|May 18, 2016
Reprocessing of Crossover Claims for Services Rendered to Qualified Medicare Beneficiaries
In adherence to Centers for Medicare & Medicaid Services (CMS) Informational Bulletin, Payment of Medicare Cost Sharing for Qualified Medicare Beneficiaries (QMBs), dated June 7, 2013, Medicaid is legally obligated to reimburse providers for cost-sharing that is due for a Qualified Medicare Beneficiary (QMB) according to the state’s CMS-approved Medicare cost-sharing payment methodology.
Effective November 1, 2015, the “lesser of” logic is being applied to services covered by both Medicare and Medicaid that are rendered to QMBs. Specifically, claims for Medicare covered services that are also covered in the Medicaid State Plan are paid at the lesser of the:
- Medicare cost-share (which is the sum of co-insurance, deductible and co-pay), or,
- Difference between the amount paid by Medicare and the Medicaid State Plan rate (if any).
For services not covered under the N.C. Medicaid State Plan, the claims are paid the Medicare cost share amount. This rule applies to both crossovers and secondary filed claims for Q-class recipients. This methodology results in the provider receiving the Medicare or Medicaid allowable and the QMB recipient not being responsible for any additional monies for services covered by Medicaid and/or Medicare.
QMB claims last processed between March 1, 2015, and Oct. 31, 2015, will be reprocessed in batches over the course of this summer.
You are receiving this message because you have claims affected by this reprocessing. While some previously denied claims will now process for payment, the majority of claims will have a lower net reimbursement due to the CMS QMB rule. The final amount will be established when the actual claims are reprocessed.
If there are not sufficient funds from new claims paid in the checkwrite to cover the adjustment from reprocessing, an accounts receivable will be created. Funds from claims paid in subsequent checkwrites will be applied to the accounts receivable until the adjustment is fully recovered. To fully satisfy the recovery, NCTracks will look for available funds from any other NPI within the same corporate structure (shared Tax Identification Number). All amounts owed to the N.C. Division of Medical Assistance that are not satisfied within 30 days from the Systematic Payment Adjustment Begin Date will incur penalty and interest.
The reprocessed claims will appear in a separate section of the paper Remittance Advice (RA) with a unique Explanation of Benefits (EOB) code: EOB 06021 – “Medicare QMB Reprocessing of Claims Processed Between March 1, 2015 and October 31, 2015”. The 835 electronic transactions will include all of the reprocessed claims along with other claims submitted for the checkwrite. (There is no separate 835.)
No action is required on the part of providers. If providers have any questions about the reprocessed Q-class claims, please contact the NCTracks Call Center at 1-800-688-6696 or NCTracksProvider@nctracks.com.
The NCTracks Team