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Medicare/Medicaid eligibility

  1. Default Medicare/Medicaid eligibility
    Medical Coding Books
    My brain is spinning. Can someone explain to me how a Pt can be paid up to 05-31-11 and then on 06-01-11 be denied. I called the local office and am confused. A Pt is only eligible for 6 months and then not? I just need a clear explanation of how it works.

    Also - when the claim was originally sent and denied and I send the claim back to them when eligible do I use corrected claim, replacement claim? It seems they come back reading duplicate.

    Totally confused.

  2. Default
    Are you having a problem with the Medicaid?

  3. Default
    Yes - both Medicare and Medicaid. I just don't understand why they pay for a while and then stop payment or deny payment. I called the local office and they said they have to be resubmitted when they are eligible.
    Are they eligible for a few months and then not? Do they only come eligible for 6 months? The local office totally confused me.

  4. #4
    Lauderdale Lakes
    This is for Medicaid not Medicare. A patient is eligible for 6 months or less depending on the state. A patient has to reverify for Medicaid every 6 months. If they dont or if there financial situation changes they can be denied for medicaid. If they are eligible for the date of service you would probably just send the claim with the proof of eligibilty to the local office to have them approve it for payment

  5. #5
    Some of our medicaid is monthly eligible and not 6 months. Depends on the program they are on. We have to check individually everytime the patient comes in.

  6. #6
    Some Medicaid patients' eligibility can end at the end of the month. Especially if the patient is Medicaid Medically Needy. In this case they have a share of cost that they have to meet each month and once they have met their share of cost they are eligible from that day to the end of the month. On the first of the next month their share of cost starts over so they are responsible for any bills until they've met their share of cost for the new month and it goes on and on. Also, if there is any change in their income their Medicaid could end. Florida's Medicaid webportal has a seperate lookup for DCF (Dept of Children & Families) that you can look up your pt by SSN and DOB to see if they are required to meet a share of cost each month. I've never heard of a patient's Medicare ending at the end of the month, unless they've enrolled in a Medicare Advantage plan which Medicare should tell you who the new payer is.

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