Wednesday, May 25, 2016

Can we QMB Medicaid patient for coins and deductible ?

Prohibition on Balance Billing Dually Eligible Individuals Enrolled in the Qualified Medicare Beneficiary (QMB) Program 

 Centers for Medicare & Medicaid Services (CMS) reminds all Medicare providers that they may not bill beneficiaries enrolled in the QMB program for Medicare cost-sharing (such charges are known as “balance billing”). QMB is a Medicare Savings Program that exempts Medicare beneficiaries from Medicare cost-sharing liability

The QMB program is a State Medicaid benefit that covers Medicare deductibles, coinsurance, and copayments, subject to State payment limits. (States may limit their liability to providers for Medicare deductibles, coinsurance and copayments under certain circumstances.) Medicare providers may not balance bill QMB individuals for Medicare cost-sharing, regardless of whether the State reimburses providers for the full Medicare cost-sharing amounts. Further, all original Medicare and MA providers --not only those that accept Medicaid--must refrain from charging QMB individuals for Medicare cost-sharing. Providers who inappropriately balance bill QMB individuals are subject to sanctions

Please ensure that you and your staffs are aware of the federal balance billing law and policies regarding QMB individuals. Contact the Medicaid Agency in the States in which you practice to learn about ways to identify QMB patients in your State and procedures applicable to Medicaid reimbursement for their Medicare cost-sharing. If you are a Medicare Advantage provider, you may also contact the MA plan for more information. Finally, all Medicare providers should ensure that their billing software and administrative staff exempt QMB individuals from Medicare costsharing billing and related collection efforts.

Sunday, May 22, 2016


If you have been paid, but paid incorrectly for a claim or received payment from a third party after Medical Assistance has made payment, you must complete and submit an Adjustment Request Form (DHMH 4518A) to correct the payment. See page 21 for a reproduction of DHMH 4518A.

If an incorrect payment was due to a keying error made by Medical Assistance, or you billed the incorrect number of units, you must complete an Adjustment Request Form following the directions on the back of the form. When completing the Adjustment Form, do not bill only for remaining unpaid amounts or units, bill for entire amount(s).

Example: You submitted and received payment for three units, but you should have billed for five units. Do not bill for the remaining two units; bill for the full five units.

Total Refunds – If you receive an incorrect payment, return the check issued by the Medical Assistance Program only when every claim payment listed on the remittance advice is incorrect, i.e., none of the recipients listed are your patients. When this occurs,
return with a copy of the remittance advice and the check with a complete Adjustment Request Form to the address on the bottom of the form.

Partial Refunds – If you receive a remittance advice, which lists some correct payments and some incorrect payments do not return the Medical Assistance Program check. Deposit the check and file an Adjustment Request Form for each individual claim paid

NOTE: For overpayments or refunds, the provider may issue and submit one check to cover more than one Adjustment Request Form.

Before mailing Adjustment Request Forms, be sure to attach any supporting documentation such as remittance advices and CMS-1500 claim forms. Adjustment Request Forms should be mailed to:
                                                           Medical Assistance Adjustment Unit
                                                                    P.O. Box 13045
                                                               Baltimore, MD 21203

If you have any questions or concerns, please contact the Adjustment Unit at 410-767-5346.

Friday, May 20, 2016

UB 04 - Fields used for cross over - primary to secondary

Medicare Crossover for Other Blue Plan Members (UB-04)

Completing a claim correctly when a member from another Blue Cross and/or Blue Shield Plan has primary coverage with Medicare will decrease your chance of receiving claim denials. The following instructions apply to items on the UB-04 form or its electronic counterpart that require specific Medicare Supplement information:

Form Locator 50 – Payer

• Enter “Medicare” as the primary payer on line A.

• Enter the appropriate Blue Plan name as the secondary payer on line B.

o Not entering the member’s actual Blue Plan as the correct secondary payer will result in claim issues. A claim crossed over in error to BCBSF cannot be processed and you may not receive a remittance notice. Therefore, be sure to enter the correct Blue Plan when you submit the claim to Medicare. If your system is set-up to automatically populate BCBSF, please change it to the correct Blue Plan.

o If you do not know the member’s Blue Plan, call BlueCard Eligibility at (800) 676-BLUE (2583), speak the alpha prefix and you will be routed to the member’s Blue Plan.

Form Locator 53 – ASG BEN

• A “Y “indicating benefits were assigned must be entered in order for you to receive payment from the Blue Plan.

• This indicator authorizes payment of mandated Medigap benefits to you if required Medicare Supplement information is included on the claim.

• The member or representative’s signature must be on file as a separate Medigap authorization.

• The Medigap assignment on file must specify the insurer. It may state that the authorization applies to all occasions of service until it is revoked.

Form Locator 54 – Prior Payments

• Enter the amount you have received toward payment of this bill from Medicare on line A.

Form Locator 58 – Insured’s Name

• Enter the last name, first name and middle initial of the insured. The name must be entered exactly as it is on the ID card.

Form Locator 59 – P. Rel

• Enter the appropriate code indicating the relationship of the patient to the insured (e.g., code 18 = self).

Form Locator 60 – Insured’s Unique ID

• Enter the patient’s Medicare HIC number as shown on the ID card on line A.

• Enter the patient’s complete Blue Plan ID number, including three-digit alpha prefix on line B. Member IDs for other Blue plans include the alpha prefix in the first three positions and can contain any combination of numbers and letters up to 17 characters.
Form Locator 61 – Group Name

• Enter the name of the group or plan through which the insurance is provided to the member.

Form Locator 62 – Insurance Group No.

• Enter the group number as identified on the ID card.

Monday, May 16, 2016

Not authorized, and should be paid by another party

3. The medical services are not covered or authorized for the provider and/or recipient.

?? There are limits to the number of units that can be billed for certain services. Verify that you entered the correct number of units on the claim form.

?? A valid 2-digit place of service code is required. Please refer to the Place of Service List on page 9 in this manual.

?? Some tests are frequently performed as groups or combinations and must be billed as such. Verify the procedure codes and modifiers that were entered on the claim form and determine if they should have been billed as a group.

?? Claims will be denied if the procedure cannot be performed on the recipient indicated because of gender, age, prior procedure or other medical criteria conflicts. Verify that you entered the correct 11-digit recipient identification number, procedure code and modifier on the claim form.

?? Verify that the billed services are covered for the recipient’s coverage type. Covered services vary by program type. For example, some recipients have coverage only for family planning services. If you bill the Program for procedures that are not for family planning, these are considered non-covered services and the Program will not pay you. Refer to regulations for each program type to determine the covered services for that program.

?? Some procedures cannot be billed with certain place of service codes. Verify that you entered the correct procedure and place of service codes in the appropriate block on the claim form.

4. The claim is a duplicate, has previously been paid or should be paid by another party.

?? MMIS-II edits all claims to search for duplications and overlaps by providers. Verify that you have not previously submitted the claim.

?? If the Program has determined that a recipient has third party coverage that will pay for medical services, the claim will be denied. Submit the claim to the thirdparty payer first.

?? If a recipient is enrolled in an MCO, you must bill that organization for services rendered. Verify that the recipient’s 11-digit MA number is entered correctly on the claim form.

Finally, some errors occur simply because the data entry operators have incorrectly keyed or were unable to read data on the claim. In order to avoid errors when a claim is scanned, please ensure that this information is either typed or printed clearly. When a
claim is denied, always compare data from the remittance advice with the file copy of your claim. If the claim denied because of a keying or scanning error, resubmit the claim.

Friday, May 13, 2016

List of Fields user for secondary cross over

Medicare Crossover for Other Blue Plan Members (CMS-1500)

Completing a claim correctly when a member has primary coverage with Medicare and secondary coverage (Medicare Supplement) from another Blue Plan will decrease your chance of receiving claim denials. The following instructions apply to items on the CMS-1500 form or its electronic counterpart that require specific Medicare Supplement information:

Item 9

• Enter the last name, first name and middle initial of the member if it is different from that shown in Item 2. Otherwise, you may enter the word “SAME”. If no Medigap benefits are assigned, leave blank.

Item 9a

• Enter the Medicare Supplement member’s policy and/or group number preceded by MEDIGAP, MG, or MGAP.

• Item 9d must be completed if you enter a policy and/or group number in 9a.

Item 9b

• Enter the birth date (MM/DD/YYYY) and gender of the member.

Item 9c

• Leave this field blank if the Blue Plan secondary payer’s name is entered in 9d.

• Enter the correct Blue Plan name as the secondary carrier in 9c. For example, if the member has a Medicare Supplement with Blue Cross and Blue Shield (BCBS) of Michigan, then BCBS of Michigan should be indicated as the secondary carrier, not Blue Cross and Blue Shield of Florida (BCBSF). Use an abbreviated street address, two letter postal code, and zip code copied from the member’s Medicare Supplement ID card. For example: 1234 Anywhere St, MD 12345.

Item 9d

• Enter the correct Blue Plan name as the secondary carrier.

Note: All information must be complete and accurate in items 9, 9a, 9b, 9c and 9d of the CMS-1500 form in order for the Medicare carrier to be able to forward claim information. If prior arrangements have been made with the private insurer, the carrier will forward the Medicare information electronically. Otherwise, the carrier will forward a hard copy of the claim to the private insurer.

Item 11d

• If you submit a claim with a Medicare Remittance Notice attached, always mark “YES” in 11d.

• If you mark “NO” in 11d, the claim will pass through the system but attachments will not be reviewed.

• If your billing system is hard-coded to mark “NO” automatically in 11d, please manually override your system to mark “YES” when submitting a claim with the Medicare Remittance Notice attached.

Item 13

• The signature in this item authorizes payment of mandated Medigap benefits to a participating physician or supplier if required Medicare Supplement information is included in items 9 through 9d.

• The member or member’s representative must sign this item or the signature must be on file as a separate Medigap authorization.

• The Medigap assignment on file in the participating physician or supplier’s office must specify the insurer. It may state that the authorization applies to all occasions of service until it is revoked.

Tuesday, May 10, 2016

Provider missing / Recipient eligibility not established


This section provides information about the most common billing errors encountered when providers submit claims to the Medical Assistance Program. Preventing errors on the claim is the most efficient way to ensure that your claims are paid in a timely manner.
Each rejected claim will be listed on your remittance advice along with an Explanation of Benefits (EOB) code that provides the precise reason a specific claim was denied. EOB codes are very specific to individual claims and provide you with detailed information about the claim. The information provided below is intended to supplement those descriptions and provide you with a summary description of reasons your claim may have been denied. Claims commonly reject for the following reasons:

1. The appropriate provider and/or recipient identification is missing or inaccurate.'

?? Verify that your NPI and 9-digit Medical Assistance provider numbers are entered in Blocks #33a/b. The ID Qualifier 1D must precede the 9-digit Medial Assistance provider number. Do not use your PIN or tax identification number.

?? Verify that a valid NPI and 9-digit Medical Assistance provider number for the requesting, referring or attending provider are entered in the Blocks #17a/b and each provider is correctly identified. The ID Qualifier 1D must precede the 9- digit Medical Assistance provider number in block 17a.

?? Verify that the NPI and 9-digit rendering Medical Assistance provider number you entered in Block #24j. is in fact, a rendering provider. The ID Qualifier 1D must precede the 9-digit Medial Assistance provider number. If you enter a group NPI and provider number in the block for the rendering provider, the claim will deny because group provider numbers cannot be used as rendering provider

?? Verify that the recipient’s 11-digit Medical Assistance identification number is entered in the Block #9a.

?? Verify that the recipient’s name is entered in Block #2, last name first.

2. Provider and/or recipient eligibility was not established on the dates of services covered by the claim.

?? Verify that you did not bill for services provided prior to or after your provider enrollment dates.

?? Verify that you entered the correct dates of service in the Block #24a of the claim form. You must call EVS on the day you render service to determine if the recipient is eligible on that date. If you have done this and your claim is denied because the recipient is ineligible, double-check that you entered the correct dates of service.

?? Verify that the recipient is not part of the Medical Assistance HealthChoice Program. If you determine that the recipient is in HealthChoice, contact the appropriate Managed Care Organization (MCO).

Wednesday, May 4, 2016

CMS-1500 MEDICARE EOMB REQUIREMENTS secondary claim submission

   Medicaid requires an EOMB for all Medicare crossover claims filed on a paper claim.

** NOTE: Medicaid will reimburse Medicare Advantage Plans co-payments, coinsurance and deductibles, with the following exceptions:

We will not reimburse Medicare Advantage Plan claims for recipients deemed eligible for the Specified Low Income Medicare Beneficiaries (SLMB) Program. Combined co-payments and coinsurance may not exceed 20%. In order to ensure that claims are processed appropriately, the following information is required on the EOMB:

Requirements for EOMB Header:

** In the absence of identifying Medicare information on the EOMB, the provider must label the EOMB attachment “MEDICARE EOMB” to assure proper
processing of the claim.
** Provider Name
** Provider Medicare Legacy Number
** Provider NPI number
** Medicare Payment Date
** Column Headings (title)

Requirements for individual claim lines CMS-1500 Part B:

** Date of service
** Procedure code plus modifiers (up to 4 spaces for modifiers when applicable)
** Charged amount for each procedure
** Allowed amount for each procedure
** List deductible amounts (if any)
** List co-insurance amounts (co-pay amounts not payable)
** Patients Medicare ID number
** Total deductible amounts (if any)
** Total co-insurance amount
** Total Medicare payment (even if zero)

Note: If Medicare denies a service or claim, a written description of the reason/remark code(s) is required for all code(s).

Failure to comply with the above requirements will result in a denial of the claim and further delay in processing of the claim for payment. You may contact the Medicare Liaison Unit at 410-767-5559 for further assistance.