Third Party Liability & Act 62 COORDINATION OF BENEFITS

1. Third Party Liability &Act 62COORDINATION OF BENEFITS DGS ANNEX COMPLEX 116 EAST AZALEA DRIVE PETRY BUILDING #17 HARRISBURG, PA 17110

2. Act 62 and TPL The PA autism insurance mandate creates a system where both private insurers and the MA program can have a role in reimbursing autism service providers, depending on the specific circumstances of the case. Two examples of how both systems may be involved are: • Above/below the $36,000 cap. • Differing medical necessity criteria.

3. Compliance Because both systems may be involved, autism service providers must comply with the requirements of both the private insurer and MA, either through: • Behavioral Health Managed Care Organization (BH-MCO) OR • Fee For Service …when providing and submitting claims for autism services for the child.

4. No Special Rules for Autism Services • DPW is not creating special rules for autism services. • Providers should follow the existing TPL regulation (Title 55 §1101.64 concerning Third Party Medical Resources). • Because of the unique requirements of Act 62, autism service providers must follow procedures for both MA and private insurers.

5. Procedures to Follow • Providers should request prior authorization from both the BH-MCO and the private insurance company (if prior authorizationis required from the private insurer.) • Prior authorization is not a guarantee of payment from the BH-MCO or Fee-for-Service. Providers must have documentation of a denial or that a service is not covered before submitting a claim to the BH-MCO or Fee-for-Service. There could be many reasons that a claim does not pay, including the billing instructions not being followed, or the incorrect completion of the claim. If a provider completes a claim incorrectly and the claim denies, the provider will be required to resubmit a clean claim to the primary insurer.

6. Procedures to Follow (cont’d) • Providers should submit a claim to the private insurer even if they don’t think the service is covered, unless there is already written documentation from the private insurer that it is not a covered service.

7. $$ TPL COST AVOIDANCE CLAIMS

8. Cost Avoidance of Act 62 Claims The procedure codes covered as Act 62 services are subject to Cost Avoidance. This means that the MA program, either through a BH-MCO or FFS, may not pay a provider for services unless the insurer denies the service.

9. How dollars are cost avoided PROMISe (the MA claims processing system) ensures that the other (aka primary) insurance was billed first. • If the private insurerwas NOT billed, the MAclaim is deniedby PROMISe • Then the provider is instructed to bill the private insurer (like Aetna, Blue Cross, Medicare or CHAMPUS)

10. Medical Necessity Denials • Act 62 allows private insurers to use their own definitions of medical necessity. The MA program will continue to use the regulatory definition of medical necessity that is now in place. (See 55 Pa. Code §1101.2) • If a service is denied by the private insurer as not medically necessary, a family may elect to -- but is not required to -- appeal the decision made by the private insurer. For families that decide to appeal, it is typically extremely beneficial for the family, the prescriber and the provider to work together to demonstrate that the denied service is medically necessary.

11. Appeal is Filed • If an appeal is filed by the family the claims can be submitted to the BH-MCO or the Office of MA Programs (for FFS) payment. If the service meets the MA program’s definition of medical necessity and the provider obtains authorization from MA for the service, if prior authorization for the service is required, then the provider may be paid through the MA program. (This assumes the child is eligible for Medical Assistance, the provider is enrolled in the MA program, and other MA program rules and conditions are satisfied.)

12. Appeal Process • When the private insurance appeal process is resolved and the finding is favorable to the recipient and the provider receives payment from the insurer, the MA payment must be returned by the provider or adjusted to reflect the third party payment.

13. Provider Must be Enrolled with the Private Insurance • If a provider refuses to join the private insurance network of the MA recipient, the MA program is not required to pay the provider for the service.

14. Payment of Private Insurance Co-Pay or Deductible • Private coinsurance and deductible payments may be made up to the payment rates of the FFS or BH-MCO program. • The MA recipient cannot refuse to use available private insurance to avoid a co-payment. • The MA recipient and the provider must follow the policies of the private insurer and the MA program.

15. Failure to Use the Private Insurance • If an MA recipient chooses to go outside the private insurance network, there is no obligation for the BH-MCO or FFS to pay for the service. • Families should not intentionally disenroll from private insurance. By law, Medical Assistance is a government program and is the designated payer of last resort.  As a condition of MA eligibility, the enrollees are agreeing to use other available insurance resources first.  Families that intentionally drop private insurance coverage are at risk of losing continued MA coverage.

16. Exhaustion of an Annual Benefit • When the annual $36,000 private insurance benefit is exhausted for the year, the provider can bill the MA program for the services and indicate that it has an exhaustion notice or include a copy of the exhaustion notice with the claim. The provider should follow the billing instructions of the BH-MCO or FFS program when submitting a claim for payment when the private insurance is exhausted.

17. For more answers - Visit the Act 62 website http://www.dpw.state.pa.us/ServicesPrograms/Autism/Act62/