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TO: ALL
Providers
Medicaid/Medicare-related claims will continue to crossover to Medicaid
automatically. However, when it is necessary to manually enter crossover claims
to be considered for payment, the patient responsibility must be greater than
zero even if the Medicare Remittance Advice (RA) indicates zero cost-sharing
liability for a QMB recipient. Patient responsibility is calculated by adding
together any co-payments, co-insurance, and deductible. Claims that do not
contain a patient responsibility will deny with one or more of the following
error status codes:
0433 – Medicare
deductible amount invalid
0434 – Medicare
coinsurance amount invalid
0836 – Medicare paid,
deductible amounts invalid – both cannot be zero
When calculating payment methodology for claims with Medicare primary,
the Medicaid allowed amount will be compared to the Medicare allowed amount and
the lesser of these two would be the maximum payment that could be made. Then,
the Medicare paid amount is subtracted from that amount to determine the
maximum amount due. The maximum amount due is compared to the patient
responsibility and the reimbursement will be the lesser of the patient
responsibility or the maximum amount due.
This change is due
to a recent implementation of new QMB status codes for claims with dates of
service on or after October 2, 2017.
New
QMB Indicators
The QMB indicators
will initiate new messages on the RA that reflect the beneficiary’s QMB status
and lack of liability for Medicare cost-sharing with new Remittance Advice
Remark Codes (RARC) that are specific to those enrolled in QMB. As appropriate,
one or more of the following new codes will be returned:
N781 – No deductible may be collected as patient is
Medicaid/Qualified Medicare Beneficiary
N782 – No co-insurance may be collected as patient is
Medicaid/Qualified Medicare Beneficiary
N783 – No-copayment may be collected as patient is
Medicaid/Qualified Medicare Beneficiary
Any questions should be directed
to the Provider Assistance Center at 1-800-688-7989.
The Current Procedural Terminology (CPT) and Current Dental Terminology
(CDT) codes descriptors, and other data are copyright © 2017 American Medical
Association and © 2017 American Dental Association (or such other date publication of CPT
and CDT). All rights reserved. Applicable FARS/DFARS apply.