§460.76.3. Claim information; third-party liability

            A. The department shall provide all known information about any health insurer or other third party that is legally liable for payment of all or part of a claim for healthcare services furnished under the Medicaid state plan to an enrollee on the Medicaid Eligibility Verification System.

            B.(1) A managed care organization shall provide notification to the department no later than two business days from the date the managed care organization verifies or has knowledge of the existence of any health insurer or other third party that is legally liable for payment of all or part of a claim for healthcare services furnished under the Medicaid state plan to an enrollee when the health insurer or other liable third party is not reflected on the Medicaid Eligibility Verification System. The notification shall include, at minimum, all of the following information about the health insurer or other liable third party:

            (a) The name, address, and phone number of the health insurer or other liable third party.

            (b) The policyholder information, including the policyholder name, policy number, and group number.

            (c) The scope of coverage, if the scope of coverage is limited.

            (d) The effective date of coverage.

            (e) Any other information required by the department.

            (2) The department may promulgate rules or may include requirements in the Medicaid managed care organization manual as necessary for the implementation of this Section.

            (3) The department shall cause the information contained in the notification to be reflected in the Medicaid Eligibility Verification System no later than three business days from receiving a notice pursuant to this Subsection.

            C. A managed care organization shall not deny, pend, reject, or recoup a claim solely on the basis of the existence of a liable third party or primary coverage that is through other health insurance unless all of the following information related to the other health insurance is available on the Medicaid Eligibility Verification system that is maintained by the department:

            (1) The name, address, and phone number of the liable third party or health insurance issuer.

            (2) The policyholder information, including the policyholder name, policy number, and group number.

            (3) The effective date of coverage by the liable third party or health insurance issuer and the scope of coverage of the liable third party or health insurance issuer, if the scope of coverage is limited.

            D. A managed care organization shall provide written or electronic notification to a provider no later than five business days after the managed care organization receives payment from a liable third party for healthcare services rendered by the healthcare provider. Such notice shall include the following:

            (1) A copy of the explanation of benefits provided to the managed care organization as a result of payment being made to the managed care organization for the healthcare services rendered by the healthcare provider.

            (2) The name, address, and phone number of the health insurer or other liable third party.

            (3) The policyholder information, including the policyholder name, policy number, and group number.

            (4) The effective date of coverage.

            (5) The scope of coverage, if the scope of coverage is limited.

            E. The department shall withhold payment to the managed care organization in an amount to be determined by the department not less than twenty-five thousand dollars or greater for each violation of the provisions of this Section by a managed care organization. However, upon a finding by the department that the managed care organization has committed multiple violations of this Section or has engaged in a pattern of violations, the minimum amount shall be at least one hundred thousand dollars.

            Acts 2025, No. 293, §1, eff. June 11, 2025.