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TO: All Providers

RE: Clarification to Third Party (TPL) Denial Claims Process

Currently, certain claims with a third party denial may be submitted via the Medicaid Interactive Web Portal or on paper with a copy of the third party denial attached.

Effective July 1, 2021, all claims with a third party denial on the approved list must be submitted electronically.

The list of approved denial codes that may be submitted electronically can be found here: https://medicaid.alabama.gov/content/7.0_Providers/7.1_Third_Party.aspx.

Claims with a third party denial that are submitted on paper will also be reviewed against the published list of acceptable TPL denials. Other denial codes which are not on the list will require additional justification and must be submitted on a paper claim to the fiscal agent. Providers must submit justification or documentation as to why the primary payer cannot be billed or will not pay the claim to prove that a good faith effort has been made to obtain payment from a primary payer. Examples of acceptable documentation may include:

• Legible copies of third party denials
• Brief explanation of additional submitted documentation, such as diagnosis codes to justify medical necessity
• Justification regarding why the provider does not meet certain requirements of the third party, such as certification

If acceptable documentation is not attached, the paper claim will be returned to the provider.

For claims with dates of service over one year to be considered for payment, the denial must be dated by the third party, and the claim must be submitted within 120 days of third party denial.

Third party denials should be attached to the paper claim or they may be submitted through the Interactive Web Portal or via Fax with an Attachment Control Number (ACN) generated through the Interactive Web Portal. Claims with a third party denial that are submitted electronically must include an ACN. Review the ALERT from May 4, 2020 found here: https://medicaid.alabama.gov/alert_detail.aspx?ID=13860, for detailed instructions for the electronic process.

Please see Ch. 20, Third Party, Rule No. 560-X-20-.04 Third Party Payments/Denials, for additional information. The chapter can be found here: https://medicaid.alabama.gov/documents/9.0_Resources/9.2_Administrative_Code/9.2_Adm_Code_Chap_20_Third_Party_2-13-15.pdf. 

If you have questions, please contact Theresa Carlos at (334) 242-5257.

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