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Dear Alaska Medicaid Behavioral Health Provider:
As we approach the transition to the new Medicaid Management Information System (MMIS), the Division of Behavioral Health (DBH) is sharing details regarding key changes in processes that may differ from your current practices. DBH, Health Care Services (HCS), and our new fiscal agent, HMS/Gainwell, have been working diligently to understand these differences and their potential impacts on providers.
Below, we outline some specific changes related to Third Party Liability (TPL) that you can expect as we move to the MMIS. Please note that these processes may evolve over time.
Third Party Liability
What is TPL?
Third Party Liability (TPL) is a legal requirement mandating that other sources of coverage pay for medical services before Medicaid will for a Medicaid-eligible individual. Medicaid acts as a secondary payer, covering the remaining balance only after all other liable sources have paid. Both the federal and state governments share the responsibility to ensure that Medicaid is appropriately identifying potentially liable third parties and coordinating benefits to reduce Medicaid program costs.
Why is enforcing TPL important?
- It’s the law that Medicaid is the “payor of last resort”.
- TPL saves State money and resources, ensuring that the Medicaid program is sustainable.
- TPL can help providers receive higher reimbursement rates from other insurers.
- TPL can help expand coverage for Medicaid members.
How is the MMIS set up for TPL services?
The MMIS does not track other coverage per Medicaid participant. However, HCS coordinates with the Division of Insurance to check for “non-covered services” to bypass TPL requirements within the MMIS. There is no TPL avoidance option within the MMIS. The only systematic TPL bypass that is applied is if procedure codes were excluded on the annual “Never Covered” survey that is done by the Division of Insurance (DOI). To keep the TPL process standardized across the entire Medicaid program Behavioral Health providers will need to submit an Explanation of Benefit (EOB) with every claim that has TPL.
Providers must submit documentation supporting that the Primary Carrier does NOT cover the services. Accepted documentation could be one of the following:
- EOB showing denial as non-covered
- Copy of the Handbook from primary showing that the service is excluded from the plan
- A Denial letter from the primary stating that the service is not covered
*An important note: providers do not have to get a new denial or EOB for each claim they bill. If the primary denies and services are non-covered, the same document can be used for the entire admittance. However, please remember that this documentation is required to be submitted with each claim submission, as each individual claim must be reviewed independently as a complete claim.
How do I find a Medicaid Participant’s TPL resources?
Providers can find TPL information for Medicaid participants by choosing one of the following methods:
- Alaska Medicaid eligibility coupons and cards Resource code / carrier code
- Look up the member’s eligibility information in Health Enterprise medicaidalaska.com
- Automatic Voice Recognition (AVR) system 855.329.8986 (toll-free)
- Provider Inquiry 907.644.6800, option 1,2 or 800.770.5650 (toll-free), option 1,1,2
How do I report a Medicaid Participant’s TPL resources?
A Provider can report a participant’s TPL resources by emailing dmatpl@alaska.gov.
Proof of TPL can also be submitted as an attachment with the EOB.
What is the process for providers to report TPL?
Providers are required to submit the Explanation of Benefits (EOB) from the other carrier(s). Ways to provide the EOB include:
Electronic claim submission
- Provider has 14 days to supply supporting documentation. If not provided, on the 15th day, the claim will deny.
- There is not a mechanism to submit EOB electronically and documents should be sent via DSM or fax the SAME DAY using the Attachment Fax Cover Sheet form. DSM address and fax numbers are listed on the form.
Paper claim submission
- Provider must include all documentation with the claim. If no documentation accompanies the claim, the claim is entered, and the claim will be denied.
Clearinghouses
- Providers need to ensure that they are transmitting the appropriate indicators intended by the providers. Please see the Electronic Attachment Quick Reference for guidance on attachment indicators.
What are MMIS’ Denial Exception Resolution for TPL?
- Excluding Indian Health Services, if the member has other health benefits that may be responsible for partial or total payment of a claim, those benefits are primary and must be billed first.
- Providers will receive a denial exception code if there is no evidence of third party billing (no attached EOB and recorded reimbursement amount) on the claim when a member has other benefits. For example: 6280 - Cost Avoid For No EOB And No TPL Dollars.
- Providers will also receive a denial exception code if the EOB from the TPL resource is not attached, but a reimbursement amount is recorded on a claim. For example: 6420 - Cost Avoid For No EOB And Has TPL dollars.
TPL Training
HMS is ready to assist providers who have TPL questions and/or concerns. You can find resources on the Alaska Medicaid website. Also, you can access the TPL training PowerPoint presentation slides.
As a reminder, please visit the Transition FAQ website for more information. And in case you missed it, please review the Behavioral Health Townhall Meeting Presentation and Responses to Questions.
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