Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 3 - General Provider Policies › Part 1 - GENERAL SCOPE AND ADMINISTRATION › Section 317:30-3-24 - Third party liability

Current through Vol. 41, No. 20, July 1, 2024
As the Medicaid Agency, the Oklahoma Health Care Authority
					 (OHCA) is the payer of last resort, with few exceptions. When other resources
					 are available, those resources must first be utilized. Exceptions to this
					 policy are those receiving medical treatment through Indian Health Services and
					 those eligible for the Crime Victims Compensation Act. Guidance for third party
					 liability under the Insure Oklahoma program is found in Oklahoma Administrative
					 Code (OAC) 317:45, Insure Oklahoma.
(1) If a member has coverage by an absent
				  parent's insurance program or any other policy holder, that insurance resource
				  must be used prior to filing a SoonerCare claim. This includes Health
				  Maintenance Organizations (HMO), Preferred Provider Organizations (PPO) and any
				  other insuring arrangements that provide a member access to healthcare. Members
				  must comply with all requirements of their primary insurance as well as
				  SoonerCare requirements in order to take advantage of both coverages. For
				  example, a member must comply with the network restrictions of both the primary
				  and SoonerCare plans as well as prior authorization requirements. If the member
				  does not comply with the requirements of the primary plan, he/she will be
				  responsible for the charges incurred. Denials by private insurance companies
				  because the member did not secure a preauthorization or use a participating
				  provider is not a sufficient reason for SoonerCare to make payment. If the
				  provider is aware of private insurance or liability, a claim must first be
				  filed with that source. When private insurance information is known to the
				  OHCA, the eligibility verification system will reflect that information. If
				  payment is denied by the primary insurance, except as stated above, the
				  provider must attach the Explanation of Benefits (EOB), stating the reason for
				  the denial, to the claim submitted to the Fiscal Agent. When payment is
				  received from another source, that payment amount must be reflected on the
				  claim form.
(2) It is possible that
				  other resources are available but are unknown to OHCA. Providers will routinely
				  question SoonerCare members to determine whether any other resources are
				  available. In some instances, coverage may not be obvious, for example, the
				  member may be covered by a policy on which he/she is not the subscriber (e.g.,
				  a child whose absent parent maintains medical and hospital coverage).
(3) If the provider receives payment from
				  another source after OHCA has made payment, it is necessary that the provider
				  reimburse OHCA for the SoonerCare payment. The provider may retain the primary
				  insurance payment, if any, that represents payment for services that are not
				  covered services under SoonerCare. By accepting the OHCA's payment, the
				  provider agrees to accept it as payment in full and, therefore, cannot retain
				  any portion of other resource money as payment for reduced charges on covered
				  services. Other than SoonerCare copayments, a provider cannot bill a member for
				  any unpaid portion of the bill or for a claim that is not paid because of
				  provider administrative error. If, after reimbursing OHCA and retaining a
				  portion of the other payment in satisfaction of any non-covered services there
				  is money remaining, it must be refunded to the member.
(4) If a member is covered by a private
				  health insurance policy or plan, he/she is required to inform medical providers
				  of the coverage, including:
(A) provision of
				  applicable policy numbers;
(B)
				  assignment payments to medical providers;
(C) provision of information to OHCA of any coverage changes;
				  and
(D) release of money received
				  from a health insurance plan to the provider if the provider has not already
				  received payment or to the OHCA if the provider has already been paid by the
				  OHCA.