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Changes to Prenatal Billing Requirements

As a reminder, the passage of the Bipartisan Budget Act of 2018, signed by President Trump in February of 2018, resulted in an amendment to section 1902(a)(25)(E) of the Act that changes how we must process Health Partners (Medicaid) and KidzPartners (CHIP) claims related to prenatal care. The amended law includes several provisions which modify third party liability (TPL) rules related to special treatment of certain types of care and payment.

Under recent law, HPP was required to make payment for prenatal care within 30 days without regard to third party liability and—if a third party was found to be liable—seek reimbursement (pay and chase) after the payment was made. However, effective April 1, 2019, Health Partners Plans will be required to cost avoid prenatal care and will no longer be allowed to pay and chase for such services from third parties.

So, if HPP determines that a third party is likely liable for a prenatal claim, we are required to return, but not deny, your claim back to you indicating there is other insurance that Medicaid believes to be legally responsible for payment. You will be expected to bill this third party directly.

If after your office bills the liable third party—and a balance remains or the claim is denied payment for a substantive reason—you will need to submit a new claim to HPP for payment of the balance (up to the maximum contracted amount or Medicaid payment amount established for the service).

Note that preventive pediatric care (including Early and Periodic Screening, Diagnostic and Treatment services) and claims for services rendered to individuals on whose behalf the state is enforcing a medical support obligation will continue to be processed using pay and chase.

For more information, please refer to the CMCS Informational Bulletin issued on June 1, 2018, by the Center for Medicaid and CHIP Services (CMCS) or contact our Provider Services Helpline at 1-888-991-9023 (Monday–Friday, 9:00 a.m. to 5:30 p.m.).