Frequently Asked Questions

How will the fee schedule be determined for new codes that come out each year?

The current Medicaid fee schedule process will continue and will be communicated to the Health Plans.

Do you have to participate with the Health Plans to receive Medicaid secondary payment?

Medicare Dual Eligibles are excluded from Bayou Health 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 Bayou Health Plan. To receive Medicaid secondary payment from a Health Plan for a core benefit or service provided to a Plan member, the provider must participate with the Health Plan.

How does billing work?

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.

What is the fixed rate floor equal to compared with fee for service?

The Bayou Health rate floor will be equal to the published Medicaid rate in place on the day that service is performed.

What constitutes a clean claim? Can providers see examples?

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.

The current Per Diems contain Medical Education as part of my institution's per diem since we are a major teaching hospital, do the Health Plans make these payments?

No, DHH will reimburse qualifying hospitals for GME.

Currently my institution does not bill Pre Evaluation services and includes these charges in the Medicaid Cost Report. I have been told that these charges should be billed to the Health Plans. In addition will there still be settlement on the Cost Report for Transplant?

Cost report settlement will still be calculated. DHH will only be responsible for payment of cost settlement for FFS. 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.

Should we bill DHH or the Health Plans for hemophilia costs in excess of $50,000 on a patient by patient basis?

DHH will only be responsible for payment of hemophilia outliers for FFS. 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.

If an out-of-network hospital receives a reduced payment for the services to a member of a Health Plan (90% of payment for example), can the hospital bill the member for the 10% difference?

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.

With the increase in per diems for NICU and PICU the volume of outliers will decrease, however is the Health Plan or DHH still responsible for Outlier Payments?

DHH will only be responsible for payment of outliers for FFS. 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.

In my practice, if a person has a Medicaid application pending, we typically hold the billing for service for three months since it can take up to 90 days for Medicaid eligibility to be determined for new applicants. If eligibility is granted, should we bill Molina or the patient's Bayou Health plan?

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.

Are the Health Plans able to accept electronic claims in the X12 835 format?

Yes