Charges Not Beneficiary’s Responsibility

Charges Not Beneficiary’s Responsibility A. Providers who have agreed to be Medicaid providers are expected to bill Medicaid for Medicaid covered services and accept Medicaid payment as payment in full. B. Some charges are not the beneficiary’s responsibility and must not be billed to the beneficiary. Those included, but not limited to: 1. The beneficiary may not be billed for Medicaid covered services except in the following situations: a) If the person is ineligible; or b) If person has chosen to receive and agreed to pay for care not covered by the Medicaid program. 2. The beneficiary may not be held liable for a claim or portion of a claim when a determination that the services were not medically necessary is made based on the professional opinion of appropriate and qualified persons performing peer review of Medicaid cases. 3. The beneficiary may not be held liable for billed charges above the Medicaid maximum allowable. 4. The beneficiary may not be billed for claims denied because of provider errors. It is the responsibility of the provider to file claims in a timely manner, to correct errors, and to provide essential information necessary to process the Medicaid claim. 5. The beneficiary may not be billed for claims denied because of errors made by DOM, the fiscal agent, or due to changes in federal or state mandates. 6. The beneficiary may not be billed for services denied because a provider failed to request required authorization for a service or failed to meet procedural requirements. 7. For dual eligibles, the beneficiary may not be billed for the portion of a claim remaining after Medicare and Medicaid have paid. 8. The beneficiary may not be billed for the completion and submission of a Medicaid claim form. If the provider agrees to accept the patient as a Medicaid beneficiary and agrees to bill Medicaid for the services rendered, the beneficiary may not be charged for this billing procedure. 9. The beneficiary may not be billed for telephone calls or missed/cancelled appointments. 10. The beneficiary may not be charged for the cost of copying medical records.