Coordination of Benefits Process

Posted 25 Noviembre 2008 by peach state & filed under Newsroom, Provider News.

Important Provider Notice – Coordination of Benefits Process
October 22, 2008

Dear Peach State Health Plan Providers:
Listed below for your reference is updated information regarding our Coordination of Benefits (COB) policies for Peach State Health Plan (Peach State) members.

As required by state and federal law, Medicaid is the payor of last resort, therefore Peach State will make every effort to cost avoid claims or services that are subject to payment from a third party health insurance carrier, and may deny a service if the third party health insurance carrier provides the services. Cost avoidance applies to all covered services except claims for Health Check/EPSDT and non-institutional pregnancy related services.

• Peach State complies with the Georgia Medicaid COB policies and utilizes a “Pay and Chase” approach for claims that are processed by the plan. Services that are paid and later determined to be covered by a third payor will be managed through the Health Management Systems (HMS) automated direct billing process with the responsible health insurance carrier.
• If a third party health insurance carrier requires the member to pay cost-sharing amounts (e.g. co-payments, coinsurance, deductible), Peach State will pay the cost sharing amounts but will not exceed the amounts we would have paid had we paid as the primary coverage.  A copy of the EOP is required to process the claim.

• When a provider bills the claim to the primary carrier and files the claims with the EOP, Peach State will coordinate with the primary payor to pay the claim up to the plan’s allowable amount, but we will not exceed the amounts we would have paid had we paid as the primary coverage.

• Information regarding the other liability coverage is available through Provider Solutions toll free call center at (866) 874-0633.

• Claims originally filed timely with a third party carrier must be received within 180 days of the primary carrier’s EOP, but never more than (12) months from the month of service.

• To the extent permitted by state and federal law, Peach State will use cost avoidance processes as required by DCH.

If you have questions regarding this notice or need additional clarification regarding our COB process, please contact the Provider Solutions department at (866) 874-0633.

Sincerely,

Peach State Health Plan