5101:3-1-08 Coordination of benefits.

(A) Definitions.

(1) "Coordination of benefits (COB)" means the process of determining which health plan or insurance policy will pay first and/or determining the payment obligations of each health plan, medical insurance policy, or third party resource when two or more health plans, insurance policies or third party resources cover the same benefits for a medicaid consumer.

(2) "Explanation of benefits (EOB)" or "remittance advice" means the information sent to providers and/or plan beneficiaries (consumers) by any other third party payer, medicare and/or medicaid to explain the adjudication of the claim.

(3) "COB claim" means any claim that meets either the definition of third party claim as described in paragraph (A)(9) of this rule or the definition of medicare crossover claim as described in rule 5101:3-1-05 of the Administrative Code.

(4) "Medicare benefits" is as defined in rule 5101:3-1-05 of the Administrative Code.

(5) "Third party (TP)" is as defined in section 5101.571 of the Revised Code.

(6) "Third party payer (TPP)" means an entity, other than the medicaid or medicare programs, responsible for adjudicating and paying claims for third party benefits rendered to an eligible medicaid consumer.

(7) "Third party benefit" means any health care service(s) available to consumers through any medical insurance policy or through some other resource that covers medical benefits and the payment for those services is either completely the obligation of the TPP or in part the obligation of the consumer, the TPP and/or medicaid. (Examples of a third party benefit include private health or accidental insurance, medicare, CHAMPUS or worker's compensation.)

(8) "Third party liability (TPL)" means the payment obligations of the TPP for health care services rendered to eligible medicaid consumers when the consumer also has third party benefits as described in paragraph (A)(7) of this rule.

(9) "Third party claim" means any claim(s) submitted to ODJFS for reimbursement after all TPPs have met their payment obligations. In addition, the following will be considered third party claims by ODJFS:

(a) Any claim received by ODJFS that shows no prior payment by a TPP, but, ODJFS's records indicate the consumer has third party benefits.

(b) Any claim received by ODJFS that shows no prior payment by a TPP, but, the provider's records indicate the medicaid consumer has third party benefits.

(B) If the existence of a third party benefit is known to ODJFS, a code number that represents the name of the third party payer covering the consumer will be indicated on the consumer's medicaid card. http://emanuals.odjfs.state.oh.us/emanuals The provider shall obtain from the consumer the name and address of the insurance company, and any other necessary information, and bill the insurance company prior to billing ODJFS.

(C) The provider must always review the consumer's Ohio medicaid card for evidence of third party benefits. Whether there is or is not an indication of a TPP on the medicaid card, the provider must always request from the consumer or his or her representative information about any third party benefit(s). If the consumer specifies no TP coverage and the medicaid card does not indicate TP coverage, the provider may submit a claim to medicaid (and the claim for the service is not considered a TP claim). If, as a result of this process, the provider determines that TP liability exists, the provider may only submit a claim for reimbursement if it first takes reasonable measures to obtain TP payments as set forth in paragraph (D) of this rule.

(D) The medicaid program must be the last payer to receive and adjudicate the claim, except as determined by rule 5101:3-1-03 of the Administrative Code, and the state sponsored program awarding reparations to victims of crime under sections 2743.51 to 2743.72 of the Revised Code. ODJFS reimburses for covered services only after the provider takes reasonable measures to obtain all third party payments and file claims with all TPPs prior to billing ODJFS. Providers who have gone through reasonable measures to obtain all third party payments, but who have not received payment from a TPP, or have gone through reasonable measures and received partial payment, may use an appropriate code on the claim to obtain payment and submit a claim to ODJFS requesting reimbursement for the rendered service(s).

(1) Providers are considered by ODJFS to have taken reasonable measures to obtain all third party payments if they comply with one of the following requirements:

(a) The provider submits a claim first to the TPP and receives a remittance advice indicating that a valid reason for non-payment applies for the service as described in paragraph (D)(2) of this rule.

(b) The provider submits a claim first to the TPP for the rendered service(s) no less than three times within a ninety-day period and does not receive a remittance advice or other communication from the TPP within ninety days of the last submission to the TPP. Providers must be able to document each claim submission and the date of the submission.

(c) The provider followed the process described in paragraph (C) of this rule for the billed service and meets the following requirements:

(i) The provider did not find a change in third party coverage;

(ii) The billed service was previously rendered to the medicaid consumer by the provider within the last three hundred sixty-five days; and

(iii) The claim for the previously rendered service met the requirements of paragraph (D)(1)(a) or (D)(1)(d) of this rule.

(d) The provider did not send a claim to the TPP, but has received and retained at least one of the following types of documentation that indicates a valid reason for non-payment for the service(s) as set forth in paragraph (D)(2) of this rule:

(i) Written documentation from the TPP;

(ii) Written documentation from the TPPs automated eligibility and claim verification system;

(iii) Written documentation from the TPPs member benefits reference guide/manual; or

(iv) Any other reliable method for obtaining information and/or documentation from the TPP that there is no third party benefit coverage for the rendered service(s).

(e) The provider submits a claim first to the TPP and receives a partial payment along with a remittance advice documenting the allocation of the billed charges.

(2) Valid reasons for non-payment from a third party payer to the provider for a third party benefit claim include, but are not limited to, the following:

(a) The service(s) is not covered under the medicaid consumer's third party benefits.

(b) The medical expenses for the medicaid consumer were incurred prior to the third party benefits coverage dates.

(c) The medical expenses for the medicaid consumer were incurred after the third party benefits coverage was terminated.

(d) The medicaid consumer does not have third party benefits through the TPP for the date of service.

(e) All of the provider's billed charges or the TPPs approved rate was applied to the consumer's third party benefit deductible amount.

(f) All of the provider's billed charges or the TPPs approved rate was applied in total across the consumer's deductible, coinsurance and/or co-payment for the third party benefit.

(g) The medicaid consumer has not met eligibility, out-of-pocket expenses, required waiting periods or residency requirements for his/her third party benefits.

(h) The medicaid consumer is a dependent of the individual with third party benefits, but the benefits do not cover the individual's dependents.

(i) The medicaid consumer has reached the lifetime benefit maximum for the medical service being billed to the third party payer.

(j) The medicaid consumer has reached the benefit maximum of his/her third party benefits.

(k) The TPP is disputing or contesting its liability to pay the claim or cover the service.

(E) Providers who have gone through reasonable measures as described in paragraph (D) of this rule to obtain all third party payments, but who have not received payment from a TPP, or received a partial payment, may submit a claim to ODJFS requesting reimbursement for the rendered service(s). If payment from the TPP is received after ODJFS has made payment, the provider is required to repay ODJFS any overpaid amount. The provider must not reimburse any overpaid amounts to the consumer.

(F) Third party claims must meet the claim submission guidelines in accordance with rule 5101:3-1-19 of the Administrative Code.

(G) Medicaid reimbursement for third party claims will not exceed the medicaid maximum payment for the service, determined in accordance with applicable rules for the service, less all third party payments for the service. If the result is less than or equal to zero dollars, there will be no further medicaid payment for the service.

(H) ODJFS will reject a TP claim when a third party claim indicates coverage by a TPP, or when the existence of third party benefits is known to ODJFS, and the submitted claim does not indicate collection of the third party payment or does not indicate compliance with paragraph (D) of this rule. Providers should complete their investigation of available third party benefits before submitting a TP claim to ODJFS for payment.

(1) Providers and/or trading partners must maintain documentation to support all required information submitted on a third party claim (for example, if the submitted information indicates one hundred per cent of approved charges were allocated to the plan deductible, then the provider must have documentation to support the TPP allocated the approved charges to the plan deductible).

(2) Providers and/or trading partners must not omit from a TP claim any required TP claim information issued to them by the TPP, by the consumer or any other source (for example, the omission of the payment denial reasons that were issued by the TPP).

(I) ODJFS will make audit exceptions if a post-payment review reveals that the provider and/or trading partner did not maintain documentation to support the information submitted on a TP claim or reveals that the omission of required TP claim information resulted in an overpayment or an inappropriate payment of the claim.

(J) The provider is prohibited from billing the consumer any charges in accordance with paragraph (A) of rule 5101:3-1-60 of the Administrative Code.

(K) If the consumer states his/her private health insurance has changed or been terminated, the provider should advise the consumer to contact his/her county caseworker to correct the case record. Once the case record has been corrected, the provider may bill ODJFS directly.

(L) ODJFS has right of recovery pursuant to section 5101.58 of the Revised Code (medicaid, or any federal or state funded public health program) against the liability of a third party for the cost of medical services paid by ODJFS, or billable to ODJFS for payment at a later date. Section 5101.58 of the Revised Code requires that a medicaid consumer provide notice to ODJFS prior to initiating any action against a liable third party. ODJFS will take steps to protect its rights of recovery if that notice is not provided. If any person, whether the consumer or an individual acting on the behalf of a consumer, requests a financial statement (a claim) from a medicaid provider for services paid by ODJFS or to be billed to ODJFS on behalf of the medicaid consumer, the provider shall meet all of the following four requirements:

(1) Require that the consumer or the consumer's representative make his/her request for access to financial statements in writing.

(2) Notify ODJFS immediately upon receipt of the consumer's written request and forward a copy of the request to ODJFS, bureau of consumer and operational support, coordination of benefits section.

(3) Release the financial statement to the consumer or the consumer's representative no later than thirty days after the date the request is received.

(4) Stamp or type on each page of the financial statement in bold font "SUBJECT TO RIGHT OF RECOVERY PURSUANT TO SECTION 5101.58 OF THE OHIO REVISED CODE. FAILURE TO COMPLY MAY RESULT IN PERSONAL LIABILITY."

This rule applies to financial statements whether or not the provider has received reimbursement from ODJFS. This rule is not intended to prevent or restrict the provider from furnishing records of medical treatment and condition to the consumer.

(M) When the medicaid consumer is covered by medicare, in addition to other third party payers, medicaid is the payer of last resort. Whether or not a TPP is the primary payer, providers must bill all other third party payers and medicare prior to submitting a claim to ODJFS in accordance with rule 5101:3-1-05 of the Administrative Code.

(N) Medicaid managed care plans (MCPs) are exempt from this rule. MCPs are responsible for coordination of benefits pursuant to Chapter 5101:3-26 of the Administrative Code.

Effective: 08/02/2011
R.C. 119.032 review dates: 09/20/2010 and 08/01/2016
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01 , 5111.02
Prior Effective Dates: 4/7/77, 12/21/77, 12/30/77, 4/1/79, 10/1/84, 10/1/87, 7/7/02, 5/1/03, 1/1/04, 12/18/06