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May 1, 2019

FOLLOW HEALTH PLAN APPEAL PROCESSES WHEN FILING A COMPLAINT

Ensure all Health Plan Claims and Appeal Processes are Followed

In a previous March 21, 2019, newsletter we’ve discussed the option to file a complaint with AHCA to address an outstanding claims issue for resolution. The article addressed claims issues related to an MMA enrollee transitioning to Medicaid LTC while residing in the nursing home. The MMA health plan is responsible for paying the claim during that transition period. This is the time-period previously billed to the state while the resident becomes Medicaid LTC eligible.

In this case, as well as other claims issues that require an AHCA complaint filed for resolution. It is important to follow the health plans processes including appeal process during this time-period. Because, if the health plans processes are not followed, the claim could be denied on a technicality. The filing of the complaint does not stop these requirements.

Generally, it is a faster process to work with the health plans to resolve the claims issue. The health plan provider portals offer the ability to submit adjustments and see resolution updates. FAHA H&S intervenes with the health plans on a regular basis to resolve member claims issues. Please do not hesitate to contact me for assistance. Sometimes a claims issue is complex and requires more time and resources for resolution. More often, a claims issue can be resolved with a phone call to the right person at the health plan.

If you have questions, please contact Dana McHugh via email or by calling her at (850) 339-2909.





RIPPED FROM THE HEADLINES

Sitting Out Bundled Payments Could Leave Skilled Nursing Providers Far Behind. For many skilled nursing providers, the launch last week of the 2020 application period for the government’s flagship bundled-payment program was low on the list of priorities. Read more...

 

MACPAC Study on Care Coordination in Integrated Programs Serving Dually Eligible Beneficiaries.  The Medicaid and CHIP Payment and Access Commission (MACPAC) recently released a study. Care Coordination in Integrated Programs Serving Dually Eligible Beneficiaries – Health Plan Standards, Challenges and Evolving Approaches, prepared Health Management Associates (HMA). Read more...

Health plan updates

Online Training. Whether you’ve recently joined our provider network, added a provider to your team or simply need the latest updates on provider information and tools, you’ll find all your online training needs here. Read More...


WellCare Medicaid LTC ALF and ADC Claims Guide. The ALF and ADC Medicaid LTC claims guide can be found here and includes provider portal information.

Copyright 2019 — Publication of FAHA H&S
Chair: Brian Robare
President/CEO: Steve Bahmer
Principal/Editor: Dana McHugh

Copyright Information: Copies of the articles and other information in this publication may be non-commercially reproduced for the purpose of educational or scientific advancement. Otherwise, no part of this publication may be reproduced or utilized in any form, or by any means, mechanical or electronic, including photocopying, microfilm and recording, or by any information storage and retrieval system, without the written permission of the managing editor. For permission to reproduce, contact the principal/editor via email or phone at (850) 999-6034. 

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