Payment and Coverage
The Centene Corporation Payment Integrity unit established a Payment & Coverage Policy Initiative in an effort to incentivize improved quality of care and enhance provider communication related to plan payment policies. The initiative was designed to Increase claims processing efficiently and effectiveness to better ensure payment of only correctly coded and medically necessary claims.
Visit the Provider Manuals page to read Bridgeway payment policies.
The Centene (Bridgeway) Payment & Coverage policies address coding inaccuracies such as unbundling, fragmentation, up coding, duplication, invalid codes and mutually exclusive procedures as well as statements of plan coverage of items and services. Coding and billing rules applied are based on industry standards and guidelines as published and defined In the Current Procedure Terminology (CPT), Centers for Medicare and Medicaid Services (CMS), and public domain specialty society edits. State contract and/or State specific regulations will be accounted for in the policies.
As a Centene Corporation health plan, Bridgeway will post a robust policy library on the website that will outline the payment and coverage rules related to different procedures. Please check the website often as policies will be reviewed and uploaded throughout the year.
If you require assistance in accessing policies, or require that polices be provided in a different format, please contact your Provider Relations Representative at 1-866-475-3129.
Thank you for your continued partnership and commitment to payment Integrity.
Third Party Liability
Third Party Liability (TPL) refers to any other health insurance plan or carrier (e.g., individual, group, employer-related, self-insured or self-funded, or commercial carrier, automobile insurance and worker’s compensation) or program, that is, or may be, liable to pay all or part of the health care expenses of the member.
Coordination of Benefits (COB) refers to members with two or more types of insurance coverage. The plan that is primary pays its full benefits first. The primary insurance carrier’s explanation of benefits (EOB) is then sent to the secondary carrier/Bridgeway, for coordination of benefits.
The primary EOB information will explain the primary’s payment or denial process. Medicaid is the payor of last resort, therefore Bridgeway makes every effort to cost avoid claims or services that are subject to payment from a third party health insurance carrier, and may deny a service if the third party health insurance carrier provides the service. Cost avoidance applies to all covered services except claims for EPSDT and non-institutional pregnancy related services.
Bridgeway complies with Arizona Medicaid COB policies and utilizes the "Pay and Chase" approach as required.
• Providers must make reasonable efforts to determine the legal liability of third parties to pay for services furnished Bridgeway members and must bill the primary payor prior to billing Bridgeway
• When a provider bills the claim to the primary carrier and files the claims with the EOP, Bridgeway coordinates with the primary payor to pay the claim up to the plan’s allowable amount, but we will not exceed the amount we would have paid had we paid as the primary coverage
• If a third party health insurance carrier requires the member to pay cost-sharing amounts (e.g. co-payments, coinsurance, and deductible), Bridgeway pays the cost sharing amount but we will not exceed the amount we would have paid had we paid as the primary coverage
• Providers will receive written notification along with primary payor information prior to Bridgeway initiating a recoupment.
• Information regarding the other liability coverage is available through our call center, and via the secure web portal.