Reminder: Provider Responsibility Regarding Third Party Liability and Secondary Billing
Per federal requirements, MaineCare is the payor of last resort, with only limited exceptions. The Office of MaineCare Services continuously refines policies and claims processing procedures to ensure that primary insurance coverage is leveraged, whenever possible. This includes reviewing Medicare and commercial coverage policies for service coverage changes in all areas, including, but not limited to, behavioral health, durable medical equipment, and physician services.
As a reminder, providers must follow the requirement to seek primary insurance payment prior to billing MaineCare even when the billing codes for same services vary between payers. Providers must also seek primary insurance payment prior to billing MaineCare if the primary payer’s service coverage only applies to a portion of the MaineCare defined service (for example, the MaineCare service is more comprehensive than the primary payer’s). The MaineCare claims system will accept an Explanation of Benefits (EOB) with primary dollars attached even if the billing codes are different, as long as the provider, member, dates of service, and billed charges match. Providers should ensure they are using the most specific codes possible to maintain billing integrity and compliance with correct claim submission.
Please review MaineCare Benefits Manual Section 1.07-3, Provider/Department/Member Responsibility Regarding Third Party Liability. Please monitor MaineCare e-messages for future communications on this topic.
We appreciate your efforts to preserve MaineCare funding and ensure compliance with these requirements.