§460.71. Claim payment information

A. Any claim payment to a provider by a managed care organization or by a fiscal agent or intermediary of the managed care organization shall be accompanied by an itemized accounting of the individual services represented on the claim that are included in the payment. This itemization shall include but shall not be limited to all of the following items:

(1) The patient or enrollee's name.

(2) The Medicaid health insurance claim number.

(3) The date of each service.

(4) The patient account number assigned by the provider.

(5) The Current Procedural Terminology code for each procedure, hereinafter referred to as "CPT code", including the amount allowed and any modifiers and units.

(6) The amount due from the patient that includes but is not limited to copayments and coinsurance or deductibles.

(7) The payment amount of reimbursement.

(8) Identification of the plan on whose behalf the payment is made.

B. If a managed care organization is a secondary payer, then the organization shall send, in addition to all information required by Subsection A of this Section, acknowledgment of payment as a secondary payer, the primary payer's coordination of benefits information, and the third-party liability carrier code.

C.(1) If the claim for payment is denied in whole or in part by the managed care organization or by a fiscal agent or intermediary of the organization, and the denial is remitted in the standard paper format, then the organization shall, in addition to providing all information required by Subsection A of this Section, include a claim denial reason code specific to each CPT code listed that matches or is equivalent to a code used by the state or its fiscal intermediary in the fee-for-service Medicaid program.

(2) If the claim for payment is denied in whole or in part by the managed care organization or by a fiscal agent or intermediary of the plan, and the denial is remitted electronically, then the organization shall, in addition to providing all information required by Subsection A of this Section, include an American National Standards Institute compliant reason and remark code and shall make available to the provider of the service a complimentary standard paper format remittance advice that contains a claim denial reason code specific to each CPT code listed that matches or is equivalent to a code used by the state or its fiscal intermediary in the fee-for-service Medicaid program.

D. Each CPT code listed on the approved Medicaid fee-for-service fee schedule shall be considered payable by each Medicaid managed care organization or a fiscal agent or intermediary of the organization.

Acts 2013, No. 358, §1, eff. Jan. 1, 2014.