HAP Midwest Health Plan Billing And Reimbursment Requirements

HAP Midwest Health Plan BillingHAP Midwest Health Plan Billing and Reimbursment process will be discribed below in this blog. MDCH contracts with HAP Midwest Health Plan to administer the Medicaid HMO benefits to its enrolled members. Medicaid is considered as payment source of last resort. Some Medicaid members have dual insurance coverage. In this case,

  • Other insurance company should be billed first because it is always considered the primary insurance over Medicaid.
  • All covered services where the HAP Midwest Health Plan is secondary carrier will not require an authorization from HAP Midwest Health Plan.
  • When submitting a claim, an EOP or EOB from the primary carrier must accompany the claim in order to coordinate benefits.
  • Professional, facility and ancillary services that are not covered by the primary insurance carrier and are billed to HAP Midwest Health Plan, must comply with authorization requirements in order to be reimbursed for these services as primary carrier. Click on link below for authorization requirements.
  • Coordination of Benefits (COB) claims should be submitted on paper with other insurance EOP attached.
  • Third Party Liability (TPL) should be submitted on paper with other insurance EOP attached. For example, automobile insurance or workman’s compensation.

HAP Midwest Health Plan Billing – Durable Medical Equipment/Prosthetics & Orthotics 

When billing for equipment/supplies that have a descriptor reflecting a daily rate or per diem (total number of days used as units), the claims must reflect “span” dates in the from and to date column.

For example: S5502 (home infusion therapy catheter care/maintenance implanted access device) per diem. If dates of service are August 1, 2011 through August 30, 2011; the dates on the claim should be reported using the “from” and “to” dates of 08/01/2011 – 08/30/2011 and report 30 units.

Note that HAP Midwest Health Plan follows CMS payment guidelines. The following physical exam codes may be billed only by Primary Care Providers and contracted OB/GYN providers:


The Medicaid benefit allows for one physical exam per calendar year for members ages ≥ 3 years only (<3 years old up to eight physical exams).

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