La. Admin. Code tit. 50 § I-8301

Current through Register Vol. 50, No. 9, September 20, 2024

Section I-8301 - Pay and Chase

A. Definition

Claim - a single document line identifying the service and/or charges for services for a single recipient from a single provider.

B. Medicaid claims for services covered under the State Plan will be cost avoided when there is probable third party liability unless the claim is for one of the following services:

1. primary preventive pediatric care diagnoses are confined to those listed under Diagnosis Codes Related to Preventive Pediatric Care Services at www.lamedicaid.com;

a. Individuals under age 21 qualify; and

b. Hospitals are not included and must continue to file claims with the health insurance carriers;

2. early and periodic screening, diagnosis and treatment (EPSDT) medical, vision, and hearing services;

3. EPSDT dental services;

4. EPSDT services to children with disabilities (formerly referred to as school-based health services) which result from screening and are rendered by school boards;

5. services which are a result of an EPSDT referral, indicated by entering "Y" in block 24H of the CMS-1500 claim form, sometimes called HCFA-1500, or "1" as a condition code on the UB-92 (form locators 24 through 30); and

6. services for Medicaid eligibles whose health insurance is provided by an absent parent who is under the jurisdiction of the state child support enforcement agency are subject to a "wait and see period" that was effective April 1, 2021.

a.Wait and See-payment of a claim only after documentation is attached to a hard copy claim and submitted to the state's fiscal intermediary demonstrating that 100 days have elapsed since the provider billed the responsible third party and remains to be paid.

C. In processing these claims, the Medicaid agency will pay the claim and seek reimbursement from liable third parties, utilizing the claims method of payment called "pay and chase".

La. Admin. Code tit. 50, § I-8301

Promulgated by the Department of Health and Human Resources, Office of Family Security, LR 13:578 (October 1978), amended by the Department of Health and Hospitals, Office of the Secretary, Bureau of Health Services Financing, LR 17:781 (August 1991), amended by the Department of Health and Hospitals, Office of the Secretary, Bureau of Health Services Financing, LR 32:848 (May 2006), Amended by the Department of Health, Bureau of Health Services Financing, LR 491743 (10/1/2023).

AUTHORITY NOTE: Promulgated in accordance with R.S. 36:254 and Title XIX of the Social Security Act.