§460.71. Claim payment information
A. Any claim payment to a provider by a managed care organization or by a fiscal
agent or intermediary of the managed care organization shall be accompanied by an itemized
accounting of the individual services represented on the claim that are included in the
payment. This itemization shall include but shall not be limited to all of the following items:
(1)The patient or enrollee's name.
(2)The Medicaid health insurance claim number.
(3)The date of each service.
(4)The patient account number assigned by the provider.
(5)The Current Procedural Terminology code for each procedure, hereinafter
referred to as "CPT code", including the amount allowed and any modifiers and units.
(6)The amount due from the patient that includes but is not limited to copay
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§460.71. Claim payment information
A. Any claim payment to a provider by a managed care organization or by a fiscal
agent or intermediary of the managed care organization shall be accompanied by an itemized
accounting of the individual services represented on the claim that are included in the
payment. This itemization shall include but shall not be limited to all of the following items:
(1) The patient or enrollee's name.
(2) The Medicaid health insurance claim number.
(3) The date of each service.
(4) The patient account number assigned by the provider.
(5) The Current Procedural Terminology code for each procedure, hereinafter
referred to as "CPT code", including the amount allowed and any modifiers and units.
(6) The amount due from the patient that includes but is not limited to copayments
and coinsurance or deductibles.
(7) The payment amount of reimbursement.
(8) Identification of the plan on whose behalf the payment is made.
B. If a managed care organization is a secondary payer, then the organization shall
send, in addition to all information required by Subsection A of this Section,
acknowledgment of payment as a secondary payer, the primary payer's coordination of
benefits information, and the third-party liability carrier code.
C.(1) If the claim for payment is denied in whole or in part by the managed care
organization or by a fiscal agent or intermediary of the organization, and the denial is
remitted in the standard paper format, then the organization shall, in addition to providing
all information required by Subsection A of this Section, include a claim denial reason code
specific to each CPT code listed that matches or is equivalent to a code used by the state or
its fiscal intermediary in the fee-for-service Medicaid program. If the claim is denied by the
managed care organization based upon an opinion or interpretation by the managed care
organization of a law, regulation, policy, procedure, or medical criteria or guideline, then the
managed care organization shall provide with the remittance advice either instructions for
accessing the applicable law, regulation, policy, procedure, or medical criteria or guideline
in the public domain or an actual copy of that law, regulation, policy, procedure, or medical
criteria or guideline.
(2) If the claim for payment is denied in whole or in part by the managed care
organization or by a fiscal agent or intermediary of the plan, and the denial is remitted
electronically, then the organization shall, in addition to providing all information required
by Subsection A of this Section, include an American National Standards Institute compliant
reason and remark code and shall make available to the provider of the service a
complimentary standard paper format remittance advice that contains a claim denial reason
code specific to each CPT code listed that matches or is equivalent to a code used by the state
or its fiscal intermediary in the fee-for-service Medicaid program. If the claim is denied by
the managed care organization based upon an opinion or interpretation by the managed care
organization of a law, regulation, policy, procedure, or medical criteria or guideline, then the
managed care organization shall provide with the remittance advice either instructions for
accessing the applicable law, regulation, policy, procedure, or medical criteria or guideline
in the public domain or an actual copy of that law, regulation, policy, procedure, or medical
criteria or guideline.
D. Each CPT code listed on the approved Medicaid fee-for-service fee schedule shall
be considered payable by each Medicaid managed care organization or a fiscal agent or
intermediary of the organization.
E. Unless the secretary of the department promulgates a rule in accordance with this
Subsection, a managed care organization shall be strictly prohibited from amending,
modifying, or changing in any manner a claim submitted by a healthcare provider or
adjusting, down-coding, or paying a claim at a lower level of service than what was
submitted by the healthcare provider. However, this Section shall not prohibit a managed
care organization from conducting required post-payment reviews and audits, and taking
action as a result of such reviews and audits. Any violation of the provisions of this
Subsection shall result in the department withholding from payment to the managed care
organization an amount to be determined by the department not less than twenty-five
thousand dollars or greater for each violation of this Section. The department may
promulgate rules in accordance with the Administrative Procedure Act that authorize a
statewide policy for managed care organizations to adjudicate payment of claims in a manner
that would otherwise violate the provisions of this Section. Such rule shall become effective
only upon the approval of the Senate Committee on Health and Welfare and the House
Committee on Health and Welfare, meeting separately or jointly.