FROM: PAUL SWATSENBARG, DEPUTY ADMINISTRATOR
Division of Medicaid
Effective May 1, 2002, Medicaid will change the reimbursement methodology for Medicare Part B crossover claims. The 1997 Balanced Budget Act (BBA) allows states flexibility in establishing the amount of payment for Medicare cost-sharing.
Currently Medicaid pays crossover claims based on the full Medicare approved amount, i.e. after the provider has received the payment from Medicare, Medicaid pays the full amount of both the co-insurance and the deductible. The new reimbursement methodology will be based on the amount that Medicaid pays for the same service for a client not entitled to Medicare. The new reimbursement methodology will treat a Medicare payment as any third party payment.
The new claims submission process is outlined below:
· A crossover claim can be submitted electronically by the carrier, or on paper.
· If submitted on paper, the Medicare EOB showing billed amount, paid amount, amount applied to deductible, and amount applied to coinsurance, must be attached.
· AIM will be modified to process crossover claims at the detail level, which means that the claim will go through the computerized audit and edit processes.
The Medicaid payment is calculated by:
1. Entering the total Medicare payment in the "other insurance" field on the claim and subtract the amount from the billed amount.
2. If the Medicaid fee for service allowed amount is equal to or less than the amount paid by Medicare, no additional payment will be made.
3. If the Medicaid fee for service allowed amount is greater than the amount paid by Medicare, the payment will be the difference between the Medicaid allowed amount and the Medicare payment.
If you have any questions, please contact Elvi Antonsson at 208-364-1810.
Thank you for your continued participation in the Medicaid Program.