N.M. Admin. Code § 8.302.3.12 - PROCESS USED IF THIRD PARTY LIABILITY IDENTIFIED
A.
Pay and chase process: When
medicaid or a managed care organization (MCO) pays a claim before learning of
the existence of health insurance coverage, or before liability has been
established, MAD or its contractors seek reimbursement, up to the amount paid.
See
42 CFR Section
433.139. This process is referred to as "pay
and chase".
B. Prior to paying a
claim, the probable liability for the claim to be paid or partially paid by a
third party must be determined by MAD for the medicaid fee-for-service program
or MCOs for members enrolled in managed care. Probable liability includes
determining if the eligible recipient or member has other primary insurance,
the type of insurance, and if that insurance resource would likely include the
coverage of the specific item or service being billed by a provider. It also
includes the potential for coverage from casualty or tort case
settlements.
C. If MAD, or the MCO
following the instructions from MAD, has established the probable existence of
third party liability at the time the claim is filed, and the probability that
the claim services will be covered by the primary insurance, the claim must be
cost avoided, which means the claim must be rejected or otherwise denied and
the provider informed of the probable coverage of the claim by another
insurance resource and the identity of that other insurance resource, subject
to the following conditions.
(1) The claim may
not be denied by MAD or a MCO due to probable third party liability from an
insurance resource or a potential casualty or tort claim settlement when any of
the following conditions apply. Rather, the claim must be paid by MAD, or the
MCO if the eligible recipient is a member of a MCO, at the full amount allowed
for the claim. MAD or the MCO must then seek reimbursement directly from the
liable third party as "pay and chase" or as a party to the settlement of a
casualty or tort claim.
(a) When the claim is
for labor and delivery or postpartum care. However, the claims for the
inpatient hospital stay for labor and delivery and postpartum care must be
cost-avoided.
(b) When the third
party liability is derived from an absent parent whose obligation to pay
support is being enforced by the state title IV-D agency.
(c) When the claim is for prenatal care for
pregnant women, or preventive services for children including early and
periodic screening, diagnosis and treatment services.
(d) When the third party liability is in the
form of a potential or determined tort or casualty recovery and the extent of
any liability is undetermined and not likely to be determined within 120
calendar days of the date of service on the claim.
(e) When the probable liability cannot be
established or information on the benefits likely to be available under the
third party resource are not available at the time claim is filed; or if third
party benefits information is not available to pay the eligible recipient or
member's medical expenses at the time the claim is filed.
(2) The claim may not be denied by MAD or a
MCO due to probable third party liability (including medicare coverage) when
the item or service or services by the type of provider are generally not
covered by the third party as determined by MAD.
D. The establishment of third party liability
takes place when MAD or the MCO receives confirmation from the provider or a
third party resource indicating the extent of the third party
liability.
Notes
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