December 1, 2017

State of Alabama
Press Release: Medicaid

Medicare QMB Changes Impact Manually Filed Crossover Claims

PDF Version
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.  


  • For more information, visit http://medicaid.alabama.gov
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