Section He-W 521.08 - Third Party Liability(a) Acceptance of medical assistance by the recipient shall constitute assignment of rights to third party medical support in accordance with RSA 167:14-a.(b) Third party liability shall be treated as the primary resource in the determination of payment of medical service claims.(c) Except as allowed by (g) below, the provider shall determine if third party coverage exists at the time the item, supply, or service is provided, and file a proper and complete claim, following all of the third party's policies, with the third party carrier before billing medicaid.(d) Except as allowed by (g) below, medicaid shall not pay unless providers comply with third party coverage requirements, such as primary insurance prior authorizations, referrals, and service restrictions, when providing services.(e) Except as allowed by (g) below, payments shall not be made for any services until all available third party benefits are exhausted.(f) Failure by a provider to comply with the requirements for payment of any third party coverage, as described in (c), (d), and (e) above, shall result in non-payment of the item, supply, or service by medicaid.(g) Providers may bill medicaid, prior to billing a known third party carrier, under the following circumstances: (1) If the provider has confirmed with the department, a recipient has established good cause through the department for not cooperating and not utilizing third party coverage in accordance with 42 CFR 433.145 (a) and 42 CFR 433.147 (c); or(2) For all preventive pediatric services in accordance with 42 CFR 433.139 (b).(h) If the provider receives a denial from the third party for administrative reasons or non-compliance with third party procedures, then the provider shall be required to correct the error with the third party for payment. Medicaid shall not pay unless the claim correction is accepted by the third party and processed for payment.(i) If any third party coverage is known to the department or MCO to provide coverage for a recipient's medical service needs, that information may be obtained from the medicaid fiscal agent or the MCO.(j) Providers shall not seek payment from a third party once they have submitted a claim to medicaid, unless they have received a rejection or denial from medicaid.(k) If the provider has filed a proper claim with the liable third party, and a payment or denial is not forthcoming within 100 days from the date of service, the provider may submit a claim to medicaid and indicate the name and address of the possible third party payment source.(l) If the provider receives a third party payment after receiving a medicaid payment due to (k) above for the same item, supply, or service, the provider shall reimburse the department or the MCO for the overpayment by submitting payment directly to the department or the MCO from which they were paid.N.H. Admin. Code § He-W 521.08
Derived from Number 10, Filed March 7, 2024, Proposed by #13884, Effective 2/22/2024, Expires 2/22/2034 (See Revision Note at chapter heading for He-W 500) (See also part heading for He-W 521).