Washington DSHS updates billing instructions ...
Nov 1, 2011
Attn: All Medicaid Providers Who Bill Managed Medicare Claims (Part C)
Claims for capitated copayments from the Medicare Part C Plan must now be billed as cross-over claims.
Billing the capitated copayment cross-over claim: if no "allowed" amount is provided, enter the sum of the payment, co-payment, coinsurance, and deductible amounts as the "allowed" amount. ProviderOne requires an "allowed" amount to be indicated on the cross-over claim in order to process the claim.
NOTE: For Medicare Advantage or Part C plans only: If the Medicare Advantage Plan (Managed Medicare) allows the service on the EOB but DOES NOT make a payment on that service, the dollar amount listed on the backup under co-payment/co-insurance or Patient Responsibility and has an EOB code that indicates copayment, then that dollar amount must be entered on the cross over claim in the deductible amount field. ProviderOne requires a deductible amount if Medicare allows the service and does not make a payment on that service in order to process the claim.
The billing information above will appear in the "Submit Medicare Crossover Claims" section of the ProviderOne Billing and Resource Guide, found at http://hrsa.dshs.wa.gov/download/ProviderOne_Billing_and_Resource_Guide/ProviderOne_Billing_and_Resource_Guide.pdf.
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