ProviderOne

Spenddown

Frequently Asked Questions (FAQs)

Last Updated 10/15/09

What will we do if we have billed Early Intervention Program (EIP) for services and find out late that the client met their spenddown and now have a medical coupon?

How will patients know to tell their providers that they have coverage changes or updates?

If a client has incurred medical bills in November and comes in for service in December and shows bills that meet spenddown, will it be retroactive to the date those expenses were incurred?

How do we bill retroactively?

What if prior authorization is needed for a service that was performed after a spenddown was net but before the patient knew? So, the PA process was not followed?

Do providers need to check every patient to see if they are on a spenddown or have coverage prior to rendering services even if the patient does not provide the information or have a history of coverage?

Q: What will we do if we have billed Early Intervention Program (EIP) for services and find out late that the client met their spenddown and now have a medical coupon?

A: The process will remain as it is today for billing. With ProviderOne, more spenddown information will be provided. The provider can look up eligibility in the Web portal and see the client’s eligibility status and determine if it’s appropriate to bill DSHS. If a client is pending spenddown, balance details will be returned.

Q: How will patients know to tell their providers that they have coverage changes or updates?

A: The process will remain as it is today, except the monthly MAID will not be sent. Coverage changes and updates will come in letter form to clients in the same way their receive eligibility change information today.

Q: If a client has incurred medical bills in November and comes in for service in December and shows bills that meet spenddown, will it be retroactive to the date those expenses were incurred?

A: In ProviderOne, spenddown will become active on the day spenddown is met. If the bills incurred in November meet the spenddown liability, eligibility will be retroactive to the date of the last expense that met the spenddown liability amount. There is no coverage for any expense that was used to satisfy the spenddown amount.

Q: How do we bill retroactively?

A: This will not change in ProviderOne. You will need to use the new ProviderOne Client ID, taxonomy, and NPI in your claims.

Q: What if prior authorization is needed for a service that was performed after a spenddown was net but before the patient knew? So, the PA process was not followed?

A: It will be the same in ProviderOne as it is today. At the time the PA is requested, the client must be Medicaid eligible.

Q: Do providers need to check every patient to see if they are on a spenddown or have coverage prior to rendering services even if the patient does not provide the information or have a history of coverage?

A: The Services Card doesn’t guarantee eligibility; providers will still need to verify client identification and complete an eligibility inquiry. Providers should check eligibility each time they deliver a service. If you do not verify eligibility at the time of service and the client is no longer eligible, you are assuming a risk that the claim could be denied. Eligibility information will include up-to-date pending spenddown information. ProviderOne will allow providers to check the client’s history of eligibility, going back as far as two years at a time, up to four years.

Providers have several free and low-cost options for checking client eligibility with ProviderOne. No matter which option providers choose, the eligibility information provided will be the same. Read the Options for Verifying Client Eligibility Fact Sheet to learn more about checking eligibility at: http://hrsa.dshs.wa.gov/providerone/Providers/Fact%Sheets/FactSheets.htm.