MO HealthNet Division (MHD) will process claims in accordance with the established MHD coordination of benefits policy for Non-Qualified Medicare Beneficiary (Non-QMB) participants enrolled in a Medicare Advantage/Part C plan. Please refer to the policy in the MHD provider manuals, General Section 5 - Third Party Liability.
In accordance with this policy, the amount paid by MHD is the difference between the MHD allowable amount and the amount paid by the third party resource. The provider may not bill the participant for any unpaid balance of the total MHD covered charge, when the other resource represents all or a portion of the MHD maximum allowable amount. The provider is not entitled to any recovery from the participant except for services or items which are not covered by the MHD program, or services/items established by a written agreement between the participant and provider indicating that MHD is not the intended payer for the specific service/item. In this case, the participant accepts the status and liability of a private pay patient.
Missouri regulation 13 CSR 70-4.030 allows the provider to bill participants for MO HealthNet covered services if, due to the participant's action or inaction, the provider is not reimbursed by the MHD Program.