TO: Hospital Providers

RE: Reimbursement Changes for Inpatient Claims with TPL

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Effective October 01, 2014, Alabama Medicaid will be changing its reimbursement for inpatient claims that have TPL. Inpatient claims will continue to capture Third Party Liability patient responsibility amounts at the header.

In order for claims with TPL to be considered for payment, the patient responsibility must be greater than zero. Patient responsibility is calculated by adding together any co-payments, co-insurance and deductible. Claims that do not contain a patient responsibility will deny with error status code 631 (TPL Patient Responsibility is Zero for Payer).

When calculating payment methodology for claims with TPL primary, Medicaid will pay the lesser of patient responsibility or Medicaid allowed amount minus TPL paid amount for inpatient claims.

System changes will be implemented at a later date for the payment methodology for Outpatient claims.

If you have any questions, please contact the Provider Assistance Center at 1-800-688-7989.