COORDINATION OF BENEFITS
When a member has other health insurance, whether it is Medicare, a Medicare HMO or a commercial carrier, Mercy Care Plan will coordinate payment of benefits.
These other insurers are considered the primary payer and Mercy Care Plan is the secondary payer. As a secondary payer, Mercy Care Plan will pay deductibles, co-insurance and co-payments for AHCCCS covered services up to the lower of our
fee schedule or the Medicare/other insurance allowed amount.
Here are some steps to follow that will
help you understand how this works:
1. Determine the lowest allowed amount (or fee schedule). Is it Mercy Care Plan’s or the other carrier?
2. Subtract the primary carrier’s payment
from the lowest allowed amount.
3. The balance due from Mercy Care Plan
is the answer to Step #2. If the difference
is 0 or a negative amount, Mercy Care
Plan has no financial liability.
HOW WE PAY
In accordance with the Balanced Budget Act of 1997, Mercy Care Plan
will pay co-payments, co-insurance and/or deductibles for AHCCCS covered
services up to the lower of our fee schedule or the Medicare/other insurance
allowed amount. Below are three examples:
| Billed Amt |
|
Medi-care Allowed |
|
Medi-care Paid |
|
MCP Allowed |
|
MCP Paid |
| $100 |
|
$80 |
|
$80 |
|
$75 |
|
$0 |
| $100 |
|
$90 |
|
$90 |
|
$90 |
|
$0 |
| $100 |
|
$90 |
|
$80 |
|
$100 |
|
$10 |
In the first example, the lowest allowed amount for the service is MCP’s fee of
$75. Subtracting Medicare’s payment of $80 from MCP’s allowed amount of $75 leaves
a negative balance of - $5. Therefore, MCP has no financial liability.
In the second example, the lowest allowed amount is $90 (both Medicare and MCP).
Medicare paid $90, leaving a balance of 0. MCP has no financial liability in this
example.
In the final example, the lowest allowed amount is the Medicare fee of $90.
Medicare paid $80. The Medicare allowed amount ($90) less the Medicare payment ($80)
equals the balance due from MCP ($10).
KEY POINTS
Remember, in all cases, providers may not bill Mercy Care Plan members for AHCCCS covered services. It is against the law.
Do not collect co-payments at the time of service. Bill MCP for the balance due (if any is owed) once the primary insurer has paid.
The balance due may include co-payments, co-insurance and/or deductibles.
If a provider is not willing to bill Mercy Care Plan for co-payments, co-insurance or deductibles after Medicare or the other
carrier has paid, the member still cannot be billed for any balance due.
Submit claims to the primary insurer right away. Be sure to submit the claim to MCP within 180 days of the date of service whether
or not you have received payment from the primary insurer. Claims received after 6 months from the date of service will not be paid.
If you have questions about coordination of benefits, please call your Provider Services Representative or our Claims Department at one of the numbers below.
4350 E Cotton Center Blvd., Building D
Phoenix, Arizona 85040
(602) 263-3000 or 1-800-624-3879
FREQUENTLY ASKED QUESTIONS
Question: What if the member has insurance other than Medicare? Which fee is used: MCP’s, Medicare’s, or the other insurance?
Answer: Whichever one is the lowest.
Question: What should I do if it looks like the primary insurance carrier will not be reimbursing me within the 180 day MCP filing limit?
Answer: If you believe you will not be paid by the primary carrier within the 180 day MCP filing limit, you may submit a claim to MCP at the same time you submit a claim to the primary carrier. We will deny the initial claim for lack of an Explanation of Benefits (EOB). This allows you up to 12 months* from the date of service to receive payment from the primary payer and resubmit the claim for reconsideration.
*Mercy Care Plan may reconsider payment of claims which have been denied for untimely filing in situations when the provider was making an effort to determine the extent of liability.
Question: Is an authorization number necessary from Mercy Care Plan if the member has other insurance?
Answer: In most cases, no authorization would be required if Mercy Care is the secondary payer. However, if the service is a covered benefit by Mercy Care, but is not a covered benefit by the primary payer, then an authorization would be required, if service is listed as a service that requires a prior authorization by Mercy Care.