Resolving Payment Discrepancies on Claims

Fecha: 28/03/24

What happened and the steps we will take to rectify the issue.

In Q3 2023, we found that Meridian Medicaid Plan (Meridian) and Ambetter of Illinois (Ambetter) enrolled members were not identified in our third-party liability (TPL) claims process, which triggers the Coordination of Benefits (COB). As a result, claims submitted by providers to Meridian 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 to mitigate member and provider impact. The process was corrected in December 2023, and claims are coordinating correctly between Meridian and Ambetter. 

• No refunds or rebilling: No need to worry about refunding previously paid claims or rebilling of claims. 
• Claims repricing and processing: Impacted claims received 12 MONTHS FOLLOWING AN ORIGINAL PAYMENT BEGINNING March 1, 2023, DOPs will be reprocessed and paid by Ambetter according to Ambetter payment rules and applicable reimbursement. 
• Reprocessed claims that result in payment amounts greater than Meridian payment amounts, will result in payment of the additional amount owed. 
• An Explanation of Payment (EOP) will be provided with the explanation code EXmk and the provider's patient control number from the original paid claim to support reconciliation of the claim paid on the EOP.
• Protecting payments: If reprocessing results 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 financial burdens.

• Waived cost shares: To minimize member inconvenience, we would waive cost share amounts members may have accrued if the claims processed under Marketplace. 
• Provider payments: We will reimburse providers’ applicable member cost share amounts when a claim is reprocessed. 

Adjudication Timeline 

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