Section 450.316 - Third-party Liability: RequirementsAll resources available to a member, including but not limited to all health and casualty insurance, must be coordinated and applied to the cost of medical services provided by MassHealth. (See 42 CFR Part 433, Subpart D.) Except to the extent prohibited by 42 U.S.C. 1396a(a) 25(E) or (F), all providers must make diligent efforts to obtain payment first from other resources, including casualty payer payments, so that the MassHealth agency will be the payer of last resort. The MassHealth agency will not pay a provider and will recover any payments to a provider if it determines that, among other things, the provider has not made such diligent efforts. Under no circumstances may a provider bill a member for any amount for a MassHealth-covered service, except as provided by 130 CMR 450.130.
(A) "Diligent efforts" is defined as making every effort to identify and obtain payment from all other liable parties, including insurers. Diligent efforts include, but are not limited to: (1) determining the existence of health insurance by asking the member if he or she has other insurance and by using insurance databases available to the provider;(2) verifying the member's other health insurance coverage, currently known to the MassHealth agency through the eligibility verification system (EVS) on each date of service and at the time of billing;(3) submitting claims to all insurers with the insurer's designated service code for the service provided;(4) complying with the insurer's billing and authorization requirements;(5) appealing a denied claim when the service is payable in whole or in part by an insurer; and(6) returning any payment received from the MassHealth agency after any available third-party resource has been identified. The provider must bill all available third-party resources before resubmitting a claim to the MassHealth agency.(B) The MassHealth agency will deem that the provider did not exercise diligent efforts pursuant to 130 CMR 450.316(A) if the insurer denies payment due to the provider's (1) noncompliance with the insurer's billing and authorization requirements, including but not limited to errors in submission, failure to obtain prior authorization, failure to submit appropriate documentation and billing, providing services outside the service network, or untimely billing;(2) request or provocation of a denial; or(3) appeal of an insurer's favorable coverage determination.(C) Failure to comply with the provisions of 130 CMR 450.316(A) may subject a provider to sanctions and liability for overpayments as determined by the MassHealth agency in accordance with 130 CMR 450.235 through 450.240.(D) Unless otherwise permitted by regulation, a provider is not entitled to receive or retain any MassHealth payment for a service provided to a member, if on that date of service the member had any other health insurance, including Medicare, that may have covered the service, and the provider did not participate in the member's other health insurance plan.(E) If at any time a provider learns of health insurance not identified by EVS, the provider must copy both sides of the member's insurance card(s), or otherwise record the member's MassHealth identification number, insurance carrier, policy number, group number, and effective date of coverage, then send this information to the MassHealth agency.(F) If a third-party resource is identified after the provider has already billed and received payment from the MassHealth agency, the provider must promptly return any payment it received from the MassHealth agency. The provider must bill all third-party resources before resubmitting a claim to the MassHealth agency.(G) If a member is covered by more than one health insurer, the provider must request payment from all of the insurers prior to submitting a claim to the MassHealth agency.Amended by Mass Register Issue 1341, eff. 6/16/2017.