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Resolving Payment Discrepancies on Claims

Date: 03/13/24

Background

In the third quarter of 2023, we identified members enrolled in Arizona Complete Health-Complete Care Plan (AzCH-CCP) (Medicaid), Care1st Health Plan Arizona (Care1st) (Medicaid) and Ambetter by Arizona Complete Health (Ambetter) (Marketplace) were not identified in our third-party liability (TPL) claims process, which triggers the Coordination of Benefits (COB) process. As a result, claims submitted by the provider to AZCH-CCP and Care1st 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 in a way that mitigates member and provider impact. The process was corrected in December 2023, and claims are coordinating correctly between AzCH-CCP, Care1st and Ambetter.

  • No refunds or rebilling

There is no need to worry about refunding previously paid claims or rebilling claims.

  • Claims repricing and processing

Impacted claims with dates of service between March 2022 and December 2023 will be reprocessed and paid by Ambetter according to Ambetter payment rules and applicable reimbursement. Reprocessed claims that result in payment amounts greater than what AzCH-CCP and Care1st paid will result in payment of the additional amount owed. An Explanation of Payment (EOP) will be provided with the:

  1. Explanation code EXmk and
  2. The provider's patient control number from the original paid claim to support the reconciliation to the claim paid on the EOP
  • Protecting payments

Should reprocessing result in a denial or lower payout, we will not recoup funds and previous payments will remain unchanged.

Mitigating member impact

Your patients will not face extra financial burdens:

  • Waived cost shares

We plan to waive any cost share the member may have accrued had the claims processed under Marketplace. This is to minimize any inconvenience to our members.

  • Provider payments

We intend to reimburse the provider any applicable member cost share amounts when the claim is reprocessed.

Timeline for adjudication

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

AzCH providers and staff:

If you have questions, please contact your AzCH Provider Engagement Specialist. If you need your assigned Provider Engagement Specialist’s contact information, please email us at AzCHProviderEngagement@azcompletehealth.com.

Care1st providers and staff:

If you have questions, please call Network Management at 1-866-560-4042 (Options in order: 5, 7) or email SM_AZ_PNO@care1staz.com.