Common use of Dual Insurance Clause in Contracts

Dual Insurance. PROVIDER is required to determine if the CONSUMER is dually insured, prior to submitting claims to PAYOR and at a minimum of monthly. In instances when the CONSUMER has dual insurance (i.e., Blue Cross and Medicaid), the PROVIDER must bill the commercial insurance first. Medicaid is always the PAYOR of last resort. It is the PROVIDER’s responsibility to follow all insurance rules and collect directly from the primary insurance. In order to qualify for any Medicaid benefit, CONSUMER must be receiving services through the CMH where services are being authorized and the PROVIDER must first obtain the Authorization Form from the PAYOR. The PROVIDER must notify the PAYORS in writing that the CONSUMER is dually insured. This should occur prior to ABA treatment beginning under the BHT benefit. If requirements are met as described, the PROVIDER must submit the actual EOBs from the primary insurance to the PAYOR in order to receive consideration of payment through Medicaid. The Medicaid benefit will only reimburse the PROVIDER for the difference between any primary insurance payment and the PROVIDER’s contracted rate with PAYOR. The PROVIDER may not seek nor accept additional or supplemental payment from the CONSUMER, their family, or other representative when the CONSUMER is enrolled in the BHT benefit. The PROVIDER must notify the PAYOR of any changes to the CONSUMER’s primary insurance at any time during treatment.