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IMPORTANT NOTICE REGARDING HB1234

What is HB1234?

HB1234, also known as the Medicaid Managed Care Bill was sponsored in the Georgia Legislature by Senator Greg Goggans and signed into law on May 12, 2008 by Governor Sonny Perdue. It affects all CMOs and Medicaid Fee for Service Plan and all three Plans and DCH are collaborating on its implementation. Rules for HB1234 will be applied retroactively to allow for implementation and system configuration and testing. The bill provides guidance on standardizing the administration of Georgia Medicaid benefits administered by Care Management Organizations. This bill is to be enacted on July 1, 2008.

How will it affect providers?

Since HB1234 offers guidance on the administration of Georgia Medicaid benefits administered by Care Management Organizations, providers will also be affected. The bill incorporates the following elements:

Appeals Processes and Procedures

• Specifically mandates that providers be allowed to batch like/similar issues into one appeal request (no change for Avesis)
• Gives providers options for Administrative review or Binding Arbitration
• Higher interest (20%) paid for claims overturned on appeal
• Interest must appear on remit (no change for Avesis)
• Changes appeals time frame

Provider directories

• The bill defines web search requirements for plans to publish provider directories

Web Portals

• The bill mandates that providers be able to submit, process, edit, adjudicate and resubmit claims via the web
• The bill also mandates that remittance advices must be provided electronically within 24 hours of payment

Time Frames

All plans and vendors must comply with DCH time frames listed below. These time frames cover claims with dates of service beginning July 1, 2008.

• Timely Filing – 180 days from DOS (no change for Avesis)
• Timely Resubmission – 90 days from date submitted (no change for Avesis)
• Clean Claim Payment – 15 business day of receipt (no change for Avesis)
• Appealed Claims – 30 days from date of denial
• COB – 90 days from the date of the primary carrier EOB (no change for Avesis)

Contracting

• Prohibits exclusivity in contracting (no change for Avesis)
• Applies to both plans and providers
• Outlines rules related to when dental providers may or may not be excluded from participation

Eligibility and Claims Payment

• Plans must accept GHP web portal eligibility screen shots as source for verification (no change for Avesis)
• Claims filed within 72 hours of verification must be paid even if member later determined ineligible
• Rates paid must be equal to the amount provider would have been paid had member been eligible with the plan
• Plans can not recoup from providers as a result of eligibility issues
• Providers will not be penalized for failure to file timely, obtain authorization, or for being non-participating with the plan as a result of verification of inaccurate member eligibility

Who do I call if I have questions or need additional information regarding these changes?

For further information regarding HB1234 and how it will affect your relationship with or your administration of any plans administered by Avesis, please contact our Provider Service department at (800) 522-0258.