Primary Carrier Disallowance

Beginning on September 18, 2020, Optima Health will implement a disallowance process through a partnership with Health Management Systems (HMS).

HMS will identify Medicare claims paid by Optima Health for which a Medicare program is liable. This process allows Optima Health to recoup the payments where we paid as the primary carrier, but should have paid as the secondary.

What to Expect:

  • Starting on September 21, HMS will send notification letters to an Optima Health approved list of providers advising that Optima Health was billed incorrectly and recoupment will be initiated in a future payment.
  • The first batch of notifications will be for claims processed September 15, 2019 - July 31, 2020. Thereafter, notifications will occur on a quarterly basis and will include claims from the previous quarter.
  • HMS will not request a refund payment from you.
  • HMS will advise which MCO should be billed as primary so you may update your records.
  • You will be able to view the status of any impacted claims via the HMS Portal.
  • HMS will send you a schedule of pre-recorded training sessions for their portal.

After recoupment, should you disagree with a determination made by Optima Health, you may be eligible to appeal the determination depending on the terms of your provider agreement. Please contact your Optima Health network educator if you have questions related to this process.