Frequently Asked Questions

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Frequently Asked Questions


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Third Party Liability (TPL)

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Can MIVS track down where other payer’s money goes if you are not paid?

No, but they can contact other payers to obtain payment information.

Can the HIIRF form be faxed?

The HIIRF can be faxed to Medicaid Insurance Verification Services at (803) 252-0870.

Can you accept a beneficiary as just a private pay patient even if they have Medicaid?

Yes, you just have to let them know before they receive any services.

Do we need to send an EOB?

An Explanation of Benefits from a third party payer should be kept on file in the provider’s office, especially if the payer didn’t submit payment.

Do we send an EOB with claims?

You do not send an EOB with claims, unless it is requested.

Do you have to ask MIVS to research TPL non-payment?

No, they do this on their own to ensure payment.

Does the Medicaid card have all the information needed?

No, you should further investigate eligibility using eligibility resources and the information provided on the card.

For HIPP referral, who should you contact?

For HIPP referral, providers should contact the Medicaid Insurance Verification Services at 1-888-289-0709 option 5, option 4. The HIPP Fax is 803-462-2580.

How do patients learn updated information?

Patients learn of updates at their enrollment anniversary dates, or you may share information with them.

How long do you have to request a hearing for an appeal?

You have 30 days to request a hearing.

If a Health Insurance Information Referral Form (HIIRF) is completed with no documentation, will the beneficiary's TPL record be updated?

No, MIVS will further investigate and draft a letterhead showing steps taken.

If a plan doesn’t cover family planning, do we bill to Medicaid and send the EOB?

Certain services are “carved out”, not covered, by the MCOs and MHNs. Those services can be billed directly to SC Medicaid. You do not need to bill to the managed care plan for a denial.

If I have a difficult payer, do I need to complete a reasonable effort document?

Yes you can. It is to show efforts made to obtain other payments from other insurers.

If I send a HIIRF, will I see anything saying it was received?

No, just wait a few days and check eligibility again.

If my third party has several addresses, which one do I choose?

You would contact the company to find out which address is for your service area.

If the beneficiary had Champus or Tri-Care and it paid 100%, why would I need to file to Medicaid?

You would need to file to Medicaid for reporting purposes and for seeing the claim through from beginning to end. 

If you know a service isn’t covered, do you still file to the other carrier?

Yes, you still file to the other carrier to obtain a valid denial. Three denials should be kept on file each year.

What do you do if monies are sent to the patient?

Change them to self pay after or before service completion.

What happens when Medicaid recoups for retro-health recovery and it is outside of the timely filing window?

Professional billers do not receive retro health letters. Medicaid contacts or solicits billing payments from the private health plan.

What if a claim is created, but the beneficiary says that he/she no longer has the insurance on file?

If a beneficiary no longer has the insurance policy that is seen on the Web Tool, the provider can refer the beneficiary to their eligibility counselor/worker, or complete the Health Insurance Information Referral Form (HIIRF) to update the beneficiary’s third party payer information. Making a change to a policy that already exists in the Medicaid Management Information System (MMIS) takes five days. The HIIRF Form can be faxed to 803-252-0870.

Where are the specifics for pay and chase?

The specifics for pay and chase are found in Section 2 (polices) and section 3 (billing) of your provider manual.

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