Troubleshooting

The questions below and their answers may help you troubleshoot questions from clients looking to you for assistance with accessing services or billing issues.

1. Is current coverage information loaded correctly?

Check to be sure that the correct information is loaded into both MAXIS, METS, and MMIS, including begin and end dates for private insurance (MMIS TPL subsystem, MAXIS STAT/INSA and METS Employer Sponsored Coverage Insurance evidence, or Benefit evidence), managed care health plan (MMIS Recipient Subsystem), and Medicare coverage (MAXIS STAT/MEDI and MMIS Recipient Subsystem). Correct information must be available in the MAXIS and MMIS systems in order for payment to be completed correctly. The coverage in effect on the date of service determines who the provider should bill.

2. Who should pay for a health care service?

You must assist the client in identifying who they should contact when questions arise about who is responsible for payment of a health care service.

Medicare recipients (not participating in an SNP) should contact Medicare regarding payments made or anticipated to be made by that program.
Managed care enrollees should contact the managed care plan’s member services number.
Fee-for-service enrollees, or those managed care enrollees who have certain services covered by fee-for-services, should contact the MA Member Services. More information about billing is provided on the client’s monthly Explanation of Medical Benefits (EOMB).

If a client receives a bill from a provider in error, request that the client contact the provider and provide coverage information.

3. My provider didn’t tell me a service wasn’t covered, what do I do?

If the client was informed that the service they are about to receive is not a covered service, the client is then responsible for paying for that service. If the client was not informed, then refer the client to your county managed care advocate or a health care ombudsman. More information about advocates and health care ombudsmen will be provided later in this module.

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