QA Review

The below pages are relevant to Vendors for when claims must be recouped/repaid due to Medicaid Eligibility.

Non-Medicaid Recoupment

I.  Purpose:

Falling Colors, Inc., as the Administrative Services Organization (ASO) for The Behavioral Health Collaborative, is the payer of last resort for adult BH services funded by the Behavioral Health Services Division (BHSD).  Services for members covered under Medicaid benefits must be billed to the Managed Care Organization (MCOs) or Fee for Service (FFS) Medicaid.  Likewise, services covered by other third-party payers, whether public or private, must be billed to the appropriate payer(s).  Services (See section V) covered by Medicaid or other payers that have been billed inappropriately to Falling Colors but paid, will be recouped by BHSD.  Also, non-Medicaid funds cannot be used to balance bill the unpaid portion of billing by another payer, such as deductibles, co-pays, or amounts exceeding treatment limits.

Audits of payments for Non-Medicaid services will occur on an ongoing basis. BHSD has set the following rules in place to audit claims paid through non-Medicaid funds.  The recoupment details are intended to assist providers on how to appropriately bill non-Medicaid funding.

II.  Recoupment Rule Detail:

A. Providers are allowed to bill only what is available through their respective approved BHSD fee schedules and only if the following criteria are met:

1. Members are not covered under a full-benefit Medicaid Category (See section III). Medicaid eligibility may be retroactive therefore BHSD will work with providers that have clients that receive Medicaid retroactively.

2. Dates of Service must fall outside Medicaid COE Begin and End Dates.

B. Providers will receive a recoupment file from Falling Colors prior to the actual recoupment and any provider concerns will be addressed subsequent to being registered with support@bhsdstar.org.  The recoupment file will include the member information, services being recouped and the MCO affiliation.

C. MCO BH Contract Managers will work with providers and the MCOs to ensure that providers are reimbursed for services rendered that are covered by Medicaid but recouped by Falling Colors.  Payment may require waiving of timely filing through Conduent for FFS or the MCOs for dates of service July 1^st, 2017 to the present.  BHSD has worked with the Assistance Division (MAD) on a Letter of Direction to waive timely filing for FFS, as well as, the MCOs.

III. Medicaid Categories of Eligibility (COE)

1. The following are full-benefit Medicaid COEs and will be in the recoupment file:('001','003','004','017','027','028','031','033','034','037','049','052','066','074','081','083','084','086','090','091','092','093','094','095','096','200','300','400','401','403','420','421')

2. The following are partial Medicaid COEs and are excluded from the recoupment file ('005','007','029','041','042','044','045','046','047', '048','050','054','085')

Exceptions to COE Rule:

1. COE 301 limited benefit category is currently covered by all four MCOS as a value-added service, so any claim falling under this COE will be recouped. (See V for Value Added Services link)

2. Clients with COE 100 and disability code PH or ME (Alternative Benefit Plan-Exempt) - The benefits package of an “ABP Exempt” recipient changes from the standard ABP recipient to that of the “standard” Medicaid full benefit recipient.  That is, the ABP benefit package ends, and the ABP Exempt recipient then has access to the same benefits as a full standard Medicaid recipient.  All claims will be recouped. (See V for Alternative Benefit Plan vs. State Plan Comparison Chart link)

IV. Services

The following chart lists services covered by Medicaid and Non-Medicaid.  The chart should be used as a guide for providers. Services covered by Medicaid and Non-Medicaid shall be billed to the appropriate payer.  The Non-Medicaid codes below currently cannot be billed to Medicaid for the adult population, therefore, should be billed through Non-Medicaid funding.

I. Resources

The below resources will assist providers with a further understanding of the Medicaid program:

1. Medicaid COE Pamphlet:

   1. http://www.hsd.state.nm.us/LookingForInformation/medical-assistance-division-1.aspx

2. Value-Added Services:

   1. http://www.hsd.state.nm.us/LookingForInformation/value-added-services.aspx

3. Alternative Benefit Plan vs. State Plan Comparison Chart:

   1. http://www.hsd.state.nm.us/LookingForInformation/client-co-payments.aspx

4. Portal:

   1. https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm#ProviderEnrollment

5. Medicaid Fee Schedule:

   1. http://www.hsd.state.nm.us/providers/fee-schedules.aspx