Provider FAQ: Billing and Reimbursement

Medicare Dual Eligibles are excluded from managed care and will continue to be enrolled in Medicaid fee-for-service. Other Medicaid enrollees who have another insurance as primary with Medicaid as secondary are enrolled with a Health Plan. To receive Medicaid secondary payment from a Health Plan for a core benefit or service provided to a Plan member, the provider must participate with the Health Plan.

Providers should follow the billing procedure instructions for the Plans with which they are enrolled. Health Plans are asked to provide this information up front and keep the process transparent to assist providers.

The manged care rate floor will be equal to the published Medicaid rate in place on the day that service is performed.

As specified in the contract, the Health Plans must keep their clean claims processes as transparent as possible for providers in their networks. The Plans must provide clean claim examples to their providers so providers can be prepared to submit claims and receive timely reimbursement for their services.

For Medicaid fee-for-service, federal guidelines specify what constitutes a clean claim.

Cost report settlement will still be calculated. LDH will only be responsible for payment of cost settlement for FFS. LDH is not responsible for payment of cost settlement on services paid through capitated rates. Whether the MCO pays is dependent on the hospital’s negotiated payment rates with the MCO.

LDH will only be responsible for payment of hemophilia outliers for FFS. LDH is not responsible for payment of hemophilia outliers on services paid through capitated rates. Whether the MCO pays is dependent on the hospital’s negotiated payment rates with the MCO.

LDH will only be responsible for payment of outliers for FFS. LDH is not responsible for payment of outliers on services paid through capitated rates. Whether the MCO pays is dependent on the hospital’s negotiated payment rates with the MCO.

Enrollment in a Health Plan will always be for a future month following a patient being added to the Medicaid eligibility file so you would continue to bill Medicaid fee-for-service as you currently do for the retroactive period of Medicaid eligibility. Molina will be the payer before the approval date and the month of approval and depending on timing, they could be in fee-for-service as long as two months following their month of approval (The only exception is a newborn who is retroactive to the date of birth). The timely filing limit for Bayou Health claims is 365 days. This includes claims submitted to Health Plans or any of their sub-contractors, and we are clarifying that for the Health Plans.