03/16/2021

Correct Billing to Medicaid when Secondary

Medicaid billing for dual plans (also Medicaid QMB plans when patient is not on crossover list from Medicare): Do we bill electronically the full amt billed to the commercial Insurer or only the amt allowed by the Insurer for Medicaid portion? Do we just resubmit after inputting the paid amt. For example either the Medicare deductible, the 20% coinsurance, or whatever other amt deemed the Medicaid responsibility? Does Medicaid receive the amt from the Insurer? #2 Do we bill the outstanding amt with a HICF 1500 form (or Medicaid form) and EOB from the Insurer?

The amount that would be billed to Medicaid as a secondary would only be the patient responsibility from the primary insurance (copays, coinsurance or deductibles). The only instance where Medicaid would be billed at the same rate as a primary insurance is when the service is not covered by the primary insurance and the balance was applied to patient responsibility. When billing Medicaid, the amount billed to them has to reflect the total patient responsibility assigned by Medicare or a Medicare Advantage plan. It is highly recommended to submit secondary claims directly in ePaces (the online portal for Medicaid providers) to be reimbursed for the patient’s cost share of the visit. It is the easiest and most accurate way to ensure prompt payment of the secondary claim. EOBs are not handled appropriately if mailed to Medicaid with a HCFA, and submitting a secondary claim electronically will have key pieces of information missing that will cause the claim to deny.