A long-standing federal rule allows states to retrospectively identify claims or services they paid for during a period when a member also had other coverage that they did not report at the time of the service. This federal provision allows states to go back up to three years to review and identify such claims or services.
The North Dakota Department of Health and Human Services (DHHS) is in the process of submitting claims with dates of service back to Jan. 1, 2021, to health insurance carriers for members with coverage outside of Medicaid during the time of service. Medicaid, as a crucial program providing health care coverage for low-income individuals and families, operates on the principle of being the payer of last resort when other sources of coverage are available. This means that Medicaid steps in to cover health care costs only after all other potential sources of coverage, such as private insurance or Medicare, are exhausted.
Health insurance carriers, including Blue Cross Blue Shield of North Dakota (BCBSND), are working with DHHS to process these claims and communicate with their members and clients they impact. BCBSND is committed to ensuring compliance with federal regulation and will work diligently with any impacted parties.
For Fully Insured Employer Groups
There is no action required for fully insured employer groups. As the insurance carrier, BCBSND is responsible for the funding of these claims.
For Self-Funded Employer Groups
Self-Funded employer groups are financially responsible for these claims under their stop-loss contract. According to the contract language, BCBSND can enforce and recover claims that other parties are responsible for, such as when a member has coverage in addition to their employer-sponsored coverage.
Self-Funded employer groups can expect their account manager to notify them.
