Claim Reprocessing for Services Rendered to QMB Recipients

As explained in a previous announcement (see link below), as of November 1, 2015, the “lesser of� logic is being applied to services covered by both Medicare and Medicaid that are rendered to Qualified Medicare Beneficiaries (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 the difference between the amount paid by Medicare and the Medicaid state plan rate (if any). For services not covered under the North Carolina Medicaid plan, the claims are paid the Medicare cost share amount. This applies to crossovers as well as 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.

The QMB claims paid between July 1, 2013, and October 31, 2015, will be reprocessed over the course of multiple checkwrites between March 29, 2016, and June 21, 2016. The claim reprocessing will address two situations:

  • Previously paid QMB crossover and secondary claims for services not covered under the North Carolina Medicaid plan, where the provider should have received the Medicare cost share amount
  • Claims that paid 100% of the Medicare cost share for services covered under the North Carolina Medicaid plan between March 1, 2015, and July 19, 2015, which resulted in an overpayment that will be recouped as a result of this reprocessing

The reprocessed claims will appear in a separate section of the paper Remittance Advice (RA) with a unique Explanation of Benefits (EOB) code. Depending on the date when the claim was originally processed, one of two EOB codes will be associated with the reprocessed claim:

  • EOB 06000 - MEDICARE QMB REPROCESSING OF CLAIMS PROCESSED BETWEEN JULY 1, 2013 AND FEBRUARY 28, 2015
  • EOB 06021 - MEDICARE QMB REPROCESSING OF CLAIMS PROCESSED BETWEEN MARCH 1, 2015 and OCTOBER 31, 2015

The 835 electronic transactions will include the reprocessed claims along with other claims submitted for the checkwrite. (There is no separate 835.)

Note that reprocessing does not guarantee payment for the claim. While some edits may be bypassed as part of the claim reprocessing, changes made to the system since the claims were originally adjudicated may apply to reprocessed claims. Therefore, the reprocessed claim could deny.

If the claim reprocessing results in a recoupment and there are not sufficient funds to satisfy the full recoupment amount from claims paid in the current checkwrite, the recoupment process will continue on each checkwrite until the full amount due is recouped.

 

October 30, 2015 announcement