(Medicare Claims Processing Manual)

Providers and suppliers may bill State Medicaid agencies for Medicare cost -sharing amounts. However, as permitted by Federal law, States may limit Medicare cost -sharing payments, under certain circumstances. Regardless, persons enrolled in the QMB program  have no legal liability to pay Medicare providers for Medicare Part A or Part B cost -sharing for covered items and services.   Medicare providers who violate these billing prohibitions are violating their Medicare Provider Agreement and may be subject to sanctions. (See Sections 1902(n)(3)(C); 1905(p)(3); 1866(a)(1)(A); 1848(g)(3)(A) of the Social Security Act.)   Note: providers may seek reimbursement for unpaid Medicare deductible and coinsurance amounts as a Medicare bad debt.  Before a provider can be reimbursed for bad debts related to dual-eligible beneficiaries, Medicare policy under CMS Pub. 15- 1, Chapter 3, Section 312 of the Provider Reimbursement Manual (PRM) requires a determination and documentation of the states liability for any cost sharing amounts.   To effectuate this, Medicare requires the provider to bill the state to determine that the state is n ot liable for payment, even if the Medicare provider is not enrolled or the service is not covered under the states Medicaid plan.   To aid compliance with QMB billing prohibitions, the Medicare claims processing system will generate notifications to Medicare providers (via the Remittance Advice) and beneficiaries (via the Medicare Summary Notice) that indicate the beneficiarys QMB status and lack of liability for cost -sharing. The Medicare Claims Processing System will use the Common Working File (CWF) to receive QMB status via the Eligibility Database (EDB).  The QMB indicators will be transmitted to the shared systems with the applic able QMB START and END dates.  The two indicators that apply to QMB individuals are Dual Status Code 01 Qualified Medicare Beneficiaries without other Medicaid (QMB -only), and Dual Status Code 02 Qualified Medicare Beneficiaries plus full Medicaid (QMB -Plus). CWF will transmit the QMB indicator if the dates of service coincide with a QMB coverage period (one of the occurrences) for the following claim types:  Part B professional claims; Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DME POS) claims; and outpatient institutional and Skilled Nursing Facility (SNF) claims.  CWF will transmit the QMB indicator if the discharge date falls within a QMB coverage period (one of the occurrences) for inpatient hospital claims.   QMB indicators will initiate messages on the Remittance Advice that reflect the beneficiarys QMB status and lack of liability for Medicare cost -sharing with Remittance Advice Remark Codes (RARCs) that are specific to those enrolled in QMB.     Effective July 2, 2018, for QMB claims the shared systems will use:    Group Code PR along with CARC 1 and/or 2, 66, as applicable, with monetary values expressed on outbound Medicare 835 Electronic Remittance Advices (ERAs) and on standard paper remittance advices (SPRs), as applicable.     Additionally, the shared systems shall include Alert Remittance Advice Remark Codes (RARC) on the ERA and SPR, as applicable, that designate that the beneficiary has QMB status and may not be billed for Medicare cost-sharing amounts.    o N781 - Patient is a Medicaid/ Qualified Medicare Beneficiary. Review your records for any wrongfully collected deductible. This amount may be billed to subsequent payer. o N782  Patient is a Medicaid/ Qualified Medicare Beneficiary. Review your records for any wrongfully collected co-insurance. This amount may be billed to subsequent payer.  Additionally, the Medicare Summary Notice (MSN) generated for all QMB individuals will include information regarding their QMB status and lack of liability for Medicare cost-sharing amounts for covered Parts A/B items and services.    MSNs with QMB claims that are paid   If an MSN includes at least  one detail line for a QMB that contains an allowed amount greater than zero, page one (the summary page), will use Message 62.0 to briefly explain the QMB billing protections (in the "Be Informed!" section). Also on page one, the patients total liability amount (in the Total You May Be billed field) will omit the deductible and coinsurance amounts for details lines that are for a QMB and include an allowed amount greater than zero.   In the claims detail section of the MSN, if the  detail line  is for a QMB  and includes an allowed amount greater than zero, such detail line will reflect $0 (in the Maximum You May Be Billed field) and include message 62.1 that informs the beneficiary of her/his QMB status and billing protections. MSNs with QMB claims that are denied   In the claim detail pages of the MSN,  if a detail line is flagged as QMB and contains an allowed amount of zero, the MSN will reflect the  beneficiary's total liability amount in the Maximum You May Be Billed field and include new MSN 11.21 message to inform the beneficiary that even though Medicare has denied the claim, Medicaid may pay for care.   Note:  For claims processed by VIPS Medicare System (VMS), if a detail line is flagged as QMB and contains an allowed amount of zero, and the beneficiary has not signed an Advance Beneficiary Notice or is subject to Waiver of Liability which has not been attached, the contractor shall not print MSN message 11.21        Transmittals Issued for this Chapter   Rev #  Issue Date  Subject  Impl Date  CR#  R12448CP  01/11/2024  Updates to Medicare Benefit Policy Manual and Medicare Claims Processing Manual for Marriage and Family Therapists (MFTs) and Mental Health Counselors (MHCs)  02/12/2024  13469  R12107CP  06/29/2023  New Fiscal Intermediary Shared System (FISS) Consistency Edit to Validate Attending Physician National Provider Identifier (NPI) - Phase 2  01/02/2024  13219  R11794CP  01/19/2023  Preventing Submission of Cross -Reference Document Control Numbers on Original Claims  04/03/2023  13008  R11633CP  10/06/2022  New Fiscal Intermediary Shared System (FISS) Consistency Edit to Validate Attending Physician National Provider Identifier (NPI)  04/03/2023  12889  R11731CP  12/09/2022  Update to the Internet Only Manual (IOM) Publication (Pub.) 100-04, Chapter 1, Section 90, to include Critical Access Hospitals (CAHs) for a Portion of a Medicare Advantage (MA) Billing Period  01/11/2023  12992  R11571CP  08/25/2022  Updates are Being Made to Chapter 1 of the Medicare Claims Processing Manual to Include Newly Created and Utilized Payer Only Codes  09/27/2022  12840  R10840CP  06/11/2021  Updates to the Internet Only Publication 100 -04, Chapter 1, Section 10.1 and Chapter 20, Section 10  07/12/21  12310  R10236CP  07/31/2020  Update to the IOM Publication (Pub) 100 -04, Medicare Claims Processing Manual, Chapters 1, 6, 8, 17, 20, 22, 24, and 31 Referencing the Active Universal Resource Locators (URLs) for the Washington Publishing Company (WPC) and the ASC X12 Organizations, and Updates to the HIPAA Eligibility Transaction System (HETS)   08/31/2020  11857   12/06/2019  Update to Medicare Claims Processing Manual, Chapters 1, 23 and 35  03/09/2020  10882  R4415CP  10/11/2019  Medicare Administrative Contractor (MAC) Guidance Related to Use of Adjustment Codes on Adjustment Claims  01/06/2020  11113  R4388CP  09/06/2019  Manual Updates to Chapters 1, 22, 24, 26, and 31 in Publication (Pub.) 100-04   10/01/2019  11331  Rev #  Issue Date  Subject  Impl Date  CR#  R4381CP  08/30/2019  Updates to Chapter 1 Payer Only Codes in the Medicare Claims Processing Manual   10/01/2019  11414  R4337CP  07/18/2019  Implementation of the Medicare Performance Adjustment (MPA) for the Maryland Total Cost of Care (MD TCOC) Model   07/01/2019  10971  R4332CP  07/03/2019  Medicare Summary Notice (MSN) Changes to Assist Beneficiaries Enrolled in the Qualified Medicare Beneficiary (QMB) Program  10/07/2019  11230  R4308CP  05/16 /2019  Implementation of the Medicare Performance Adjustment (MPA) for the Maryland Total Cost of Care (MD TCOC) Model - Rescinded and Replaced by Transmittal 4337   07/01/2019  10971   R4290CP  05/03/2019  Medicare Summary Notice (MSN) Changes to Assist Beneficiaries Enrolled in the Qualified Medicare Beneficiary (QMB) Program  - Rescinded and Replaced by Transmittal 4332    10/07/2019  11230  R4271CP  03/29/2019  Update to the Internet -Only -Manual (IOM) Publication (Pub.) 100 -04, Chapters 1 and 3  04/29/2019  11188  R4257CP  03/14/2019  Implementation of the Medicare Performance Adjustment (MPA) for the Maryland Total Cost of Care (MD TCOC) Model - Rescinded and Replaced by Transmittal 4308  07/01/2019  10971  R4230CP  02/01/2019  Implementation of the Medicare Performance Adjustment (MPA) for the Maryland Total Cost of Care (MD TCOC) Model - Rescinded and Replaced by Transmittal 4257  07/01/2019  10971   R4201CP  01/18/2019  Update to Pub. 100 -04 Chapter 1 to Provide Language-Only Changes for the New Medicare Card Project  02/19/2019  10916  R4163CP  11/02/2018  Internet Only Manual Updates to Pub. 100 -01, 100 -02 and 100-04 to Correct Errors and Omissions (SNF) (2018 Q4)  12/04/2018  11004  R4035CP  04/27/2018  Enhancements to Processing of Hospice Routine Home Care Payments  10/01/2018  10573  R4047CP  05/11/2018  Updates to Publication 100 -04, Chapters 1 and 27 to Replace Remittance Advice Remark Code (RARC) MA61 with N382  08/13/2018  10619  R4001CP  03/16/2018  Internet Only Manual Updates to Pub. 100 -01, 100 -02 and 100 -04 to Correct Errors and Omissions 06/19/2018  10512  Rev #  Issue Date  Subject  Impl Date  CR#  (SNF) (2018)  R3993CP  03/06/2018  Reinstating the Qualified Medicare Beneficiary Indicator in the Medicare Fee -For-Service Claims Processing System from CR 9911  07/02/2018  10433  R3965CP  02/02/2018  Reinstating the Qualified Medicare Beneficiary Indicator in the Medicare Fee- For-Service Claims Processing System from CR 9911 Rescinded and Replaced by Transmittal 3993   07/02/2018  10433  R3933CP  12/07/2017  Revisions to the Home Health Pricer to Support Value-Based Purchasing and Payment Standardization  01/02/2018  10167  R3920CP  11/05/2017  Qualified Medicare Beneficiary Indicator in the Medicare Fee -For-Service Claims Processing System  07/03/2017  9911  R3829CP  08/04/2017  Revisions to the Home Health Pricer to Support Value-Based Purchasing and Payment Standardization - Rescinded and Replaced by Transmittal 3933