Vaida Posted Fri 06th of February, 2015 22:41:57 PM
We are located in Florida and we need some clarification about Medicaid not covering Medicare deductible. If patient has Medicare as primary, Medicaid as secondary and if Medicare applies some charges to that patient's deductible, the claim then gets processed by Medicaid with the famous N45 remark - "Charges exceed reasonable and customary amounts" and therofore no payment made by them, do we need to write the charges applied by Medicare to deductible off or we can charge the paitent? I know coinsurances need to be written off of those claims that get processed by Medicaid and not covered due to exceeding Medicaid allowed amounts. But what is the general rule when it comes to deductible. This whole Medicare - Medicaid deal is so confusing! Just not sure when we can charge patients and when we can't...
SuperCoder Answered Tue 10th of February, 2015 11:32:17 AM
Thanks for your patience. One of the issues that will come into play is the type of Medicaid the patient has. This is a factor to consider when determining whether to write off the balance or bill the patient. The Medicaid EOB will indicate in a separate column the amount to bill the patient if there is any. Since you are receiving the N45 code, Medicaid is adjusting the amount because the Medicare allowable is larger than the Medicaid allowable for the service. I would suggest that you first review the EOB and determine if there are any amounts in the patient responsibility columns and then just verify the type of Medicaid that the patient has to make sure that they are not just covered for Medicare premiums only or some other restricted Medicaid. If none of those other factors are applicable, you should write off the amount. Take a look at this CMS article for more information. Hope this helps.