New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 302 - MEDICAID GENERAL PROVIDER POLICIES › Part 2 - RECIPIENT POLICIES -GENERAL RECIPIENT REQUIREMENTS › Section 8.302.2.12 - BILLING FOR DUAL-ELIGIBLE MEDICAID RECIPIENTS

Current through Register Vol. 35, No. 13, July 16, 2024
To receive payment for services furnished to an eligible
				  recipient or member who is also entitled to medicare, a provider must first
				  bill the appropriate medicare payer. The medicare payer pays the medicare
				  covered portion of the bill. After medicare payment, MAD pays the amount the
				  medicare payer determines is owed for co-payments, co-insurance and
				  deductibles, subject to MAD reimbursement limitations. If a medically necessary
				  service is excluded from medicare and it is a MAD covered benefit, MAD will pay
				  for service. When the medicare payment amount exceeds the amount that MAD would
				  have allowed for the service, no further payment is made for the coinsurance,
				  deductible, or co-payment. The claim is considered paid in full. The provider
				  may not collect any remaining portion of the medicare coinsurance, deductible,
				  or co-payment from the eligible recipient or their authorized representative.
				  For behavioral health professional services for which medicare part B applies
				  to a "psych reduction" to the provider payment and increases the eligible
				  recipient or member coinsurance rate, medicare coinsurance and deductible
				  amounts are paid at an amount that allows the provider to receive eighty
				  percent of the medicare allowed amount even if such amount exceeds the MAD
				  allowed amount for the service. A provider must accept assignment on medicare
				  claims for MAD eligible recipients and members. A provider who chooses not to
				  participate in medicare or accept assignment on a medicare claim must inform
				  the MAD eligible recipient, member or his or her authorized representative that
				  the provider is not a medicare provider or will not accept assignment; and
				  because of those provider choices, MAD cannot pay for the service.
				  Additionally, the provider must inform the eligible recipient, member or his or
				  her authorized representative of the estimated amount for which the eligible
				  recipient or member will be responsible, that service is available from other
				  providers who will accept assignment on a medicare claim, and identify an
				  alternative provider to whom the eligible recipient or member may seek
				  services. The provider cannot bill a dually eligible MAP recipient or member
				  for a service that medicare cannot pay because the provider chooses not to
				  participate in medicare, or which MAD cannot pay because the provider chooses
				  not to accept assignment on a claim, without the expressed consent of the
				  eligible recipient, member or his or her authorized representative even when
				  the medicare eligibility is established retro-actively and covers the date of
				  service.
A.
Claim
				crossover:
If there is sufficient information for medicare to identify
				an individual as an eligible recipient or member, medicare may send payment
				information directly to the MAD claims processing contractor in a form known as
				a "cross-over claim". In all cases where claims fail to crossover automatically
				to MAD, a provider must bill the appropriate MAD claims processing contractor
				directly, supplying the medicare payment and medicare "explanation of benefits"
				(EOB) information and meet the MAD filing limit.
B.
Medicare replacement plan or other
				health maintenance organization (HMO) plan:
When an eligible recipient
				or member belongs to a medicare replacement plan or HMO, MAD pays the amount
				the payer determines is owed for co-payment, coinsurance or deductible, subject
				to MAD reimbursement limitations. When the payer payment amount exceeds the
				amount that MAD would have allowed for the service, no further payment is made
				for the co-payment, coinsurance or deductible. The claim is considered paid in
				full. The provider may not collect any remaining portion of the payer
				co-payment, coinsurance or deductible from the eligible recipient, member or
				his or her authorized representative. For behavioral health services for which
				medicare part B applies to a "psych reduction" to the provider payment and
				increases the eligible recipient or member coinsurance rate, medicare
				coinsurance and deductible amounts are paid at the amount that allows the
				provider to receive up to eighty percent of the payer amount allowed even if
				the amount exceeds the MAD allowed amount for the services.
C. All other HMO and medicare replacement
				plan requirements, including provider network restrictions must be met for MAD
				to make payment on a claim.