Commercial Insurance Disallowance Audits

Health Management Systems (HMS) is the Third Party Liability (TPL) contractor for MO HealthNet Division (MHD) and works closely with the Missouri Medicaid Audit and Compliance (MMAC) Unit to provide federally required third party liability services. HMS matches MHD participants to carrier eligibility rolls across the country. When a match is found, the claim and carrier information will be sent to providers to directly bill the carriers themselves. The Commercial Insurance Disallowance (CID) project allows providers the opportunity to bill and be paid by the carriers and, in many instances, be paid more money than the Medicaid rate.

A new cycle is released every 90 days allowing providers adequate time to bill the carriers. HMS includes claims with verified coverage and only those that meet the business rules of MHD and MMAC. This reduces the burden on providers.

HMS has a Provider Portal for providers to send documentation or communicate with HMS during each cycle. Instructions on the process are included in the letter and listing. If there are any issues, HMS Provider Representatives are there to help. A toll-free number and email address are included in the initial cycle letters.

The HMS Provider Operations team contacts each provider after the CID cycle is released. The HMS Provider Representatives ensure the letters and listings were received, the documentation was understandable, and answer any questions. The representatives contact providers during the cycle to ensure they understand the timeframe of the cycle and to answer any questions. Before the cycle closes, providers are contacted again to advise them of the closing of the cycle.

After a cycle closes, claims that remain open for recovery are turned over to MMAC, who sends the provider an overpayment letter advising the claim(s) will be recouped in forty-five (45) days. Providers can appeal a recoupment to the Missouri Administrative Hearing Commission (AHC) by following instructions contained in MMAC’s letter.

For more information, please contact Dawn Pehle in MMAC’s Financial Unit, at 573-522-5633.