Commercial Insurance and Medicaid HMO in Florida


Jasper, FL
Best answers
I hope you can assist me with an issue we have gone back and forth with in our office. If a patient has a commercial policy & Medicaid managed care (Sunshine, Staywell, Prestige) policy as secondary, is the patient responsible for the co-pay & or deductible?

Example 1: We submit a claim to BCBS for $150. They apply the allowable of $100 to patient deductible, our contractual adj. is $50. We submit a secondary claim to Medicaid managed care plan. The Medicaid MMA pays their allowable $50. What happens to the other $50? Is it adjusted off as contractual adj under secondary or is it patient responsibility?

Example 2: We submit a claim to BCBS $150. They allow $100, $50 payment and $50 co-pay, our contractual adj. is the $50. We bill the Medicaid product $50 patient responsibility. The Medicaid MMA does not pay anything because primary paid over Medicaid allowable. Can we bill the patient for that $50 co pay balance.