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Louisiana Department of Health & Hospitals | Kathy Kliebert, Secretary

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Statewide Initiatives



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Medicaid Management Information Systems

Recipient Reimbursement

The Recipient Reimbursement Unit is responsible for processing retroactive reimbursement requests for Medicaid recipients.  Enrollees, who are certified for Medicaid on or after February 15, 1995, may be reimbursed for part or all of any medical expenses paid by them from the effective date of eligibility through receipt of the initial Medical Eligibility Card (MEC) or the reactivation of the MEC.

  • Recipients are eligible for reimbursement of medical expenses paid three months prior to the month of application if they requested retroactive coverage on their application and received approval.
  •  The enrollee is given thirty (30) calendar days from the date of the Notice of Decision Letter to contact Medicaid and request consideration for reimbursement.
  •  Enrollees may be given up to ten (10) additional calendar days to submit their reimbursement request if the extension is requested on or before their deadline date. If a request is made for a second extension, the enrollee is given no more than 10 additional days. No extensions are granted beyond this timeframe.

 

Who Qualifies?

 To qualify for reimbursement, the following criteria must be met:

  1. The enrollee is Medicaid eligible for the date of service.
  2. The Agency has verified that the provider was an enrolled Medicaid provider on the date the enrollee received service and is approved to provide the service rendered.
  3. The bills must be for services received on or after the Medicaid effective date through receipt of the initial MEC or reactivation of the MEC. Reactivation of the MEC would take place when an enrollee of Medicaid status has an interruption in coverage, reapplies and is certified for coverage in a qualifying Medicaid program. The certification period is usually twelve months.
  4. The enrollee has not received reimbursement from Medicaid, the Medicaid provider or received payment in full by a third party entity.
  5. The medical bills must be for medical care, services or supplies covered by the Medicaid Program at the time the service was delivered.
  6. The enrollee must provide proof of payment to Medicaid. Bills which were paid in full by a third party (such as Medicare, an insurance company, charitable organization, family or friend) cannot be considered for reimbursement unless the enrollee remains liable to the third party. It is a requirement that continuing liability of the enrollee be verified.

 

Bills Not Eligible for Reimbursement:

  • Unpaid bills - the recipient should present his/her MEC to the provider along with the unpaid bill so that the provider can file a claim.
  • Bills paid by the enrollee after receipt of the initial MEC or reactivation of the MEC.
  • Bills paid to a non-Medicaid provider who does not participate in the Medicaid Program.

 

Required Documentation

A Medicaid recipient seeking to obtain reimbursement will be asked to provide the following:   

1. A copy of the bill(s) or other acceptable verification which includes the following;

  • Name of the individual who received the service
  • Name, address and phone number of the physician or facility providing the service
  • Date of service
  • Procedure and Diagnosis codes
  • Amount of billed charges and verification of payment
  • Proof of payment by any Private Insurance - Explanation of Benefits (EOB)
  •  If Durable Medical Equipment (DME) - proof of medical necessity from Physician and prescription for each item if one was issued
  • If Dental - Diagnosis and Procedure codes per tooth
  • If Pharmacy - date prescription was filled, National Drug Code (NDC), quantity dispensed, and retail cash price if insurance or discount card was used or the amount paid by the third party entity.

And:

2. Receipt(s) or other acceptable proof showing that the bill was paid by the Medicaid enrollee or someone else. If paid by someone else, proof that the eligible is still liable for repayment to the individual who paid the bill.

Mail Documentation To:

 DHH/MMIS/Retroactive Reimbursement Unit

P.O. Box 91030

Baton Rouge, LA 70821-9030

Contact Number:  866-640-3905 or 225-342-1739

If the Recipient Reimbursement Unit determines that additional information is needed from the enrollee, the enrollee will be mailed a Recipient Verification Request Form.

 The enrollee shall be allowed fifteen (15) days to provide the additional documentation, and upon request for additional time, given an extension. If an extension is requested, no more than fifteen (15) additional days will be granted. Enrollees who fail to provide the requested documentation or fail to request an extension shall have the request for reimbursement denied.

 

Payment

If all criteria are met, a reimbursement check will be issued to the payee at the Medicaid maximum allowable amount along with a Notice of Recipient Reimbursement Decision that explains the reimbursement decision.  Reimbursements are made at the Medicaid rate less any Third Party payments.

If all criteria are not met, a Notice of Recipient Reimbursement Decision will be mailed to the enrollee to advise that eligibility for reimbursement has not been established. The enrollee shall be given a clear and concise explanation of the reason(s) for ineligibility for reimbursement.  The enrollee has the right to appeal the decision.