| (a) To the extent allowed by federal law, a health
care service provider must seek reimbursement from any third party
resource that the provider knows about or should know about before
billing Medicaid, except for Medicaid programs and services that are
required to be paid first prior to billing the third party resource.
(b) Providers cannot bill Medicaid recipients for copayments,
deductibles, or coinsurance for Medicaid-covered services. If a recipient's
third party resource does not cover a copayment, deductible, or coinsurance,
the provider must bill Medicaid for reimbursement of the copayment,
deductible, or coinsurance, as follows.
(1) Deductible or coinsurance: Include the explanation
of benefits from the third party resource with the claim showing the
payment amount was applied directly to the recipient's deductible
or coinsurance.
(2) Copayment: Include the copayment code on the claim
form in order to be eligible for reimbursement.
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