As the Medicaid Agency, the Oklahoma Health Care Authority
(OHCA) is the payer of last resort, with few exceptions. When other resources
are available, those resources must first be utilized. Exceptions to this
policy are those receiving medical treatment through Indian Health Services and
those eligible for the Crime Victims Compensation Act. Guidance for third party
liability under the Insure Oklahoma program is found in Oklahoma Administrative
Code (OAC) 317:45, Insure Oklahoma.
(1) If a member has coverage by an absent
parent's insurance program or any other policy holder, that insurance resource
must be used prior to filing a SoonerCare claim. This includes Health
Maintenance Organizations (HMO), Preferred Provider Organizations (PPO) and any
other insuring arrangements that provide a member access to healthcare. Members
must comply with all requirements of their primary insurance as well as
SoonerCare requirements in order to take advantage of both coverages. For
example, a member must comply with the network restrictions of both the primary
and SoonerCare plans as well as prior authorization requirements. If the member
does not comply with the requirements of the primary plan, he/she will be
responsible for the charges incurred. Denials by private insurance companies
because the member did not secure a preauthorization or use a participating
provider is not a sufficient reason for SoonerCare to make payment. If the
provider is aware of private insurance or liability, a claim must first be
filed with that source. When private insurance information is known to the
OHCA, the eligibility verification system will reflect that information. If
payment is denied by the primary insurance, except as stated above, the
provider must attach the Explanation of Benefits (EOB), stating the reason for
the denial, to the claim submitted to the Fiscal Agent. When payment is
received from another source, that payment amount must be reflected on the
claim form.
(2) It is possible that
other resources are available but are unknown to OHCA. Providers will routinely
question SoonerCare members to determine whether any other resources are
available. In some instances, coverage may not be obvious, for example, the
member may be covered by a policy on which he/she is not the subscriber (e.g.,
a child whose absent parent maintains medical and hospital coverage).
(3) If the provider receives payment from
another source after OHCA has made payment, it is necessary that the provider
reimburse OHCA for the SoonerCare payment. The provider may retain the primary
insurance payment, if any, that represents payment for services that are not
covered services under SoonerCare. By accepting the OHCA's payment, the
provider agrees to accept it as payment in full and, therefore, cannot retain
any portion of other resource money as payment for reduced charges on covered
services. Other than SoonerCare copayments, a provider cannot bill a member for
any unpaid portion of the bill or for a claim that is not paid because of
provider administrative error. If, after reimbursing OHCA and retaining a
portion of the other payment in satisfaction of any non-covered services there
is money remaining, it must be refunded to the member.
(4) If a member is covered by a private
health insurance policy or plan, he/she is required to inform medical providers
of the coverage, including:
(A) provision of
applicable policy numbers;
(B)
assignment payments to medical providers;
(C) provision of information to OHCA of any coverage changes;
and
(D) release of money received
from a health insurance plan to the provider if the provider has not already
received payment or to the OHCA if the provider has already been paid by the
OHCA.
(5) Members are
responsible for notifying their providers of the intent to make application for
SoonerCare coverage and of any retroactive eligibility determinations. Members
may be responsible for any financial liability if they fail to notify the
provider of the eligibility determinations and as a result, the provider is
unable to secure payment from OHCA.
(6) Members must present evidence of any
other health insurance coverage to a medical provider each time services are
requested. Members may be responsible for any financial liability if they fail
to furnish the necessary information before the receipt of services and as a
result, the provider is unable to secure payment from OHCA.
Notes
Okla. Admin.
Code §
317:30-3-24
Added at 12 Ok Reg
751, eff 1-5-95 through 7-14-95 (emergency); Added at 12 Ok Reg 3131, eff
7-27-95; Amended at 16 Ok Reg 685, eff 12-28-98 (emergency); Amended at 16 Ok
Reg 1429, eff 5-27-99; Amended at 27 Ok Reg 293, eff 11-3-09 (emergency);
Amended at 27 Ok Reg 929, eff 5-13-10; Amended at 27 Ok Reg 2736, eff 7-20-10
(emergency); Amended at 28 Ok Reg 1395, eff
6-25-11
Amended by
Oklahoma
Register, Volume 35, Issue 24, September 4, 2018, eff.
9/14/2018