Who is responsible for payment of professional services when a medical assistance client is treated in the hospital and the provider does not have a Core Provider Agreement?
We expect that hospitals have provisions in their provider contracts to address the treatment needs of the Medical Assistance population and payment mechanisms for any provider that does not have a Core Provider Agreement or contract with a Healthy Options plan (non-participating provider). Each hospitals approach may be different, but in general the following policies are applicable.In the case of emergency treatment, the client cannot be told to wait until a Medical Assistance provider is available to treat him/her. The client must be treated timely. The hospital may bill MAA for the facility costs, but not for the professional fee. The non-participating provider cannot bill MAA either, and the client cannot be billed for the professional fee. The hospital may choose to pay the non-participating provider.In the case of non-emergent services, the client can only be billed for professional services if the client understands that the provider does not accept Medical Assistance and he/sh
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