GENERAL NEWS
Balance Billing Medicaid Members Prohibited
Utah Medicaid is reporting an increase in balance billing referral cases to the Utah Office of Inspector General (OIG). Balance billing Health Choice Utah Medicaid members, or any other Medicaid managed care organization (MCO) member, is a direct violation of your MCO or Medicaid contract.
What You Need to Know
- If a member has both Medicaid and coverage with a responsible third party, do not collect a copayment that is usually due at the time of service.
The following information is available in the Utah Medicaid Provider Manual – Section I: General Information, Section 3-4 (pages 37–38):
"If a member has both Medicaid and coverage with a responsible third party, do not collect a co-payment that is usually due at the time of service. The provider may not bill the member for services covered by Medicaid, Hospital Presumptive, or Baby Your Baby or by an MCO. The payment received from Medicaid or from an MCO is intended to include any deductible, co-insurance, or co-payment owed by the Medicaid member. In addition, the administrative cost of completing and submitting Medicaid claim forms are considered part of the services provided and cannot be charged to Medicaid members."
This applies to Medicaid managed care organizations, including Health Choice Utah.
Billing for Non-Covered Services
Utah Medicaid allows billing a Medicaid member only in limited circumstances, including non-covered services, spenddown medical claims, Medicaid cost sharing, and broken appointments. Detailed requirements are outlined in Section 3-5, Exceptions to Prohibition on Billing Members, of the Utah Medicaid Provider Manual.
A provider may bill a Medicaid member for a non-covered service only when all of the following conditions are met:
- The provider has an established policy for billing all members for services not covered by a third party (the charge cannot be billed only to Medicaid members).
- The member is advised prior to receiving the service that Medicaid will not pay for the service.
- The member agrees to be personally responsible for payment.
- The agreement is made in writing between the provider and the member and includes the service being provided and the amount the member agrees to pay.
We appreciate the services you provide to our Health Choice Utah members. If you have questions about this clause in your Health Choice Utah or Utah Medicaid agreement, please contact your provider relations consultant or a Medicaid representative.
Reference
- Medicaid Information Bulletin: May 2024, 24-30 — View PDF
- Utah Medicaid Provider Manual, Section 3-5 – Exceptions to Prohibition on Billing Members — View Manual