Federal Rule Change for Prenatal Claims


TO:  Hospitals and Prenatal Care Providers

The passage of the Bipartisan Budget Act of 2018 requires states to “cost avoid” claims for prenatal services when there is a known liable third party. Prior to this change, states were federally required to “pay and chase” claims with a designated prenatal procedure or diagnosis code. The federal “pay and chase” provision enabled providers to bill Medicaid for prenatal care and receive payment without having to bill the other third party. Medicaid was required to seek reimbursement from the other liable third party.

Because of this federal change, the Alabama Medicaid Agency will implement changes within its claims processing system to require providers to bill other known insurance coverage prior to receiving Medicaid payment for prenatal services. Effective January 1, 2019, for prenatal services claims received for dates of services on or after February 9, 2018, Alabama Medicaid will deny claims when there is other insurance coverage, but no payment or denial by the other insurance is indicated on the claim.

Once the provider has billed the third-party carrier, if a denial is received or a balance remains, the provider may then submit the claim to the Alabama Medicaid Agency for consideration of payment.

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