HealthChoices Coverage and Billing

Community Care requires that for members who have a diagnosis in the autism spectrum and who are also eligible for autism treatment benefits by commercial insurance, HealthChoices providers bill the primary insurance carrier and send an Explanation of Payment to get paid via Community Care.

As stated in the Claims Handbook, we expect to receive secondary claims within 30 days of receipt of the Explanation of Payment from the primary insurance carrier. This process is required to assure payment for all services.

When a primary insurance carrier does not cover a particular service, HealthChoices providers must submit one Explanation of Payment documenting that the service is not a covered benefit for each member. Community Care cannot accept blanket letters stating that a primary insurance carrier does not cover a specific service because we do not know the coverage for each individual child. When the provider cannot obtain a claims denial (Explanation of Payment or letter from the insurance company), Community Care will accept a letter, on original company letterhead, with an original signature, attesting that for the specific member in question, the insurance company informed the provider that the service in question is not covered.

Community Care will keep this Explanation of Payment on file for the duration of that member's benefit year and pay claims as primary. When a member's new benefit year begins, if the service continues to be a non-covered benefit, and the commercial coverage is still in force, providers must submit a new Explanation of Payment documenting this.

Please make sure to collect the benefit year begin date for all of your members who are covered under Act 62. Community Care care management staff will need this information.