MO HealthNet Provider Hot Tip of the Week

Third Party Resources

September 15, 2014

MO HealthNet funds are used after all other potential resources available to pay for the medical service have been exhausted. Please refer to the provider manual General Section 5 – Third Party Liability (TPL). The intent of requiring MO HealthNet to be payer of last resort is to ensure that tax dollars are not expended unnecessarily when another liable party is responsible for all or a portion of the medical service charge. It is to the provider’s benefit to bill the liable third party resource before billing MO HealthNet because some liable parties may pay in excess of the maximum MO HealthNet allowable.

Credit balances may occur when a provider receives payments from MO HealthNet and another third party payer for the same services. Providers should reconcile invoice records with credit balances to include a review of all charges and payment records, and, if the reconciliation identifies a MO HealthNet overpayment, the provider should report the overpayment to the State.

If the provider receives payment from a liable party after receiving MO HealthNet reimbursement for the covered service, the provider must promptly submit an Individual Adjustment Request form to MO HealthNet for the partial or full recovery of the MO HealthNet payment. The amount to be refunded must be the full amount of the other resource payment, not to exceed the amount of the MO HealthNet payment. Please refer to the provider manual, Section 6 for information regarding adjustments.

The MO HealthNet Division provides weekly tips to providers to assist them in receiving timely reimbursement for services provided. As each new tip is posted, existing ones are archived on the same site for easy reference. Please share these weekly tips with your billing staff.