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7.2.3 CAUSES AND RESOLUTIONS

Causes and A Good Faith claim can occur when:

 

  1. A recipient presents an ID card that is invalid because:
     

    1. You issued a temporary ID card for a prior period or manually determined case and didn’t update CARES Client Assistance for Re-employment & Economic Support or send EDS a to update the recipient’s eligibility file.  EDS will apply the dates of eligibility indicated on the card with med stat 71.  A letter will be sent to you to confirm that the recipient is eligible for the dates on the card.  The letter will include instructions on how to complete a ( HCF 10111 ) and the information that is needed.
     
    1. The provider suspects the recipient of misusing or abusing a Medicaid ID card (i.e. using an altered card or a card that belongs to someone else).  If the provider submits a copy of the card and EDS can tell that it was altered, EDS will contact you to verify the recipient was eligible or forward it to the Division of Health Care Financing ( DHCF ) for review.
     

  2. The recipient’s name has changed since the card was issued.  EDS can usually resolve claims that are denied with code “029” and “614”.  If necessary, EDS will contact you to confirm the information.

 

With the implementation of the Forward ID cards, providers are less likely to receive one of the eligibility-related denials used for Good Faith claims submission.  Providers are told to verify eligibility using the variety of methods available to them through the Eligibility Verification System ( EVS ).  When the provider verifies the client’s eligibility, they are getting the most current information available on the MMIS.  Therefore, it is unlikely that they will be told the client is eligible when s/he is not.

 

The most likely reason a Good Faith situation arises is when a provider sees a temporary paper ID card issued by the agency.  The provider may bill MA before the eligibility is updated on MMIS, or perhaps the eligibility was never sent to MMIS.  In either case,if the client presents a valid temporary Medicaid ID card for the dates of service, and the provider sends a copy of the card with the Good Faith claim , EDS will update the client’s eligibility file with a good faith segment and pay the claim immediately.

 

EDS will then attempt to resolve the discrepancy from information on file or contact you to confirm eligibility and correct the eligibility segment.  If the provider doesn’t send a copy of the ID card with the claim, EDS must confirm eligibility with you before the claim can be paid.  

 

The definition of a ‘valid’ card is either a:

 

  1. Forward card that indicates eligibility for the dates of service through the EVS.
     

  2. A temporary paper card showing dates of eligibility.

 

This page last updated in Release Number : 01-02

Release Date :04/01/01

Effective Date : 04/01/01