Special Billing For Medically Needy Recipients

Introduction 
A Medically Needy recipient is an individual who would qualify for Medicaid,
except that the individual’s income or resources exceed Medicaid’s income or
resource limits. On a month-by-month basis, the individual’s medical expenses
are subtracted from his or her income. If the remainder falls below Medicaid’s
income limits, the individual may qualify for Medicaid for the month or for part of
the month. The amount of expenses that must be deducted from the
individual’s income to make him or her eligible for Medicaid is called a “share of
cost.”

Medically Needy recipients can receive targeted case management services.
Medically Needy recipients are not eligible to receive home and communitybased
waiver services.



Split Billing and CF-ES 2902 Form


If a recipient incurred medical expenses from multiple providers on the date he
met his share of cost (first day of eligibility), any medical expenses from a
single provider that were used in full to meet the share of cost are not eligible for
Medicaid reimbursement. Any expenses from a single provider that were not
used in full to meet the share of cost are eligible for reimbursement. This
process, known as “split billing,” is actually split-day billing—no individual
claims are split and no claims from a single source are split. This process
occurs infrequently.

If not all of the recipient’s medical expenses incurred on the first day of eligibility
are eligible for Medicaid reimbursement, the MEVS split bill indicator will be “Y.”
The public assistance specialist will mail a pink copy of the Medically Needy
Billing Authorization, CF-ES 2902 Form, to the providers whose expenses are
eligible for reimbursement. Providers must submit the CF-ES 2902 Form with
their claims so the Medicaid fiscal agent will know that the claims are eligible
for reimbursement.

If the MEVS split bill indicator is “N,” then all the recipient’s expenses incurred
on the first day of eligibility are eligible for reimbursement and a CF-ES 2902
Form is not required.



Receiving a CF-ES 2902 Form
When a provider receives a pink copy of a CF-ES 2902 Form, the provider must
check the bottom right-hand corner of the form, under the caption “Period of
Eligibility,” and make sure that the dates of service on the claim fall within the
recipient’s period of eligibility.

If the service was performed on the first day of eligibility indicated on the
CF-ES 2902 Form, the form must be submitted with the claim. If the service
dates are after the first day of eligibility, the form does not need to be submitted
with the claim.

Instructions for Submitting a CF-ES 2902 Form


If one or more services were provided on the first day of eligibility, follow the
instructions below.
·  Attach the pink copy of the CF-ES 2902 Form to the claim being sent to the
Medicaid fiscal agent if appropriate as described above.
·  The provider should make a photocopy of the pink copy for the office record.
·  If a claim is for a Medically Needy recipient and was originally filed with a
pink CF-ES 2902 Form and must be resubmitted or adjusted, a photocopy
of the CF-ES 2902 must accompany the claim resubmission or adjustment.
·  When submitting a photocopy of CF-ES 2902 Form, the provider must enter
the transaction control number (TCN) of the previous claim on the
photocopy of the CF-ES 2902 Form, in the box labeled “For Provider Use
Only” in the upper right corner of the CF-ES 2902 Form. The photocopy will
be rejected if the provider does not enter the previous claim’s TCN on the
form.