MMP Crossover

Nature of Issue: Inaccurate Denials against the Member's Aligned Benefits (Medicare/Medicaid)

Date Identified: 5/3/2024

Dates of Service Impacted: 1/1/2023 to Current

Product Line Impacted: MMP

Summary of Issue: If member is not active in CHAMPS for Medicaid at the time of claim processing, claim does not process across the Medicaid benefits as required (member not treated as aligned). Per State requirements, system must treat the member as aligned if enrolled in MMP regardless of the misalignment in CHAMPS.

New Claim Submission Issue Resolution Date: 10/1/2024

Prior Claim Correction Issue Resolution Date: Monthly identification beginning with April 2024 DOS to identify claims matching this scenario and adjust to finalize against the Medicaid benefits.

Any action required by the provider if applicable: Escalate any denials to your Provider Representative for overturn and review.