Wiki QMB claims processing question (denial by Medicare needed)

[stephaniefreeman1986@yahoo.com]

Good afternoon, have been getting claims denial by Medicaid for HCPCS T1017 (not payable by Medicare). Client is only QMB. Medicaid is saying that we need to bill Medicare first, which we have tried. Claim was transmitted electronically to the clearinghouse to transmit to Palmetto, which I just found out Medicare rejected it due to HCPCS/CPT. What do I do? Drop to paper? Is there any way around this, so that we can get a denial by Medicare?

 

[julieordway]

Medicare needs to process the claim in order for your State Medicaid carrier to process it. Sounds like a HCPCS/CPT code issue. What codes are you billing?

 

[stephaniefreeman1986@yahoo.com]

Medicare needs to process the claim in order for your State Medicaid carrier to process it. Sounds like a HCPCS/CPT code issue. What codes are you billing?

This is a T1017 Targeted case management, each 15 minutes, not payable by Medicare. With Modifier U3. Medicaid is saying they want us to bill Medicare first, however, in the electronic processing it is rejected due to Due to 'HCPCS Acknowledgement/Rejected for Invalid Information - The claim/encounter has invalid information as specified in the Status details and has been rejected.'

 

[sls314]

Good afternoon, have been getting claims denial by Medicaid for HCPCS T1017 (not payable by Medicare). Client is only QMB. Medicaid is saying that we need to bill Medicare first, which we have tried. Claim was transmitted electronically to the clearinghouse to transmit to Palmetto, which I just found out Medicare rejected it due to HCPCS/CPT. What do I do? Drop to paper? Is there any way around this, so that we can get a denial by Medicare?

If you're billing for a service that isn't a Medicare covered benefit, the QMB Medicaid isn't going to pay for it either.

QMB is a limited benefit plan that helps cover Medicare premiums, deductibles, and coinsurance. It acts basically like a Medicare supplement.

See this document on claims errors from Virginia Medicaid - the excerpt below is on page 2 of the PDF. https://www.dmas.virginia.gov/media/2141/top-50-error-reason-codes-with-resolutions.pdf

0039

Qualified Medicare Beneficiary Only Enrollee. Medicaid coverage limited to deductible and coinsurance.

Qualified Medicare Beneficiary (QMB) Only clients are eligible only for payment of Medicare premiums, deductibles, and coinsurance. If a QMB Only claim is denied by Medicare then there will be no reimbursement by Medicaid.

 

[stephaniefreeman1986@yahoo.com]

If you're billing for a service that isn't a Medicare covered benefit, the QMB Medicaid isn't going to pay for it either.

QMB is a limited benefit plan that helps cover Medicare premiums, deductibles, and coinsurance. It acts basically like a Medicare supplement.

See this document on claims errors from Virginia Medicaid - the excerpt below is on page 2 of the PDF. https://www.dmas.virginia.gov/media/2141/top-50-error-reason-codes-with-resolutions.pdf

0039

Qualified Medicare Beneficiary Only Enrollee. Medicaid coverage limited to deductible and coinsurance.

Qualified Medicare Beneficiary (QMB) Only clients are eligible only for payment of Medicare premiums, deductibles, and coinsurance. If a QMB Only claim is denied by Medicare then there will be no reimbursement by Medicaid.

Thank you so much. This is really helpful!