Sec. 10.14.02.17. Reimbursement

A. The Department shall reimburse a participating health care provider only for a medical service or procedure related to the diagnosis and treatment of breast cancer, cervical cancer, or a precancerous cervical lesion for an eligible patient.

B. The Department shall reimburse a participating health care provider a medical management fee pursuant to Regulation .15 of this chapter.

C. The participating health care provider shall reimburse the Department for an overpayment.

D. Insurance or Other Coverage.

(1) If the patient has insurance or other coverage, the participating health care provider shall first seek payment from that source.

(2) The provider shall submit a copy of the insurance carrier’s notice or remittance advice with the invoice.

(3) If the insurance carrier provides coverage for a reimbursable procedure or service, the Department shall pay the deductible and patient contribution amount.

(4) If an insurance carrier rejects the claim or pays less than the amount of the allowed Medical Assistance Program rate, the provider may submit a claim to the Department.

(5) The Department shall pay the difference between what was paid by the insurance carrier and the maximum allowable Medical Assistance Program rate.

(6) If payment is made by both the Department and the insurance carrier or other source for the same service, the provider shall refund to the Department within 60 days of receipt the amount paid by the Department, or the Department may recoup those funds.

E. The Department may not make a direct payment to the eligible patient.