HCBS waiver claims sent to third-party insurers

HCBS waiver claims sent to third-party insurers

On May 4, 2016, HMS, a vendor of the Indiana Health Coverage Programs (IHCP), sent a number of paid Medicaid claims for home and community-based services (HCBS) to third-party insurers for waiver members who carry private insurance. This action was taken in accordance with Code of Federal Regulations 42 CFR §433 Subpart D, which requires Medicaid to bill potentially liable third-party insurers to ensure that Medicaid is the payer of last resort. Because this process had not previously been followed for HCBS waiver claims, the claims recently sent, called reclamation claims, related to dates of service (DOS) back to 2013.

In response to this action by HMS, the third-party insurance carriers are currently processing the Medicaid reclamation claims and sending out explanations of benefits (EOBs) to their policyholders, notifying them whether the claim has been paid or denied by the private insurer. These notifications are not bills, and members should be assured of this if they inquire. In most cases, the EOB explains to the member that the private insurer does not cover HCBS waiver services.

Because these claims were already paid by Medicaid, there should be no action required of  waiver providers or members. However, if questions arise pertaining to the member's third-party insurance or reclamation claims, contact Kathy Myers at HMS by telephone at (317) 696-6266 or by email at Kathy.Myers@hms.com. You may also call HMS toll-free at 1-888-831-2715. Please have the EOB from the third-party insurance carrier available when making inquiries to HMS.