Apple Health (Medicaid): Clarifying the Process for Billing Commercial Insurance Information


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Apple Health (Medicaid): Provider Alert

This alert is a clarification to a provider alert issued on June 14, 2017.


The section titled “Verifying and Reporting Commercial Insurance Information” applies to all providers.


The subsequent sections regarding billing claims and submitting other payer denials and payments apply to claims billed to the Health Care Authority (agency) through the ProviderOne system only; they do not apply to prescription drug claims billed through the point-of sale (POS) system. Pharmacies billing claims through ProviderOne must follow the instructions for billing claims and submitting other payer denials and payments.


Clarifying the Process for Billing Commercial Insurance Information


The agency is issuing this provider alert to clarify the process for billing commercial insurance information on a claim. Providers must verify other coverage information for the client prior to billing the agency.


Verifying and Reporting Commercial Insurance Information


Prior to billing the agency, you must check Client Inquiry in ProviderOne to find out if the agency has Other Payer coverage for the client. If you know about other coverage that is not on file with the agency, send that information to the agency before submitting your claim, using the following process:


  1. Go to the Washington State Health Care Authority website and choose the “Contact HCA” option near the bottom of the first page.
  2. Choose the “I am an Apple Health (Medicaid) biller or provider” option.
  3. In the “Contact” section, click the “Online: Secure web form” hyperlink under “Medical Assistance Customer Service Center (MACSC).”
  4. Click the “Medical Provider” button and fill out the appropriate information.
  5. Choose “Private Commercial Insurance” in the “Select Topic” dropdown menu.
  6. Click on “Submit Request.” 

Billing Claims in ProviderOne


You should wait 3-5 business days to check Client Inquiry again. Once the agency has the Other Payer coverage on file, you may bill your claim. Use the Carrier Code listed for that coverage as the ID in the “Additional Other Payer Information” section.


You must bill using the electronic fields for client coverage information and Other Payer denial or payment information. Claim comments can be used in addition to using the electronic fields, but not using the electronic fields could cause claim denials.


Submitting Other Payer Denials


For claims denied by the Other Payer, you must submit the denial Claim Adjustment Reason Code(s) (CARC(s)) electronically at header or line level. Do not bill with electronic CARC codes unless you have documented justification for their use. For 837 Health Insurance Portability and Accountability Act (HIPAA) transactions, enter the CARC information in Loop 2320, CAS Segment, Data Element CAS02. The agency will deny claims that were denied by the Other Payer if you do not include electronic CARC codes or backup information.


Submitting Other Payer Payments


For claims paid by the Other Payer, you must submit the payment amount at header level. You may also submit line level payment information, but the sum of all line payment amounts must equal the header payment amount. If all lines are paid by the Other Payer, it is not necessary to bill with CARC codes.


NOTE: When billing for FQHC, RHC, or Tribal Encounters using T1015, do not list line level payments for any line. Always bill using header payment amounts only. Billing with line payment amounts on claims with procedure code T1015 may cause improper payment amounts or claim denials.


For claims in which the Other Payer has paid some lines and denied others, you may bill all lines on the same claim. Bill the payment amount as applicable. For lines denied by the Other Payer, you must include all appropriate CARC codes at header or line level.


NOTE: For billing Medicare coverage or payments, including Part C or Medicare Advantage plans, refer to the “Submitting Medicare Crossover Claims” section ProviderOne Billing and Resource Guide.