Claim Processing Requirements

TPL Claim Processing Requirements (Oklahoma Medicaid)

Providers are required to bill all other insurance carriers prior to billing the OHCA, except for programs that are secondary to the OHCA. The TPL Unit is available to assist with determining other insurance resources and maintaining the most current member TPL files.

Billing Documentation Requirements

The OHCA must deny claims if there is evidence that TPL exists and documentation indicating that the third party was billed is not submitted with the claim. To prevent claims from being denied, providers must be aware of responsibilities concerning third parties and comply with the procedures described in this chapter.

Third Party Liability Identification

Prior to rendering a service, the provider must verify that the member is eligible. Use the EVS described in the Member Eligibility chapter of this manual to check eligibility status for all members. Additionally, the EVS should be used to verify TPL information so providers can determine if another insurer is liable for all or part of the bill. EVS has the member’s most current TPL information, including, the insurance carrier, benefit coverage and policy numbers. In some cases, it is not possible to determine by the EVS if a specific service is covered. If a specific service does not appear to be covered by the stated TPL resource, providers must still bill that resource to receive a possible denial or payment.

For example, some insurance carriers cover optical and vision services under a medical or major medical plan. Medical services that are covered by a primary insurer must be billed first to the primary insurer. If there is no other insurer indicated on the EVS and the member reports no additional coverage, bill the service to the OHCA as the primary payer. When the EVS shows a member is a qualified Medicare beneficiary (QMB) only or a specified low-income Medicare beneficiary (SLMB) only, the provider should contact Medicare to confirm medical coverage.

Failure to confirm medical coverage with Medicare could result in claim denial because the Medicare benefits may have been discontinued or recently denied. The OHCA pays the Medicare premiums for SLMB only and QMB only members but does not provide medical coverage. The coinsurance and deductible are covered for members with Medicare entitlement.

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