Managed Care Recoupments and Medicare Updates in Provider One

Washington State Health Care Authority sent this bulletin at 09/23/2020 05:44 PM PDT

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Managed Care Recoupments and Medicare updates in ProviderOne

If your claims for Apple Health (Medicaid) clients have been denied because of a managed care (MC) plan's recoupment, specifically related to retroactive Medicare eligibility, Health Care Authority (HCA) would like to share some guidance to reprocess those claims through ProviderOne.

What you need to do

Submit claims related to the MC Recoupment to ProviderOne with the claim note:

MC RECOUP Dated [MM/DD/YYYY]

The claim must be entered into ProviderOne according to HCA's billing guide instructions. Claims that are submitted incorrectly will be denied and must be resubmitted before the HCA can adjudicate the claim.

UPDATE: For any claims filed as of today, September 23, 2020 please attach relevant Managed Care Organization (MCO) documents verifying that the MCO paid the lines of service you are requesting in your HCA claim.

If there is a claim that has been awaiting adjudication, adding MCO documents to the already submitted claim may help expedite the process.

What you need to know

If the MC Recoupment-related claim is submitted according to HCA's billing guide instructions, it will be adjudicated in the following manner:

If the MCO paid the claim in full or partially, the claim will be processed and paid according to HCA's published billing guide and fee schedule.
If the MCO paid for a service that requires a prior authorization, the HCA will process the claim as long as the MCO paid for that service and recouped those funds from the provider.

Remember: These claims must not be billed to Apple Health clients.

For claims denied due to timely filing

When the claim is submitted, it will be denied for timely filing and you must contact HCA with the claim numbers to be reprocessed.

About the Health Care Authority (HCA)

The Washington State Health Care Authority (HCA) is committed to whole-person care, integrating physical health and behavioral health services for better results and healthier residents.

HCA purchases health care for more than 2.5 million Washington residents through Apple Health (Medicaid), the Public Employees Benefits Board (PEBB) Program, the School Employees Benefits Board (SEBB) Program, and the COFA Islander Health Care Program. As the largest health care purchaser in the state, we lead the effort to transform health care, helping ensure Washington residents have access to better health and better care at a lower cost.

Please do not reply directly to this message. For more information, visit the HCA website, where you'll also find contact information.

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The Washington State Health Care Authority (HCA) complies with all applicable federal and Washington state civil rights laws and is committed to providing equal access to our services. Visit HCA’s website to view complete nondiscrimination statements.