Election of Third Party Billing Process. Contractor shall select an option for participating in serial billing of third- party payors for services provided through this Agreement through the completion of Attachment C – Election of Third Party Billing Process. The completed Attachment C shall be returned to the County with the signed Agreement. Based upon the option selected by the Contractor the appropriate following language shall be in effect for this Agreement.
Election of Third Party Billing Process. Effective July 1, 2005, the San Mateo County Health System will be required to xxxx all other insurance (including Medicare) before billing Medi-Cal for beneficiaries who have other coverage in addition to Medi-Cal. This is called “serial billing.” All claims sent to Medi-Cal without evidence of other insurance having been billed first will be denied. In order to comply with the serial billing requirement you must elect which of the two following options to use in our contract with you. In either case, you will need to establish the eligibility of your clients through the completion of the standard form (Payor Financial Form) used to collect this information. Please select and complete one of the two options below: Option One Our agency will xxxx other insurance, and provide San Mateo County Health System, Behavioral Health and Recovery Services Division (BHRS) with a copy of the Explanation of Benefits provided by that insurance plan before billing BHRS for the remainder. We Xxxx Xxxxx Youth Center elect option one. Signature of authorized agent Name of authorized agent Telephone number Option Two Our agency will provide information to San Mateo County Health System, Behavioral Health and Recovery Services Division (BHRS) so that BHRS may xxxx other insurance before billing Medi-Cal on our agency’s behalf. This will include completing the attached client Payor Financial Form and providing it to the BHRS Billing Office with the completed “assignment” that indicates the client’s permission for BHRS to xxxx their insurance. We Xxxx Xxxxx Youth Center elect option two. Signature of authorized agent Name of authorized agent Telephone number Please note if your agency already bills private insurance including Medicare for services you provide, then you must elect Option One. This is to prevent double billing. Please return this completed form to: Xxxxxx Xxxxx, Business Systems Manager Behavioral Health and Recovery Services Division 000 00xx Xxxxxx Xxx Xxxxx, XX 00000 (650) 573-2284 Attachment D - Payor Financial Form AGENCY NAME: Client’s Last Name/MH ID # (if known) First Name M.I. Alias or other names Used Client Date of Birth Undocumented? □ Yes □ No If no, Social Security Number (Required) 26.5 (AB3632) □ Yes □ No IEP (SELPA) start date Does Client have Medi-Cal? □ Yes □ No Share of Cost? □ Yes □ No Client’s Medi-Cal Number (BIC Number)? Please attach copy of MEDS Screen If client is Full scope Mcal, skip the remaining sections of this form and fax to MIS/...
