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