Wiki Medicare and Medicaid Preventive visit


Best answers
Hello. I have 2 claims that I am having problems with. They have the same issue:

Provider saw a Dual Eligible Medicare/Medicaid Pt for preventive visit, Q0091 and G0001. Medicare paid the Q0091 and G0001. The Prev was transferred to Medicaid. When Medicaid EOB came back, it was denied. I called Medicaid and they said that they cannot pay for it because Medicare put a code PR204: This service/equipment/drug is not covered under the patient's current benefit plan.

I told her that it is an uncovered code by Medicare, but a covered code by Medicaid. I said that usually, when Pt only has Medicare, the payment by Medicare is carved out from the billed charge for the Preventive. Since, Medicare does not pay for Prev, it was transferred to Medicaid, because Dual Eligible cannot be charged anything. Medicaid should pay.

My claim keeps coming back. Medicaid refused to pay unless I could ask Medicare to change the code PR204 to something else.

What is your experience with this? Do I just write off the Preventive code?
Did you use the GY modifier with medicare on the CMS non covered service. It should cause it to deny as patient liable so you can send to secondary.
I actually checked my other claims that have the same problem. I actually used GY for the other claim, and it still did not get paid.

Has anybody been successful and having Medicaid pay for the Preventive visit?
Our Medicaid when secondary to Medicare does not pay for services when the primary (Medicare) denies them as a PR-204. Not to mention our Medicaid does not pay for CPEs (99381-99397) beyond the age of 21 anyways.
Which state are you practicing in?

So, Medicaid only pays for preventive visit when Medicaid is the only payer? Medicaid never pays for preventive visit if Pt is Dual Eligible? BTW, I'm from Illinois. Medicaid Illinois pays for preventive visit but not for Q0091 and G0101.
Last edited: