Responsibilities of Enrolling MCO. When the enrolling MCO learns through the disenrolling MCO, through ODM, or other means that a new member previously enrolled with another MCO was admitted prior to the effective date of enrollment and remains an inpatient on the effective date of enrollment, the enrolling MCO must contact the hospital/inpatient facility. The enrolling MCO must verify that it is responsible for all medically necessary covered services from the effective date of MCO membership, including professional charges related to the inpatient stay. The enrolling MCO must inform the hospital/inpatient facility that the admitting/disenrolling MCO remains responsible for the hospital/inpatient facility charges through the date of discharge. The enrolling MCO must work with the hospital/inpatient facility to facilitate discharge planning and authorize services as needed. When the MCO learns that a new member who was previously on Medicaid fee-for-service was admitted prior to the effective date of enrollment and remains an inpatient on the effective date of enrollment, the MCO must notify the hospital/inpatient facility and treating providers that the MCO is responsible for the professional charges effective on the date of enrollment, and must work to ensure discharge planning provides continuity using MCO-contracted or authorized providers. Except as provided below regarding members under the age of 21 admitted for an inpatient behavioral health stay, if a member is admitted to a hospital prior to the first day of Medicaid eligibility and retroactive eligibility does not apply, the MCO is responsible for reimbursement of the inpatient hospital claim for the days the member is enrolled in the MCO. The days prior to Medicaid eligibility would be considered non-covered days, and the claim should be processed for payment based upon partial eligibility.
