Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 20 - ADMINISTRATION OF MEDICAL ASSISTANCE SERVICES › Part IV - Third Party Liability › Section 12VAC30-20-200 - Requirements for third party liability; payment of claims

Current through Register Vol. 40, No. 24, July 15, 2024
1. Probable liability is established at the
				  time claim is filed.
a. When the Title XIX
				  agency has established the probable existence of third party liability at the
				  time the claim is filed, the agency rejects the claim and returns it to the
				  provider for a determination of the amount of liability. The establishment of
				  third party liability takes place when the agency receives confirmation from
				  the provider or a third party resource indicating the extent of third party
				  liability. When the amount of liability is determined, the agency pays the
				  claim to the extent that maximum payment allowed under the agency's payment
				  schedule exceeds the amount of the third party payment.
b. Exhausting all available third party
				  resources is the responsibility of the providers. The Medicaid Management
				  Information System (MMIS) does not allow payments to be made by Virginia
				  Medicaid unless the invoice indicates that the third party has either paid or
				  denied the claim.
c. There are
				  certain circumstances in which cost avoidance may not be utilized:
1. Medical support enforcement. In the case
				  of any service covered under Medicaid provided to an individual on whose behalf
				  child support enforcement is being carried out by the IV-D agency, Medicaid
				  makes payment for such service in accordance with the usual payments schedule.
				  These payments are made without regard to any third party liability, if such
				  third party liability is derived, through insurance or otherwise, from the
				  parent whose obligation to pay support is being enforced by the IV-D agency.
				  Medicaid shall make these payments providing that they have not been made by
				  such third party within 30 days after such service is furnished.
Providers shall not be required to bill the third party in
					 this situation. When the provider does bill Medicaid, he must certify
					 either:
(a) That he has not billed the
				  third party documented on the claim due to medical support enforcement,
				  or
(b) That he has billed the third
				  party documented on the claim but that he has not received payment or denial
				  for the service from the third party within 30 days after the service was
				  furnished. In this case, 30 days must elapse from the date of service to the
				  date of provider certification.
2. Prenatal Care. When the claim is for
				  prenatal, labor and delivery, or postpartum care that is covered under the
				  State Plan, the Commonwealth makes payment for such services in accordance with
				  the usual payment schedule without regard to the liability of a third party for
				  payment for such services.
3.
				  Preventive Pediatric Care. When the claim is for preventive pediatric care,
				  including Early and Periodic Screening, Diagnosis and Treatment (EPSDT)
				  services that are covered under the State Plan, the Commonwealth makes payment
				  for such services in accordance with the usual payment schedule without regard
				  to the liability of a third party for payment for such services.
4. In order to accomplish this pay and chase
				  activity, in accordance with 42 CFR 433.139, (once the claims
				  have been processed for payment), a report is generated advising the third
				  party unit so that recovery of funds can be made.