Medicaid Secondary to Medicare

Purpose

To ensure the proper procedure is utilized when identifying specific denials received by Medicaid when they are secondary to Medicare.

Policy

At the time the claim balance is submitted to Medicaid as the secondary insurance to the primary payer, it is identified that Medicare’s reimbursement rate exceeds the maximum allowable from Medicaid. With this Medicaid will deny for “Payments adjusted due to the impact of the prior payer(s) adjudication including payments and/or adjustments” (OA23).

This will result in a zero ($0) dollar payment from Medicaid and the denial code reason of OA23.

At the time that this denial is identified, Clinicient will adjust the remaining balance as a contractual adjustment.

Medicaid Secondary to Medicare Definitions

Medicaid becomes a secondary insurance to Medicare for a patient who is determined to be a “dual eligible beneficiary.” This includes patients with Medicare Part A and/or Part B who receive full Medicaid benefits and/or assistance with Medicare premiums or cost sharing through one of the following Medicare Savings Program (MSP) categories:

Qualified Medicare Beneficiary (QMB) Program

Helps pay premiums, deductibles, coinsurance, and copayments for Part A, Part B, or both programs

Specified Low-Income Medicare Beneficiary (SLMB) Program

Helps pay Part B premiums

Qualifying Individual (QI) Program

Helps pay Part B premiums

Qualified Disabled Working Individual (QDWI) Program

Pays the Part A premium for certain disabled and working beneficiaries

 

Clinicient (the “Company”) is providing this information for general guidance. The application, impact and change of laws can vary widely. Accordingly, the information is provided with the understanding that it is not offered as legal or any other professional advice or services and as such should not be used as a substitute for consultation with professional and licensed advisers. While we have made every attempt to ensure that the information contained herein is accurate at the published time, the Company is not responsible for any errors or omissions, or for the results obtained from the use of this information. All information is provided "as is," with no guarantee of completeness, accuracy, timeliness or of the results obtained from the use of this information, and without warranty of any kind, express or implied, including, but not limited to warranties of performance and fitness for a particular purpose. In no event will the Company or its subsidiaries, agents or employees thereof be liable to you or anyone else for any decision made or action taken in reliance on the information.

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