Frequently Asked Questions

Third Party Liability (TPL)

If a Health Insurance Information Referral Form (HIIRF) is completed with no documentation, will the member'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 member 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 member says that he/she no longer has the insurance on file?

If a member no longer has the insurance policy that is seen on the Web Tool, the provider can refer the member to their eligibility counselor/worker, or complete the Health Insurance Information Referral Form (HIIRF) to update the member’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.

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