Kansas Family Medical Assistance
Manual (KFMAM)
Eligibility Policy - 11/21/2024
08000 >>> 08340
08330
08340 Computing the Claim - In calculating the amount of the claim, the agency shall determine the point at which the correct information should have been reported and acted upon timely allowing for timely notice as appropriate. From that point, the correct coverage shall then be compared against the actual coverage received to determine the difference. The difference in the coverage received versus the coverage entitled to receive is the amount of the claim. The actual amount of the claim shall be:
8341 No Eligibility - For instances where there was no eligibility, the claim is calculated based on whether or not the coverage was provided as managed care or fee for service.
a. Managed Care – The amount of the capitated payment made each month,
b. Fee for Service – The amount of the paid claims.
8342 CHIP Premiums - For instances related to CHIP premiums, the claim is the amount of the understated premium.
8343 Spenddowns - For Spenddown, the claim is the difference between the capitated payment for an unmet spenddown versus a met spenddown.