| SUBJECT: |
| spend down BILLING REVIEW PROCESS
MANUAL REVISION #38: SECTION 0810.010.15.15 |
| DISCUSSION: |
| Division of Medical Services (DMS) has
a process to research denied spend down claims that come to their attention
from the claimant, the provider or the worker. These are claims submitted
for the day spend down was met that were not paid through the normal automated
billing procedure as they were less than the client liability. DMS
can authorize payment if verification is received that the bill was not
used to meet spend down.
In order to facilitate the research, DMS
Recipient Services Unit may from time to time be requesting information
directly from the FSD county office. Information requested would
be limited to a copy of what expenses were submitted to meet the spend down
and a phone number for the client, if one is available. The county
office is to provide the requested information within a reasonable time.
This could include the notes made on the
Example: Claimant had a $50.00 spend down and saw the doctor on October 2,2003. This service was charged. He then went to the pharmacy and paid for a $40.00 prescription the same day. The pharmacy does not submit the bill to be paid by Medicaid because the client paid the $40.00 out of pocket to meet his spend down. Division of Medical Services will be withholding the spend down out of the doctor bill. The doctor then will bill the client the $50.00 after finding out the spend down was withheld. At this point, the provider, client or the caseworker (if made aware of the billing problem) can request DMS Recipient Services Unit to do a review for that month.The contact from DMS will be made initially by email or by mail. The request will include where to fax or mail the information. When the county is initiating the request, send the spend down documentation with the cover sheet (attachment  ). |
| NECESSARY ACTION: |
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