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Vaida Posted Tue 03rd of March, 2015 13:06:06 PM

Hi. I was wondering if our office does not participate with Medicaid Managed Care plan (Simply Insurance, to be exact), are we allowed to bill patient for services that were denied for non-participating provider and no authorization reasons?

SuperCoder Answered Thu 05th of March, 2015 02:24:45 AM

Hi Vaida,

Thank you for the query.

Yes, you can bill for the services which are normally covered without authorization and were denied for non-participating provider. But they will be reimbursed at a lower rate than the participating provider with authorization.

Vaida Posted Mon 23rd of March, 2015 12:38:36 PM

Hi

Thank you for your response, but my question was whether we can bill patients for services that were denied by Medicaid Managed Care plan for "non-participating provider" or "no enrollment".
I am asking because we are not allowed to bill patients that have Medicare-Medicaid combo, however if patient has Medicaid Managed Care Plan that we do not participate with, does it mean we can forward the 20% that Medicare did not cover to the patient?

SuperCoder Answered Wed 25th of March, 2015 07:51:53 AM

No we can not bill patients for services that were denied by Medicaid Managed Care plan for "non-participating provider.
Thanks

Vaida Posted Wed 25th of March, 2015 09:58:50 AM

Can you please clairfy why? If we do not participate with a particular plan, why can't we charge patients for Medicare coinsurance?

SuperCoder Answered Thu 26th of March, 2015 03:21:58 AM

No, you cannot bill patients for services that were denied by Medicaid Managed Care plan for "non-participating provider; however, in the case of an individual contract or a group contract covering no more than 300 lives, imposing a co-insurance obligation of more than 25% upon out-of-network services, which has been sold to five or more groups, managed care coverage also includes a contract which requires all services be provided pursuant to a referral from a primary care provider and that services provided pursuant to the referral be rendered by a participating provider in order for the member to obtain the maximum reimbursement.

Vaida Posted Fri 27th of March, 2015 12:19:54 PM

I am sorry, but I do not understand your answer. I got the part where you said we can not bill patients for services that were denied by Medicaid Managed Care plan. Can you please explain WHY NOT in layman's terms?

SuperCoder Answered Mon 30th of March, 2015 02:47:27 AM

It means, if your Medicaid Managed Care plan do not cover more than 300 individuals under the contract, you can charge for 25% of the medicare co-insurance.

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