Section He-W 521.11 - Third Party Payment(a) All third party payors shall comply with RSA 167:4-b.(b) If third party coverage is determined after a medicaid claim is processed, then the third party payor shall reimburse medicaid even if the third party's plan policies and procedures were not performed at time of service.(c) Third party payors shall not deny medicaid's or MCO's claim for reimbursement for claim type, claim format, or failure to comply with the third party's plan policies and procedures, which include, but are not limited to:(1) No prior authorization obtained;(2) Not submitted on Health Care Financing Administration or UB red forms;(3) Claim not submitted electronically;(4) No National Provider Identification number provided for medicaid;(5) Medicaid is not a participating provider;(6) Not submitting reimbursement within the third party payors' time limit; and(7) Not having subscriber information on payment request.(d) If a third party payor has reimbursed medicaid, and then a provider requests payment on the same claim, the third party payor cannot reverse payment made to medicaid to pay the provider.(e) If a third party payor has reimbursed medicaid or the MCO, then the third party payor requests a payment reversal or adjustment, such requests shall be received within 12 months of initial payment to medicaid or MCO. All reversal or adjustment requests after 12 months shall be denied, and the third party payor cannot recover those payments on future payments to medicaid or MCO.(f) Third party payors cannot make a payment to a provider after paying medicaid or MCO and reverse or adjust the payment made to medicaid or MCO.N.H. Admin. Code § He-W 521.11
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).