Resolving Payment Discrepancies on Claims

Date: 03/15/24

Understand what happened and steps we will take to rectify the issue

In Q3 of 2023, we identified members enrolled in Nebraska Total Care and Ambetter from Nebraska Total Care were not identified in our third-party liability (TPL) claims process, which triggers the Coordination of Benefits (COB).  As a result, claims submitted by the provider to Nebraska Total Care for the impacted members were processed and paid under the member’s Medicaid coverage rather than coordinating and adjudicating under the member’s Ambetter Marketplace coverage.

Our commitment to resolution

We value our member and provider partnerships and are committed to resolving this in a manner that mitigates member and provider impact.  The process was corrected in December of
2023, and claims are coordinating correctly between Nebraska Total Care and Ambetter from Nebraska Total Care.

• No refunds or rebilling: No need to worry about refunding previously paid claims or rebilling of claims.
• Claims repricing and processing: Impacted claims received between January 2023 and December 2023, will be reprocessed, and paid by Ambetter according to Ambetter payment rules and applicable reimbursement.  Reprocessed claims that result in payment amounts greater than what Nebraska Total Care paid will result in payment of the additional amount owed. An Explanation of Payment (EOP) will be provided with the explanation code EX mk and the provider's patient control number from the original paid claim to support with reconciliation to the claim paid on the EOP.
• Protecting payments: Should reprocessing result in a denial or lower payout, we will not recoup funds and previous payments will remain unchanged.

Mitigating member impact

Your patients won't face extra financial burdens:

• Waived cost shares: We plan to waive any cost share the member may have accrued had the claims processed under Marketplace. This is to minimize any inconvenience to our members.
• Provider payments: We intend to reimburse the provider any applicable member cost share amounts when the claim is reprocessed.

Timeline for adjudication

Repricing will begin in early March 2024. Our goal is to adjudicate all impacted claims by June 1, 2024.

Accounts receivables reconciliation or additional questions.

We are here to assist you! Please contact Provider Relations if you have questions.