This measure is important because maintaining accurate commercial insurance information ensures that Medicaid is the payer of last resort by requiring that other insurance companies be billed as the primary insurance for the services received by the member. The Deficit Reduction Act of 2005 requires insurers to provide State Medicaid Agencies with data files of eligibles and State of Vermont Statute 33 V.S.A. § 1908 supports the requirement that insurers provide data files of their eligibles to the State of Vermont Medicaid Program.
The Member and Provider Services (MPS) Unit’s Third-Party Liability (TPL) Team completes data matching, which is comparing the data files of insurer eligibles to Medicaid eligibles. When a member on the insurer file is also a Medicaid eligible; insurance information is added or updated in the Medicaid systems. This ensures that providers bill claims to the insurer before they are billed to Medicaid. When claims are received for a Medicaid eligible with other insurance, providers are directed to bill other insurance for the services before billing Medicaid. The TPL Team currently receives monthly insurer files from United Health Care (UHC) and BCBS of Vermont. Insurer files are reviewed, and insurance data is manually entered or updated in the Medicaid Systems.
In early January of 2023 the first PIE automation file went live using Blue Cross Blue Shield of Vermont’s December 2022 data match. As of right now Blue Cross Blue Shield of Vermont is the only insurer that is being automated by this new process. Our United Health Care data match file was not manually processed in December of 2022, due to system limitations and hope to have that information processed for the next reporting month.
Last updated: 01/12/23
It is important to being all insurance companies to the table to identify and cost avoid medicaid payments. In 2022, The TPL Team will be working with CIgna to receive a monthly file so that monthly reporting and trendlines can be captured and reported. In addition, begin outreaching and explore onboarding with MVP and Express Script carriers.