurance; in these situations, the provider does not bill Medicaid. If the provider or the client receives a payment directly from the insurer, the payment must be sent to the Coordination of Benefits and Third Party Liability Unit.

005.12(C)PAYMENT RECEIVED BY THE DEPARTMENT. Whenever the Department receives any payments from long-term care insurance which exceed what Medicaid has paid toward the care of the client, the Department will apply the excess to any Medicaid expenditure for the Medicaid client regardless of whether the expenditure was covered by the third party. The application of the excess third party liability payment is not limited to a particular Medicaid service and can be applied to any claims paid by Medicaid. After the excess payment has been applied to all claims, any remaining amount will be paid to the client or the client's authorized representative.

005.13MEDICAL SUPPORT FROM NON-CUSTODIAL PARENTS. When children with a non-custodial parent become Medicaid eligible, medical support is court ordered in compliance with Omnibus Budget Reconciliation Act 1993. The County Attorney's staff or Child Support Enforcement staff will notify the Coordination of Benefits and Third Party Liability Unit of any health insurance coverage and medical support court orders obtained for a child who is eligible for Nebraska Medicaid. When a non-custodial parent is ordered by the court to furnish health insurance or make payment for medical services, the provider may bill Medicaid for the services if the provider has not received payment from the health insurer or non-custodial parent within 30 days of the date of service. Medicaid will pay the claims and the Department will seek recovery from the health insurer or non-custodial parent.

005.13(A) BILLING WHEN A COURT ORDER EXISTS. To determine whether a court order exists, the provider may contact the Coordination of Benefits and Third Party Liability Unit. The provider is not required to continue to seek payment from the health insurer or non-custodial parent before billing Medicaid when there is court-ordered medical support.

005.13(B)SEEKING PAYMENT FROM THE NON-CUSTODIAL PARENT. Non-custodial parent medical support court orders may include an obligation by the non-custodial parent to pay a percentage of medical expenses after the health insurer has made payment. The provider is not required to seek payment from the non-custodial parent in these cases. If the provider receives a payment from a non-custodial parent, the provider will indicate this amount and the amount received from the health insurer as a prior payment or amount paid on the claim submitted to Medicaid. The provider must submit with the claim a copy of the documentation showing the non-custodial parent made the payment. If the provider receives payment from the non-custodial parent after Medicaid has paid the claim, the provider must refund Medicaid according to the requirements of this chapter.

005.13(C)HEALTH INSURER OBLIGATION WHEN THE NON-CUSTODIAL PARENT HAS A MEDICAL SUPPORT COURT ORDER. A health insurer cannot deny a child insurance coverage if the non-custodial parent has a court or administrative order for medical support. An insurer must provide the custodial parent information to file claims, allow the custodial parent or provider to file claims, and pay claims to the custodial parent, provider, or the Department, as required by Neb.Rev.Stat. Section 44-3,149. If the provider receives a denial of insurance coverage for any of these reasons from an insurer and the client is a child, the provider must contact the Department.

005.14PROVIDER REFUNDS TO THE DEPARTMENT. When a provider receives payment from a third party resource on a claim previously paid by Nebraska Medicaid, the provider must submit a refund to the Department. The provider must include the third party documentation with the refund. If the payment from the third party resource equals or exceeds the Nebraska Medicaid payment on the claim, the total payment must be refunded to the Department. If the payment from the third party resource is less than the Nebraska Medicaid payment on the claim, the total third party payment must be refunded to the Department.

005.15BILLING THIRD PARTY RESOURCES AFTER NEBRASKA MEDICAID PAYMENT. If, after Nebraska Medicaid has paid, a provider learns of a third party resource which would have paid more for the service than Nebraska Medicaid, in cases where health insurance is the third party resource, the provider must supply the Department with the third party resource information, refund the Department the full Nebraska Medicaid payment, and then seek recovery from the third party resource. If a Medicaid client becomes retroactively eligible for Medicare, the provider must refund the Department the full Nebraska Medicaid payment and seek reimbursement from Medicare for payment unless Medicare filing time limits for dates of service on the claims have been exhausted. In cases where casualty insurance is the third party resource, the provider will not refund Nebraska Medicaid's payment and then seek recovery from a third party resource, unless the refund is requested by the Department.

005.15(A)DEPARTMENT REQUESTS FOR REFUNDS. When the Department receives information indicating the provider has received a third party resource payment on a Medicaid paid claim, the Department will request a refund from the provider. The provider has 30 days to submit a refund check, show the refund has already been made, document the refund request is in error, or appeal. Failure to comply with this request within 30 days is cause for the Department to withhold future provider payments until the situation is resolved or impose sanctions on the provider. The refund request constitutes notice of sanction.

005.16CLIENT RIGHTS AND RESPONSIBILITIES

005.16(A)CLIENT RIGHTS. A provider cannot refuse to furnish services to an individual who is eligible for Nebraska Medicaid because of a third party's potential liability for payment of service.

005.16(B)FAILURE TO COOPERATE. A Nebraska Medicaid client has the obligation to assist the provider and the Department in obtaining payment from all available third party resources. This may include complying with any requests from the insurer for additional information, ensuring the provider or the Department receives remittance advice, coordination of benefits, and payments from the insurer, or appearing in court in litigation situations. If the client fails to cooperate with the provider in securing third party resources, the provider may contact the Department. Failure by the client to cooperate may cause the client to lose Nebraska Medicaid eligibility. The client will be responsible for payment of the denied services.

005.16(C)CLIENT RESPONSIBILITY WHEN ENROLLED IN A HEALTH MAINTENANCE ORGANIZATION OR PREFERRED PROVIDER ORGANIZATION PLAN. Clients are required to utilize the services provided through and obtain all necessary prerequisites as set out by the health maintenance organization or preferred provider organization. Failure to do so is considered lack of cooperation and may result in loss of Medicaid eligibility. The client is responsible for the payment of the denied services.

005.16(D)CLIENT RESPONSIBILITY WHEN HEALTH INSURANCE PREMIUMS ARE PAID BY THE DEPARTMENT. If the Department determines it is cost effective to pay the premiums for a Medicaid eligible client to maintain his or her current commercial insurance coverage, the client must follow any preauthorization or referral provisions of the plan or utilization of specific providers in the network. Claims denied by third party resources because client did not utilize a network provider or obtain necessary authorizations or referrals will not be paid by Medicaid. The client will be responsible for payment of the denied services.

005.16(E)CLIENT RESPONSIBILITY WHEN CHOOSING TO ENROLL IN MEDICARE ADVANTAGE PLANS. Nebraska Medicaid will not pay claims denied by Medicare for Medicaid clients enrolled in Medicare Advantage plans who move out of the service area without complying with notification requirements or who do not utilize a network provider or obtain necessary authorizations and referrals. The client will be responsible for payment of the denied services.

005.17COVERAGE INFORMATION REQUESTS. The Department may request coverage information from a licensed insurer or a self-funded insurer about a specific individual without the individual's authorization to determine eligibility for state benefit programs or coordinate benefits with state benefit programs. The Department will specify the individual recipients for whom information is being requested.

005.17(A)RESPONSE TO REQUESTS. Self-funded insurers and licensed insurers must respond within 30 days of receipt of any request for coverage information from the Department. The information must be provided within thirty days after the date of the request unless good cause is shown.

005.17(B)FAILURE TO ACKNOWLEDGE AND RESPOND TO COVERAGE INFORMATION REQUESTS. If a self-funded insurer fails to acknowledge and respond to a request from the Department for coverage information about an individual, the Department may find this a violation of the requirements of this chapter and impose a civil money penalty.

005.17(C)CIVIL MONEY PENALTY. The Department may impose a civil money penalty of no more than $1,000 for each violation, not to exceed an aggregate penalty of $30,000, unless the violation by the self-funded insurer was committed flagrantly and in conscious disregard of the requirements of this chapter in which case the penalty will not be more than $15,000 for each violation, not to exceed an aggregate penalty of $150,000.

005.17(D)HEARING. A licensed insurer or a self-funded insurer's request for a hearing to appeal an action by the Department must comply with Department regulations.

005.18SERVICES REQUIRING PRIOR AUTHORIZATION. Services which require prior authorization for payment of claims, prior authorization requirements, and methods are listed in the chapter of the Nebraska Department of Health and Human Services Finance and Support Manual related to the specific type of service.

005.18(A)LIMITATIONS OF PRIOR AUTHORIZATION. Prior authorization is issued only if the client is eligible for Nebraska Medicaid for the period for which services are authorized. If the client becomes ineligible for Nebraska Medicaid during the authorization period, the authorization is invalid in the period of ineligibility. The authorizing agent will not submit a prior authorization request until eligibility for Nebraska Medicaid has been determined. Prior authorization is not transferable to other clients or other providers.

005.18(B)DUAL MEDICARE AND MEDICAID ELIGIBILITY. If the client is eligible for Medicare as well as Medicaid and the requested services are covered by Medicare, prior authorization is not issued. In some cases, as defined in the specific service policy, the provider must receive a denial of coverage from Medicare before a prior authorization is issued. The provider must submit a copy of the denial with the claim form to receive payment.

005.18(C)NOTIFICATION OF THE CLIENT. The provider or Department will notify the client of approval or denial of prior authorization according to the prior authorization procedures under the individual chapters of this Title.

471 Neb. Admin. Code, ch. 3, § 005

Amended effective 9/10/2017

Amended effective 6/6/2022