When you verify eligibility for a MO HealthNet participant, you may be surprised to learn the participant has commercial insurance, which includes Medicare Part C plans, in addition to MO HealthNet benefits. Individuals who have commercial health insurance may still be eligible for MO HealthNet benefits. Commercial insurance will always be the first source of payment as MO HealthNet is the payor of last resort.
The participant’s commercial health insurance carrier is billed first for consideration of coverage and payment. If services are not covered by the commercial insurance policy, MO HealthNet pays for the covered services with proof of a valid denial from the commercial insurance carrier.
There is no duplication of payment and if the other insurance pays as much as or more than MO HealthNet’s maximum allowed amount, the claim is considered paid in full. No additional payment will be made by MO HealthNet and the participant can't be billed for the balance.
Private insurance information is initially obtained by eligibility specialists at the Family Support Division when an individual makes application for public assistance. Once eligible, the participant is responsible for reporting to their eligibility specialist any changes to coverage by their commercial insurance carrier.
When checking the participant’s eligibility, you are given information about known possible insurance coverage. The insurance information on file at the MO HealthNet Division (MHD) does not guarantee the insurance(s) listed is (are) the only resource(s) available nor does it guarantee the coverage is currently in effect. If the participant has not informed the eligibility specialist of changes, the information on file may need to be updated.
As a provider, you have the ability to inform MHD of changes to a participant’s commercial insurance information by completing and submitting the MO HealthNet Insurance Resource Report form, commonly known as the TPL-4 form. This form should be mailed to: MO HealthNet Division, ATTN: TPL Unit, PO Box 6500, Jefferson City, MO, 65102-6500. Third Party Liability staff will verify the information before updating the TPL data on the participant’s eligibility file.
For detailed information on third party resources, refer to Section 5 of the MO HealthNet Provider Manual.