Providers

Dual Eligible Claims

Billing Medical Recipients for Medicare/Medicaid Dual Eligible Members

Dual eligibles are recipients who have Medicare and Medicaid coverage. Medicaid will reimburse the provider an amount up to the full amount of Medicare’s statement of liability for co-insurance and deductible for the beneficiary.  For claims in which Medicare’s reimbursement exceeds the maximum allowable by Medicaid, Medicaid will “zero” pay the claim. This means that the claim Explanation of Payment will have a “$0” shown in the payment column. This claim is considered “paid in full” and the provider may not seek additional remuneration from the recipient.

This is Medicaid policy concerning the processing and payment of Medicare Crossover claims. Providers are responsible for establishing internal billing procedures to ensure that Medicaid recipients are not being inappropriately billed for Medicare/Medicaid services. Please note that Medicaid does not necessarily pay the full Medicare deductible and co-insurance on a claim. Providers may not balance-bill recipients in these instances.

Per Medicaid guidelines, Total Health Care will pay up to the Medicare deductible and coinsurance on Medicare approved claims for beneficiaries receiving both Medicare and Medicaid, provided the procedure is covered by Medicaid. Medicaid will reimburse the provider an amount up to the full amount of Medicare’s statement of liability for co-insurance and deductible as long as it does not exceed Medicaid’s allowable reimbursement for the service. Total Health Care will “zero’ pay the claim/claim line when Medicare’s reimbursement exceeds the maximum allowable by Medicaid.

For more information regarding the prohibition on “balance-billing” Qualified Medicare Beneficiaries (QMB) for Medicare cost-sharing, including deductible, coinsurance, and copayments please visit http://www.cms.gov/MLNMattersArticles/Downloads/SE1128.pdf