Electronic vs. Paper Billing - basic overview from Molina insurance

Medicaid  claims  that  are  secondary  to  insurance  or  Medicare  coverage,  including  Medicare HMOs, may be billed electronically either through electronic vendors or through Molina’s web portal.  Contact the EDI Help Desk for access to submitting claims on the web portal.

Medicare Primary Claims 

Many Medicare primary claims crossover to Medicaid automatically from the Medicare Part A and Part B carriers through the Coordination of Benefits Agreement (COBA), but some do not.  Claims that do not crossover, and therefore must be billed separately by providers include:

*** Outpatient claims from Part A Medicare carriers (such as NGS)
*** Long Term Care (LTC) claims from Part A Medicare carriers
*** Anesthesia claims from Part B Medicare carriers (on crossover, these are rejected because
claims are billed in “minutes” not “units”)
*** Claims processed by Medicare HMOs.

All of these types of claims may be billed electronically to Medicaid.  Medicare paid amounts, deductible amounts, and coinsurance amounts are required for Medicare approved services and Medicare Action Codes are required for services denied by Medicare.  This information is re-quired at the claim line level for professional services billed on the 837P format and at the head-er level for institutional services billed on the 837I format.  

***  Allowed amount, paid amount, deductible, and co-insurance information must be billed in the Medicare segments, not the TPL segments, or the claim will not process correctly.  

***  Medicare HMO co-pay amounts are to be billed as deductible.  ***  Claims denied by Medicare HMOs may be billed electronically if the denial is a HIPAA com-pliant denial code or Medicare Action Code (MAC).

***  Denied claims that are not denied with a MAC must be billed on paper with copy of EOMB including the denial reason in addition to the denial code.  

***  All Medicare HMO claims billed on paper must have “Medicare HMO” written on the EOMB to assure correct processing .

Third Party Liability—TPL Primary claims 

Providers must seek reimbursement from private insurance prior to billing Medicaid.  These sec-ondary claims may be billed electronically if the insurance carrier approved the service. Claims that were denied by the primary carrier, or contain denied claim lines, must be billed on paper with a copy of the EOB that includes a description of the denial in addition to the denial codes.

Medicare and TPL Claims 
If a member has Medicare and TPL coverage, claims may be billed electronically if both carriers made payments for the service.

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