Updating TPL Information for Recipients Whose Primary Insurance Does Not Cover Nursing Care

If a recipient is in a Nursing Home, but the recipient's primary insurance on file does not cover skilled nursing facility care, the SNF claims may deny with EOB 00094. The description of EOB 00094 may be misleading. NCTracks does not recognize occurrence code 24 in this situation.

If it is a valid policy, but does not cover skilled nursing facility care, the provider may have the record updated by faxing the following information to DMA Third Party Recovery at (919) 831-1812:

NPI,
Recipient ID,
Recipient Name, and
Admission Date.

The fax should specify that the recipient has a valid third party insurance policy, but it does not cover skilled nursing facility care. DMA Third Party Recovery can update this information in NCTracks, and then the provider can resubmit the denied claim. This should only have to be done once for a given policy for the recipient.