CurrentAgency for Health Care AdministrationPolicy 59G-1.052

Third-Party Liability Requirements

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This policy governs how Florida Medicaid recipients, providers, and other responsible parties must identify, notify, exhaust, and report third-party payment sources before Florida Medicaid reimbursement. It also establishes reimbursement, claim submission, Medicare coordination, dually eligible recipient, and exceptional claims requirements.

Policy Summary

PayerAgency for Health Care Administration

PolicyThird-Party Liability Requirements

Policy CodePolicy 59G-1.052

Change TypeNo material change

Effective DateNot specified

Next Review DateNot specified

Key ActionExhaust all available third-party payment sources before submitting or resubmitting a claim to Florida Medicaid.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Last resortFlorida Medicaid payment priority

12 monthsStandard filing limit after service

6 monthsAlternative filing period after Medicare notice

21–100Nursing facility coinsurance days

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CurrentAgency for Health Care AdministrationPolicy 59G-1.052

Third-Party Liability Requirements

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Sign up for Agency for Health Care Administration Policy 59G-1.052 alerts

Get alerted when Policy 59G-1.052 changes without checking for updates manually.

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Policy Summary

PayerAgency for Health Care Administration

PolicyThird-Party Liability Requirements

Policy CodePolicy 59G-1.052

Change TypeNo material change

Effective DateNot specified

Next Review DateNot specified

Key ActionExhaust all available third-party payment sources before submitting or resubmitting a claim to Florida Medicaid.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Last resortFlorida Medicaid payment priority

12 monthsStandard filing limit after service

6 monthsAlternative filing period after Medicare notice

21–100Nursing facility coinsurance days

50%Specified Part B service rate

23Insurance coverage types

Third-Party Liability and Reimbursement Criteria

Payer of Last Resort and Service Access

Florida Medicaid is the payer of last resort. Providers must pursue and exhaust available third-party liability (TPL) sources before submitting or resubmitting a claim to Florida Medicaid, while continuing to provide covered services when required.

ALL of the following

Exhaust all available TPL sources of payment before submitting or resubmitting a claim to Florida Medicaid, including Medicare, TRICARE, private health insurance, AARP plans, and automobile coverage.
Providers may not refuse to furnish a covered Florida Medicaid service solely because the recipient has other insurance, including Medicare, under 42 CFR 447.20(b).
EXCEPTIONS to payer-of-last-resort status
- Federal funds for Individuals with Disabilities Education Act (IDEA), Part B or Part C.
- Indian Health Services, under 42 CFR 136.61.
- State- or county-funded programs, including AIDS drug assistance programs; county health departments; Department of Health indigent drug programs; substance abuse, mental health, and developmental disabilities programs operated by the Department of Children and Families or the Agency for Persons with Disabilities; victims' compensation funds; and vocational rehabilitation programs.

Third-Party Reimbursement and Reporting

Providers must identify applicable TPL, submit claims to responsible third parties, and report third-party payments and recipient liability accurately on Florida Medicaid claims.

TPL reimbursement and reporting requirements

Inquire whether the recipient has third-party insurance coverage and whether any existing third-party coverage has changed.
Review TPL information available through the Florida Medicaid fiscal agent's Web site at http://portal.flmmis.com/flpublic or the Florida Medicaid Automated Voice Response System (AVRS) at 1(800)239-7560.
Determine whether the insurance shown on the Florida Medicaid file applies to the services being provided.
Treat contributions made to a facility on behalf of a specific recipient as third-party payments and include them on the claim form.

Standard reimbursement calculation

Dually Eligible Recipient Coordination

For dually eligible recipients, coordinate Medicare and Medicaid payment in accordance with the applicable eligibility category, Medicare benefit, and Florida Medicaid methodology.

Medicare premium and enrollment rules

Florida Medicaid pays the Medicare Part B premium for dually eligible recipients with full Florida Medicaid, QMB, SSI, SLMB, or QI1 benefits, and for Medically Needy recipients with QMB, SLMB, or QI1 benefits.
Do not reimburse expenditures that could have been paid under Medicare Part B but were not because the individual was not enrolled in Part B, under 42 CFR 431.625(d).
This applies to all recipients eligible for Part B enrollment, whether individually or through an agreement under section 1843(a) of the Social Security Act.
Do not pay Medicare Part C premiums.
Do not pay Medicare Part D premiums or Part D copayments, coinsurance, or deductibles.

Special Claim and Patient Responsibility Rules

Additional rules apply to patient responsibility, inpatient services, secondary claims, and exceptional fee-for-service claims.

Patient responsibility

For dually eligible recipients, reimburse services under the dually eligible reimbursement methodology minus applicable service-specific patient responsibility.
When a recipient has QMB benefits and full Florida Medicaid benefits, or is receiving SSI, do not charge patient responsibility during Medicare coinsurance days 21 through 100 for nursing facility services.
This rule applies notwithstanding rule 59G-4.200, F.A.C.

Timely filing of claims secondary to Medicare

Submit claims to Florida Medicaid within 12 months from the date of service or within 6 months after AHCA or the provider receives notice of Medicare claim disposition, whichever period is greater.

Fee-for-service exceptional claims

Insurance Coverage Types and Billing Rules

Florida Medicaid two-digit insurance coverage type codesmixed

03	Basic surgical
04	Basic hospital/medical/surgical
05	Pharmacy administrator (TPA)
06	Major medical
07	Accident only (non-auto)
08	Vehicle all inclusive
09	Major medical with TPA or no pharmacy
10	Cancer
11	Medicare Special Need Plan
12	Medicare supplement

1–10 of 21

1/3

Third-Party Payment Threshold

ThresholdNo Florida Medicaid reimbursement is made when any third-party payment, including Medicare, is equal to or exceeds the Florida Medicaid rate for the service.

Payment comparisonThe third-party payment is compared with the Florida Medicaid rate for the service.

Applicable paymentsThe rule applies to payments from any third party, including Medicare.

Medicare Part B Enrollment Limitation

Non-reimbursement ruleFlorida Medicaid does not reimburse expenditures that could have been paid under Medicare Part B but were not because an individual was not enrolled in Part B.

Eligible individualsThe limitation applies to all recipients who are eligible for enrollment under Medicare Part B.

Required Provider and Billing Actions

Billing Rule

Submit TPL Notices to the Designated AHCA Address

Submit notices regarding any third-party benefit, including trust, annuity, or estate probate actions, to the appropriate address listed on the AHCA website. Notice sent to another AHCA office or address is not effective to fulfill the notice requirement.

AHCA address: http://www.ahca.myflorida.com/Admin/
Notices must comply with sections 409.910 and 409.9101, Florida Statutes.

Billing Rule

Exhaust Third-Party Resources Before Medicaid Billing

Florida Medicaid is the payer of last resort. Exhaust all available third-party payment sources before submitting or resubmitting a claim to Florida Medicaid.

Examples include Medicare, TRICARE, private health insurance, AARP plans, and automobile coverage.

Key Terms

Dually Eligible Recipient

TermDually Eligible Recipient

Governing authorityDefined in Rule 59G-1.010, Florida Administrative Code.

Policy definitionA recipient who meets the definition in Rule 59G-1.010, Florida Administrative Code.

Rate

TermRate

Governing authorityDefined in Rule 59G-1.010, Florida Administrative Code.

Policy definitionAs defined in Rule 59G-1.010, Florida Administrative Code.

Policy Summary

PayerAgency for Health Care Administration

PolicyThird-Party Liability Requirements

Policy CodePolicy 59G-1.052

Change TypeNo material change

Effective DateNot specified

Next Review DateNot specified

Key ActionExhaust all available third-party payment sources before submitting or resubmitting a claim to Florida Medicaid.

SourceLink

On This Page

Florida Medicaid reimburses the difference between the Florida Medicaid rate and the third-party payment, less any applicable Florida Medicaid copayment or coinsurance, unless otherwise specified.

Do not seek Florida Medicaid reimbursement when third-party payment, including Medicare, equals or exceeds the Florida Medicaid rate.

Florida Medicaid does not reimburse the service in this circumstance.

Do not seek Florida Medicaid reimbursement when the provider's TPL claim was denied for failure to obtain the third-party's required authorization.

Services approved by Medicare do not require Florida Medicaid prior authorization.

Discounted contracts

When a provider has agreed with a third party to accept an amount below customary charges as payment in full, limit Florida Medicaid reimbursement to remaining recipient liability, such as a copayment or deductible.
When the discounted contract's allowable fee is below Florida Medicaid's maximum allowable rate and recipient liability remains, calculate the recipient responsibility, subtract it from the Florida Medicaid rate, and report the result as the third-party payment on the claim.
Prorate the discounted contract's allowable TPL payment and recipient responsibility across each line item when the TPL explanation of benefits is not itemized.

DRG/EAPG and related limitations

For claims reimbursed through a Diagnosis Related Group (DRG) or Enhanced Ambulatory Patient Grouping (EAPG), ensure Florida Medicaid reimbursement is equal to or less than any contracted or negotiated TPL rate.

Do not reimburse drugs for dually eligible recipients who are eligible for Medicare Part D but are not enrolled.

Reimburse drugs excluded by Medicare from Part D for dually eligible recipients who are otherwise eligible for prescribed drug services under the Florida Medicaid prescribed drug services coverage policy.

Dually eligible claim reimbursement

Reimburse Medicare Parts A, B, and C deductibles, coinsurance, and copayments based on the lesser of the amount billed or the Florida Medicaid rate, in accordance with section 409.908, Florida Statutes.
Subtract the Medicare-paid amount and any other third-party payment from the Florida Medicaid rate.
If the resulting amount is zero or negative, make no payment.
If the resulting amount is positive, compare it with the sum of the coinsurance, copayment, and deductible amounts, and pay the lesser amount, except as otherwise specified in section 409.908, Florida Statutes.
For Medicare Part B services not covered by Florida Medicaid provided to dually eligible recipients with QMB benefits, with or without other Florida Medicaid benefits, or to SSI recipients, use 50 percent of the Medicare-allowed amount as the Florida Medicaid rate and apply the same reimbursement methodology.

Inpatient and nursing facility coordination

Dually eligible recipients age 21 years and older with Medicare Part A or Part C benefits simultaneously deplete Medicare and Florida Medicaid covered hospital days.
After Medicare Part A benefits are exhausted, or when the recipient has no Medicare Part A coverage, bill Medicare for Medicare-allowable Part B inpatient ancillary services and report any Medicare Part B reimbursement as TPL on the Florida Medicaid inpatient claim.
Reimburse Medicare-approved Part B nursing facility services not included in the nursing facility's cost report under the methodology in section 11.

Submit an exceptional claim only for a Florida Medicaid-covered service when the claim was denied by the Florida Medicaid fiscal agent.

Ensure that a third-party payer or Medicare also denied the claim.

This requirement does not apply when Medicare determined that the service was not medically necessary.

Submit the fee-for-service exceptional claim to the appropriate address listed on the AHCA Web site: http://ahca.myflorida.com/Medicaid/Operations/assistance/providers.shtml.

Enrollment basisThe limitation applies whether Part B eligibility is individual or established through an agreement under section 1843(a) of the Social Security Act.

Specified Medicare Part B Service Rate

Applicable recipientsThe rule applies to dually eligible recipients with QMB benefits, with or without other Florida Medicaid benefits, and to SSI recipients.

Medicaid coverageThe service must be a Medicare Part B service that is not covered by Florida Medicaid.

Florida Medicaid rateThe Florida Medicaid rate is 50% of the Medicare-allowed amount, with payment made under the applicable dually eligible recipient reimbursement rules.

Timely Filing Secondary to Medicare

Standard filing periodProviders may submit claims within 12 months from the date of service.

Alternative filing periodProviders may submit claims within 6 months after AHCA or the provider receives notice of the disposition of the Medicare claim.

Applicable periodThe longer of the 12-month period from the date of service or the 6-month period after notice of Medicare disposition applies.

Exceptions include certain IDEA, Indian Health Services, and state- or county-funded programs.

Denial Risk

Do Not Refuse Covered Services Because of Other Insurance

Do not refuse to furnish a covered Florida Medicaid service solely because the recipient has other insurance, including Medicare.

This prohibition applies in accordance with 42 CFR 447.20(b).

Unsupported block type: prior_auth

Documentation Required

Verify Applicable Third-Party Coverage

Inquire whether the recipient has third-party insurance and whether coverage has changed. Review the third-party liability information available through the Florida Medicaid fiscal agent and confirm that insurance on file applies to the services provided.

Fiscal agent portal: http://portal.flmmis.com/flpublic
Florida Medicaid AVRS: 1 (800) 239-7560

Billing Rule

Apply Contracted Rates for DRG and EAPG Claims

For claims reimbursed through Diagnostic Related Groups (DRG) or Enhanced Ambulatory Patient Grouping (EAPG), ensure Florida Medicaid reimbursement is equal to or less than the applicable contracted or negotiated third-party rate.

Apply the contracted or negotiated TPL rate when determining the Medicaid reimbursement amount.

Billing Rule

Coordinate Medicare and Medicaid for Dually Eligible Recipients

Coordinate Medicare and Medicaid billing for dually eligible recipients. Florida Medicaid’s payment is generally based on the lesser of the amount billed or the Medicaid rate, after subtracting Medicare and other third-party payments, and is limited by applicable coinsurance, copayment, deductible, and patient-responsibility rules.

Florida Medicaid pays eligible Medicare Part A and Part B premiums, but not Medicare Part C premiums.
Florida Medicaid does not pay Medicare Part D premiums or Part D copayments, coinsurance, or deductibles; drugs excluded from Part D may be reimbursable under the Florida Medicaid drug policy.
Do not bill QMB recipients with full Medicaid or SSI for nursing-facility patient responsibility during Medicare coinsurance days 21 through 100.
For certain Medicare Part B services not covered by Medicaid provided to QMB or SSI recipients, use 50% of the Medicare-allowed amount as the Medicaid rate.

Billing Rule

Bill Medicare Part B Inpatient Ancillary Services

Once a dually eligible recipient has exhausted all Medicare Part A benefits, or when the recipient has no Medicare Part A coverage, bill Medicare for allowable Part B inpatient ancillary services and report any Medicare Part B reimbursement as TPL on the Florida Medicaid inpatient claim.

Recipients age 21 and older with Medicare Part A or C simultaneously deplete Medicare and Florida Medicaid covered hospital days.
Medicare-approved Part B nursing-facility services not included in the facility’s cost report are reimbursed under the applicable dually eligible methodology.

Denial Risk

Submit Exceptional Fee-for-Service Claims

Submit a fee-for-service exceptional claim when the Florida Medicaid fiscal agent denied the claim and a third-party payer or Medicare also denied it, unless Medicare determined that the service was not medically necessary. Submit the claim to the appropriate address listed on the AHCA website.

Exceptional claims address: http://ahca.myflorida.com/Medicaid/Operations/assistance/providers.shtml
For claims secondary to Medicare, file within 12 months from the date of service or within 6 months after AHCA or the provider receives notice of the Medicare disposition, whichever is greater.

Third-Party Liability Vendor

Contracted roleAHCA contracts with the Third-Party Liability Vendor to identify, manage, and recover funds and overpayments paid on behalf of recipients when a third party is or was responsible.

Recovery programsThe vendor administers Florida Medicaid third-party liability recovery programs for casualty, estate, trust, and annuity matters on behalf of deceased Medicaid recipients.

Responsible entityThe Third-Party Liability Vendor is the contracted entity responsible for third-party liability identification, management, and recovery activities.