02/25/2021

Billing Dual Eligibles with Medicare Advantage Plans

If a patient is a dual eligible patient ( on Medicare and medicaid) and is insured with a managed Medicare program and the payment is applied to patients deductible my understanding is that we can not bill the patient. So in essence we are treating all these patients for free or is there a way to get paid?

There is a way to get paid for a portion of the balance that would be applied to the patient’s deductible (as long as you are participating with Medicaid). Once the primary insurance processes the claim, the details can be entered manually on ePaces (the New York State Medicaid web portal for providers) to create a secondary claim. When processed by ePaces, it will cover a portion of the balance applied to the patient’s deductible, up to the allowed amount on the Medicaid fee schedule. Once payment is received, the balance would need to be adjusted as a contractual write off. It is not recommended to submit the claim on paper or electronically to Medicaid since it will not contain the information that is needed to pay as secondary that need to be entered on ePaces.