Cost Effective Health Insurance Billing

10-19-18

Cost Effective Health Insurance (CEHI) Billing-

Our CEHI workers are determining eligibility, the fiscal team approves payment, and we have someone
that bills.  With the new CEHI policies we are running into a problems when we are billing.

Every time there is a circumstance change in the case (some examples include: MA ended/started, new
baby, premium change, number of people covered by insurance changes). Per the instructions, we
need
to make re-determinations of the CEHI eligibility. Typically this change will change the amount approved
for reimbursement and date range in the TPCO screen in MMIS (this is where we get the obligation
number for billing). Our CEHI workers are updating the TPCO screen every time they re-determine
eligibility or end eligibility.  Our clients, once approved for the program, will need to send in paystubs
along with a claim form. The TPCO is ready for billing once the payment is processed. We also make a
detailed case note when the eligibility is determined in MAXIS/METS on approved amount, OB number,
who is covered, insurance amount deducted per check.

Our clients are not very timely about turning in claims forms and paystubs. This is where the issue
comes in. 

1. The claim comes directly to the Fiscal team to issue payments.  In the meantime the case had to
   be re-determined 1,2 or even 3 times. Per the instructions for the CEHI eligibility worker they
   are to update the TPCO screen payment amount and date but the OB number is staying the
   same.  We are running into problems when billing because the worker is making changes on the
   obligation number before we bill the state for the payments we made. Right now we bill
   monthly but are looking at possibly billing weekly after each payment.  
2.  In the example below we were unable to bill 2017 because in March 2018 it was determined
   they
   were eligible back to July 2017- 2 different amounts approved. We approved one payment to
   the client from July 2017-Feb 2018 but because we never billed the for 2017. The Obligation ID
   was reused.

MMIS-TPCO will not give you a new obligation number unless a payment has been billed.

This is the last correspondence with the state:

The system isn’t capable of having more than one obligation open on a policy at a time so that is not an
option.  I think your temporary solution of making
the dollar amount high enough works except that it goes against our updated policies and procedures in
regards to tracking purposes.  In other words,  if we were to audit you, what you have listed on the
TPCO screen would possibly not match the dollar amount from the 3767D.  The correct way to proceed
would be to bill the state before you update the obligation #, which requires you to be diligent in your
tracking and record keeping.  And I realize this is why it has been brought to my attention.  I will discuss
this internally next week and let you know what, if anything, we can figure out.  Thank you!

Health Insurance Recovery Unit

Is anyone else running into this problem? Or have any ideas?

Thank you for your help!

Kate Dahl • Fiscal Supervisor WRIGHT COUNTY, MINNESOTA: Health & Human Services direct: (763) 684-8457   •   fax: (763) 682-7701 Human Services Center, 1004 Commercial Drive, Buffalo, MN 55313 www.co.wright.mn.us