Medicare Dual Eligibles and enrollees in LaHIPP are excluded from Health Plans and will continue to be enrolled in Medicaid fee-for-service. Other Medicaid enrollees who have another insurance as primary with Medicaid as secondary are enrolled with a Health Plan. To receive Medicaid secondary payment from a Prepaid Plan for a core benefit or service provided to a Plan member, the provider must participate with the Health Plan.
In the Shared Savings model, primary care providers must participate to receive Medicaid secondary payments for Plan members, but specialists and other types of providers are not part of the Plan’s network.
Providers should follow the billing procedure instructions for the Plans with which they are enrolled. Bayou Health Plans are asked to provide this information up front and keep the process transparent to assist providers. With the Prepaid plans, the entities administering those networks will handle payments directly, and with the Shared-Savings model for Medicaid, the fiscal intermediary administers billing.
As specified in the contract, the Health Plans must keep their clean claims processes as transparent as possible for providers in their networks. The Plans must provide clean claim examples to their providers so providers can be prepared to submit claims and receive timely reimbursement for their services.
For Medicaid fee-for-service, federal guidelines specify what constitutes a clean claim.
Yes. Note that the two Shared Savings Plans (Community Health Solutions and UnitedHealthcare Community Plan) also have electronic payer IDs and many claim types should be submitted to them for pre-processing. You can find additional information in the document titled EDI Submissions.
Cost report settlement will still be calculated. DHH will only be responsible for payment of cost settlement for FFS and shared services. DHH is not responsible for payment of cost settlement on services paid through capitated rates. Whether the MCO pays is dependent on the hospital’s negotiated payment rates with the MCO.
DHH will only be responsible for payment of hemophilia outliers for FFS and Shared services. DHH is not responsible for payment of hemophilia outliers on services paid through capitated rates. Whether the MCO pays is dependent on the hospital’s negotiated payment rates with the MCO.
Depending on the claim type, it may be submitted to the Shared Savings Plan or to Molina (DME). The claims are pre-processed by the Health Plans and then submitted to Molina who will make the actual payment within two working days. For more information reference the following document.
No, hospitals cannot "balance bill" the patient in such situations. If a hospital treats a patient who is out of network for a non-emergency-after the patient has been stabilized -and the patient acknowledges that they will be responsible for the bill, the patient can be billed. If they treat them and they have not informed them, they cannot bill them. If the hospital is not "in network" and the services provided do not meet the prudent layperson definition of emergency services, it is highly likely that they will be reimbursed zero by the Health Plan-not 90%.
Here is the language from the contract:
•20.1.Hold Harmless as to the CCN Member
•20.1.1. The CCN hereby agrees not to bill, charge, collect a deposit from, seek cost sharing or other forms of compensation, remuneration or reimbursement from, or have recourse against, CCN members, or persons acting on their behalf, for health care services which are rendered to such members by the CCN and its subcontractors, and which are core benefits and services.
•20.1.2. The CCN further agrees that the CCN member shall not be held liable for payment for core benefits and services furnished under a provider contract, referral, or other arrangement, to the extent that those payments would be in excess of the amount that the member would owe if the CCN provided the service directly. The CCN agrees that this provision is applicable in all circumstances including, but not limited to, non-payment by CCN and insolvency of the CCN.
20.1.3. The CCN further agrees that this provision shall be construed to be for the benefit of CCN members, and that this provision supersedes any oral or written contrary agreement now existing or hereafter entered into between the CCN and such members, or persons acting on their behalf.
DHH will only be responsible for payment of outliers for FFS and shared services. DHH is not responsible for payment of outliers on services paid through capitated rates. . Whether the MCO pays is dependent on the hospital’s negotiated payment rates with the MCO.
Enrollment in a Bayou Health Plan will always be for a future month following a patient being added to the Medicaid eligibility file so you would continue to bill Medicaid fee-for-service as you currently do for the retroactive period of Medicaid eligibility. Molina will be the payer before the approval date and the month of approval and depending on timing, they could be in fee-for-service as long as two months following their month of approval (The only exception is a newborn who is retroactive to the date of birth). The timely filing limit for Bayou Health claims is 365 days. This includes claims submitted to Health Plans or any of their sub-contractors, and we are clarifying that for the Health Plans.
Mailing Address: Department of Health & Hospitals | P. O. Box 629 | Baton Rouge, LA 70821-0629 Physical Address: 628 N. 4th Street | Baton Rouge, LA 70802 | PHONE: 225.342.9500 | FAX: 225.342.5568 | DisclaimerCustodian of Records For Bayou Health1-855-BAYOU4U (1-855-229-6848 )