Special Billing For Medically Needy Recipients

Introduction 

A Medically Needy recipient is an individual who would qualify for Medicaid,except that the individual’s income or resources exceed Medicaid’s income or resource limits. On a month-by-month basis, the individual’s medical expenses are subtracted from his or her income. If the remainder falls below Medicaid’s income limits, the individual may qualify for Medicaid for the month or for part of the month. The amount of expenses that must be deducted from the individual’s income to make him or her eligible for Medicaid is called a “share of cost.”

Medically Needy recipients can receive targeted case management services. Medically Needy recipients are not eligible to receive home and community based  waiver services.

Split Billing and CF-ES 2902 Form

If a recipient incurred medical expenses from multiple providers on the date he

met his share of cost (first day of eligibility), any medical expenses from a single provider that were used in full to meet the share of cost are not eligible for Medicaid reimbursement. Any expenses from a single provider that were not used in full to meet the share of cost are eligible for reimbursement. This process, known as “split billing,” is actually split-day billing—no individual

claims are split and no claims from a single source are split. This process occurs infrequently.

If not all of the recipient’s medical expenses incurred on the first day of eligibility are eligible for Medicaid reimbursement, the MEVS split bill indicator will be “Y.” The public assistance specialist will mail a pink copy of the Medically Needy Billing Authorization, CF-ES 2902 Form, to the providers whose expenses are  eligible for reimbursement. Providers must submit the CF-ES 2902 Form with their claims so the Medicaid fiscal agent will know that the claims are eligible for reimbur sement.

If the MEVS split bill indicator is “N,” then all the recipient’s expenses incurred on the first day of eligibility are eligible for reimbursement and a CF-ES 2902 Form is not required.

 

Receiving a CF-ES 2902 Form

When a provider receives a pink copy of a CF-ES 2902 Form, the provider must check the bottom right-hand corner of the form, under the caption “Period of  Eligibility,” and make sure that the dates of service on the claim fall within the recipient’s period of eligibility.

If the service was performed on the first day of eligibility indicated on the CF-ES 2902 Form, the form must be submitted with the claim. If the service dates are after the first day of eligibility, the form does not need to be submitted with the claim.

Instructions for Submitting a CF-ES 2902 Form

If one or more services were provided on the first day of eligibility, follow the instructions below.

·  Attach the pink copy of the CF-ES 2902 Form to the claim being sent to the Medicaid fiscal agent if appropriate as described above.

·  The provider should make a photocopy of the pink copy for the office record. ·  If a claim is for a Medically Needy recipient and was originally filed with a pink CF-ES 2902 Form and must be resubmitted or adjusted, a photocopy of the CF-ES 2902 must accompany the claim resubmission or adjustment. ·  When submitting a photocopy of CF-ES 2902 Form, the provider must enter

the transaction control number (TCN) of the previous claim on the photocopy of the CF-ES 2902 Form, in the box labeled “For Provider Use Only” in the upper right corner of the CF-ES 2902 Form. The photocopy will be rejected if the provider does not enter the previous claim’s TCN on the form.