Commercial Insurance Disallowance

Tuesday, December 17, 2019

North Carolina Medicaid’s third-party liability (TPL) contractor, Health Management System, Inc. (HMS), will implement the Commercial Insurance (CI) disallowance project to streamline North Carolina’s coordination of benefits direct billing processes. The expected implementation date is Jan. 1, 2020. This will result in higher recoveries for the state and higher pay rates for providers. HMS will assist Medicaid providers by identifying and validating other (non-Medicaid) health coverage so that providers can maximize payment rates by billing commercial rates rather than Medicaid rates.

The CI disallowance process will be like the Medicare Disallowance projects that have been operational in North Carolina for more than 10 years. HMS will validate policy coverage for all claims selected for CI disallowance to mitigate unnecessary work on the part of providers, load the data into HMS’ provider portal and then initiate the CI disallowance billing cycle.

Providers should register for access to the HMS provider portal. The provider portal is a secure web-based application that allows 24-hour access to your claims’ listings. You can access the complete list of patients, claims and primary insurance information necessary to file claims to other carriers when a patient has health insurance that is primary to Medicaid.

To set up your account please choose one of the following options:

HMS, (877) 260-0270