Participant Liability for Medical Services Not Reimbursable to the Provider by the MO HealthNet Agency

PURPOSE: This rule establishes the guidelines for determination of participant liability for medical services not reimbursable to the provider by the MO HealthNet agency. (1) When an enrolled MO HealthNet provider provides an item or service to a MO HealthNet participant eligible for the item or service on the date provided, there shall be a presumption that the provider accepts the participant’s MO HealthNet benefits and seeks reimbursement from the MO HealthNet agency in accordance with all of the applicable MO HealthNet rules. This presumption shall be overcome only by written evidence of an agreement between the provider and the participant indicating that MO HealthNet is not the intended payor for the specific item or service but rather that the participant accepts the status and liabilities of a private pay patient. All third-party resource benefits must be exhausted before payment will be made by the division for the item or service rendered to that participant. For purposes of this rule, neither the provider nor the participant shall be required to exhaust all third-party resources in those situations where the provider or participant elect not to pursue contingent liability from a third-party tortfeasor. Both the provider and the participant have an affirmative duty to report the existence of contingent liability to the MO HealthNet Division and the participant has the duty to cooperate with the MO HealthNet Division if the division elects to pursue the contingent liability. (2) When an item or service is rendered to a MO HealthNet participant who was eligible for the item or service on the date provided and provision of the item or service is billed to the MO HealthNet agency by an enrolled MO HealthNet provider who is not reimbursed by the agency for the item or service claimed, the item or service will not be the liability of the participant if the item or service would have been otherwise payable by the MO HealthNet agency at the MO HealthNet allowable amount had the provider followed all of the policies, procedures and rules applicable to the item or service as of the date provided. If the item or service is not otherwise payable for reasons unrelated to the actions of the provider, the participant is liable to the provider for payment of the item or service. (3) The creation of a presumptive acceptance by a provider of the MO HealthNet benefits for a MO HealthNet covered service and the requirement for written evidence of an agreement to overcome presumptive acceptance, as established in this rule, shall not be applicable to services provided to a participant who is dually eligible and entitled to both MO HealthNet and Medicare Part B medical insurance benefits. (4) The provisions of this rule shall apply to items or services provided on or after July 11, 1985. AUTHORITY: section 207.020, RSMo 2000 and sections 208.152 and 208.153, RSMo Supp. 2007.* This rule was previously filed as 13 CSR 40-81.140. Original rule filed April 16, 1985, effective July 11, 1985. Amended: Filed March 2, 1988, effective May 12, 1988. Amended: Filed Oct. 12, 2007, effective April 30, 2008. *Original authority: 207.020, RSMo 1945, amended 1961, 1965, 1977, 1981, 1982, 1986, 1993; 208.152, RSMo 1967, amended 1969, 1971, 1972, 1973, 1975, 1977, 1978(2), 1981, 1986, 1988, 1990, 1992, 1993, 2004, 2005, 2007; and 208.153, RSMo 1967, amended 1967, 1973, 1989, 1990, 1991, 2007.