Friday, December 17, 2010

Third Party Liability Denial - what need to do

If a claim has been denied for "Bill Medicare for these services," the provider must file and obtain Medicare payment for the service or obtain a Medicare denial before Medicaid payment can be made. The denial can be in the form of a letter from the Social Security Administration or Supplemental Security Income Division, Form SSA-1600 or Form SSA-2458.

Upon receipt of the denial, resubmit the Medicaid claim to the Medicaid fiscal agent, indicating the transaction control number (TCN) of the denied original claim, and attach a copy of the Medicare denial. The claim is then paid according to Medicaid payment policies.

When the provider determines that a Medicaid beneficiary is eligible for Medicare in addition to being covered by private insurance, the provider must follow these guidelines:

Medicare Part A
The Medicare Part A intermediary will only crossover claims to Medicaid; therefore, submit separate claims to Medicare Part A (with no listing of Medicaid involvement) and the private third party source. When the third party payments or explanation of benefits (EOB) of denial are received from Medicare Part A and the private third party source, file the Medicaid claim as required.

Medicare Part B The Medicare Part B intermediaries will crossover all claims to the appropriate third party source; therefore, the provider should complete the CMS-1500 listing the private third party source but with no mention of Medicaid. When the third party payments or EOBs of denial are received from Medicare Part B and the third party source, file the Medicaid claim as required. If a beneficiary is found to have Medicare coverage after Medicaid claims have been paid, the fiscal agent may automatically recoup the payments from the provider and print a message on the payment register that explains the action to the provider with instructions to bill Medicare. The fiscal agent may perform this process monthly.

Medicare Part C The Medicare Part C Advantage plans will not automatically crossover claims for payment to DOM for dually eligible beneficiaries. To submit these claims to DOM for payment, the provider must complete either Part A or Part B Mississippi Medicaid Crossover Claim Form. Please refer to sections 2.3 or 3.2 for specific instructions for completing these claim forms.

To access the form, visit the DOM website at, select the link Medicaid Provider Information. Then choose the link Forms for Providers. Complete the appropriate form per the instructions, and send the claim form along with the EOB attached to the fiscal agent for processing. These claims are subject to the 180 day time limit from the EOB payment date.

Medicare Part D Medicaid considers Medicare Part D payments for prescription drugs to be considered payment in full.

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