Third-party Liability: Payment Limitations on Other Health Insurance Claim Submissions

(A) Subject to compliance with all conditions of payment, for members who have other health insurance in addition to MassHealth, the MassHealth agency’s liability is the lesser of: (1) the member’s liability, including coinsurance, deductibles, and copayments, as reported on the explanation of benefits or remittance advice from the insurer; or (2) the provider’s charges or maximum allowable amount payable under the MassHealth agency’s payment methodology, whichever is less, minus the insurance payments. (B) For the purposes of 130 CMR 450.317, if the provider has entered into an agreement with any third party to accept payment for less than the amount of charges, the member’s liability will be calculated based on such payment amount. (C) Unless specifically provided for in law or by contract or interagency service agreement with the MassHealth agency, the MassHealth agency is not liable for payment of a service for which a member is not liable, including, without limitation, services available through an agency of the local, state, or federal government, or through a legally obligated person or entity. (D) The MassHealth agency will deny a claim for a service payable in whole or in part by one or more other insurers unless the claim is accompanied by a final disposition from each insurer.