New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 302 - MEDICAID GENERAL PROVIDER POLICIES › Part 3 - RECIPIENT POLICIES -GENERAL RECIPIENT REQUIREMENTS › Section 8.302.3.12 - PROCESS USED IF THIRD PARTY LIABILITY IDENTIFIED

Current through Register Vol. 35, No. 13, July 16, 2024
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.