eharloff

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8
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Grand Rapids, Michigan
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First off, I absolutely hate Medicaid with a passion (lol)

I'm located in Michigan and I received a denied claim Adjustment Reason Code 16: Claim/service lacks information or has submission/billing error(s) which is needed for adjudication. Do not use this code for claims attachment(s)/other documentation. At least one Remark Code must be provided.
Here is the Remark Code:
MA125: Per legislation governing this program, payment constitutes in full.
N442: Payment based on an alternate fee schedule.
N131: Total payments under multiple contracts cannot exceed the allowance for this service.


The one highlighted in red is the one I am confused about. This was processed as a secondary claim. Total billed amount was $108.00 which went to her primary insurance, Healthgram Inc., they paid $53.71 and adjusted $29.29, leaving patient's balance $25.00 (co-pay/co-insurance according to EOB). Is Medicaid not covering this because it is patient's copay, and do I write this amount off then? Thanks in advance!
 

trarut

Expert
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415
Location
Columbus, OH
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What is the Medicaid allowance for the charge if they paid as primary? Ohio Medicaid often does the same because the primary PAYMENT exceeds the Medicaid allowed amount for the charge. So no payment for us. Of course, there's usually nothing that tells you this and you have to be lucky enough to get a rep (1) to talk to you and (2) who has been there long enough to really understand how claims process.

And I think it's a written rule that we must despise the Medicaid programs, isn't it? :)
 

SharonCollachi

True Blue
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1,503
Location
Clovis, CA
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3
So here is what I usually see (I'm in California, not Michigan, so there's that), all numbers are just examples:

1. Medicare (or anyone) will allow $100 on a service and pay $80, leaving $20 for copay.
2. Medicaid allows $50 total on that same service, and since Medicare already paid $80, they pay nothing, and the $20 is written off.

The only time (with a few exceptions) that I see Medicaid pay anything when they are secondary is when the patient's Medicare deductible hasn't been met.

So it looks like that's what they mean... $53.71 is already the same as, or more than, Medicaid would have paid so they are paying nothing.
 

sls314

Networker
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73
Location
Toledo, OH
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Medicaid wouldn't issue any additional payment if you've already received above Medicaid's allowed amount. You would adjust it off.

In my experience, when a commercial plan pays primary, it's very rare that you collect any money from a Medicaid secondary claim. More often than not, it's an adjustment because the primary payment exceeded the Medicaid allowable amount.

However, you still need to bill the claims to Medicaid for documentation of why you're performing the adjustment.

(Also, you'll want a Medicaid claim on file timely in case the primary ever recoups their payment. That happens periodically. Maybe the patient wasn't actually eligible on the date of service or something like that, and the primary recoups payment. It's much easier to get payment from Medicaid on the secondary claim if you already had a claim on file and just need an adjustment, as opposed to trying to file a late claim after the recoupment & arguing for a timely filing appeal.)
 

leagle

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7
Location
Ishpeming, MI
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I'm in Michigan...I agree this basically just means that primary paid more than their allowed and it's an adjustment. And I also agree that dealing with MI Medicaid stinks. They are way more complicated and confusing than some of the other states I've dealt with!
 
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