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Providers say MCOs are asking for Medicare denials for MAP‑34 claims; DMS to follow up
Summary
Home‑health providers said two MCOs have been requiring Medicare denials before processing MAP‑34 claims, creating billing delays. Providers asked DMS to clarify whether internal home‑health rejections may be used instead and requested a state representative at the next MAP meeting.
At the meeting Annalyn Purdon of Hayswood Home Health described two patients whose MAP‑34 submissions were being rejected because MCOs were requiring a Medicare denial before processing the Medicaid pathway.
"They’re still telling us that we have to have a Medicare denial," Purdon said, describing a longstanding provider practice of marking claims as rejected by internal home‑health review. Providers said Medicare fee‑for‑service bypass logic and Medicare Advantage (Part C) plan differences can create inconsistent handling by MCO systems. Blair Hanchu (clinical program manager, Division for Long Term Services and Support) said she would take the issue back to staff and that DMS would review the MAP‑34 instructions and advise providers.
Providers asked that the state prepare a presentation for the next MAP meeting explaining how MCOs should handle MAP‑34 claims, noting that in many cases MCO systems do not reliably distinguish Medicare fee‑for‑service from Medicaid when a claim is first received.
