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

 

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