Medical Insurance Processing
SECONDARY HIC / COVERAGE SIMILAR TO PRIMARY
/ SUPPLEMTAL HIC COVER ONLY DED, COPAY, COINS
MCR SUPPLEMENTED BY MCD
MEDI / MEDI * Follows MCR guidelines for filing deadlines * MCR beneficiaries w/ low incomes – limited resources may get help from MCD * MCR/ FULL MCD eligible (MCR is supplememted by MCD services from the state) a) more than 100 day limit for SNF , b) rx c) eyeglasses d) hearing aids
DUAL ELIGIBLES * MCR low income/ lmt resources (may receive help w/ out of pocket expenses) * eligilble for full MCD/MCR –services and supplies from state’s MCD program * services covered by both programs- paid 1st by MCR difference by MCD
PAYER OF LAST RESORT
MCD IS SECONDARY PAYER
Any other coverage must be billed first. Medicaid is billed only if the other coverage denies responsibility for payment, pays less than the Medicaid fee schedule, or if Medicaid covers procedures not covered by the other policy. * Medicaid covered services are payable only when the service is determined by the provider to be medically necessary. * inpatient (no mental) * outpatient hospital * lab/ xray * pediatric / nurse practitioner * NSF 21/ OLDER * kids under 21 physicals * family planning/supplies * dentist med/surg * home health serv / entitled to NFS (MCD program) * home health aids * med supplies / appliances * mid wife * complications preg * 60 days postpartum preg related services
MEDICALLY NEEDY GROUPS * prenatal / postnatal * post partum under 18 * under 21/over65 institute for mental disease * COPAYMENTS / COINSURANCE EXEMPT * * Accept Medicaid determined payment? you’re paid in full * Medicaid covered benefits = patients cannot be billed * Benefit not covered? patient can be billed * Medicaid patients must assign benefits to providers. * It’s illegal to attempt collection of the difference between the
/ SUPPLEMTAL HIC COVER ONLY DED, COPAY, COINS
MCR SUPPLEMENTED BY MCD
MEDI / MEDI * Follows MCR guidelines for filing deadlines * MCR beneficiaries w/ low incomes – limited resources may get help from MCD * MCR/ FULL MCD eligible (MCR is supplememted by MCD services from the state) a) more than 100 day limit for SNF , b) rx c) eyeglasses d) hearing aids
DUAL ELIGIBLES * MCR low income/ lmt resources (may receive help w/ out of pocket expenses) * eligilble for full MCD/MCR –services and supplies from state’s MCD program * services covered by both programs- paid 1st by MCR difference by MCD
PAYER OF LAST RESORT
MCD IS SECONDARY PAYER
Any other coverage must be billed first. Medicaid is billed only if the other coverage denies responsibility for payment, pays less than the Medicaid fee schedule, or if Medicaid covers procedures not covered by the other policy. * Medicaid covered services are payable only when the service is determined by the provider to be medically necessary. * inpatient (no mental) * outpatient hospital * lab/ xray * pediatric / nurse practitioner * NSF 21/ OLDER * kids under 21 physicals * family planning/supplies * dentist med/surg * home health serv / entitled to NFS (MCD program) * home health aids * med supplies / appliances * mid wife * complications preg * 60 days postpartum preg related services
MEDICALLY NEEDY GROUPS * prenatal / postnatal * post partum under 18 * under 21/over65 institute for mental disease * COPAYMENTS / COINSURANCE EXEMPT * * Accept Medicaid determined payment? you’re paid in full * Medicaid covered benefits = patients cannot be billed * Benefit not covered? patient can be billed * Medicaid patients must assign benefits to providers. * It’s illegal to attempt collection of the difference between the