Medicaid claims
that are secondary to insurance or
Medicare coverage, including Medicare HMOs, may be
billed electronically either through electronic vendors or through Molina’s web
portal. Contact the EDI Help Desk for access to submitting claims on the
web portal.
Medicare Primary Claims
Many Medicare primary claims crossover to Medicaid automatically from the
Medicare Part A and Part B carriers through the Coordination of Benefits
Agreement (COBA), but some do not. Claims that do not crossover, and
therefore must be billed separately by providers include:
*** Outpatient claims from Part A Medicare carriers (such as NGS)
*** Long Term Care (LTC) claims from Part A Medicare carriers
*** Anesthesia claims from Part B Medicare carriers (on crossover, these are
rejected because
claims are billed in “minutes” not “units”)
*** Claims processed by Medicare HMOs.
All of these types of claims may be billed electronically to Medicaid.
Medicare paid amounts, deductible amounts, and coinsurance amounts are
required for Medicare approved services and Medicare Action Codes are required
for services denied by Medicare. This information is re-quired at the
claim line level for professional services billed on the 837P format and at the
head-er level for institutional services billed on the 837I format.
*** Medicare HMO co-pay amounts are to be billed as deductible. ***
Claims denied by Medicare HMOs may be billed electronically if the denial
is a HIPAA com-pliant denial code or Medicare Action Code (MAC).
*** Denied claims that are not denied with a MAC must be billed on paper
with copy of EOMB including the denial reason in addition to the denial code.
*** All Medicare HMO claims billed on paper must have “Medicare HMO”
written on the EOMB to assure correct processing .
Third Party Liability—TPL Primary claims
Providers must seek reimbursement from private insurance prior to billing
Medicaid. These sec-ondary claims may be billed electronically if the
insurance carrier approved the service. Claims that were denied by the primary
carrier, or contain denied claim lines, must be billed on paper with a copy of
the EOB that includes a description of the denial in addition to the denial
codes.
Medicare and TPL Claims
If a member has Medicare and TPL coverage, claims may be billed electronically
if both carriers made payments for the service.
No comments:
Post a Comment