Attention All Medicaid Providers - Medicare Crossover Update

This weekend, NCTracks implemented system logic to more precisely pay Medicare crossover claims in accordance with State law and the North Carolina State Plan approved by the Centers for Medicare and Medicaid Services (CMS) on a claim specific basis. The amount of payment is the difference in the amount paid by Medicare and the Medicaid Allowable amount up to the actual amount of the Medicare Coinsurance or Deductible or both.

This information applies to all secondary claims submitted to NCTracks, not just Medicare crossovers (with the exception of pharmacy). This includes institutional claims. Secondary claims previously paid will be reprocessed by February 15, 2014. No action is required by providers.

The Medicare crossover claim adjudication logic is as follows:

Medicaid Allowable minus Medicare Paid Amount equals the Net Medicaid Allowable. Next, the Net Medicaid Allowable is compared to the Medicare Coinsurance Amount and the lesser of the two is the amount payable by Medicaid.

The following examples illustrate this calculation:

  Example #1 Example #2
Total Billed Charges 159.00 159.00
Medicare Allowed Amount 100.34 80.26
Medicare Paid Amount 79.95 64.21
Medicare Contractual Adjustment (58.66) (78.74)
Medicare Coinsurance Amount 20.39 16.05
     
Medicaid Allowable 84.29 85.20
Medicare Paid Amount (79.95) (64.21)
Net Medicaid Allowable 4.34 20.99
     
Lesser of Medicare Coinsurance and Net Medicaid Allowable Amount 4.34 16.05

Please also note example 2 in NCTracks Fact Sheet dated May 30, 2013. This bulletin is to further clarify the payment logic.

Although Medicare crossover claims have been processed based on logic that limited the Medicaid reimbursement to the “lesser of” the Medicare cost share amount (coinsurance, deductible, or both) or the Medicaid allowable, the amounts paid to professional providers (i.e., submitted on claim format CMS 1500 or 837P) may not be equal to the amount paid for claims processed on the prior Medicaid claims system administered by HP/EDS because it lacked the capability to perform such calculations on a claim specific basis. Instead, the prior Medicaid claims system included a “work around” that estimated the amount payable. In some cases, the “work around” paid more than the amount payable in accordance with State law and the North Carolina State Plan approved by CMS.

In addition, the prior Medicaid claims system made such payment determinations based on “header level” rather than a “detail level.” As a result of NCTracks processing claims based on the “detail level,” specific services that are not covered by Medicaid will be denied and not included in the payment calculation.

Medicare crossover claims previously processed by NCTracks with dates of service on and after July 1st will be reviewed and re-processed, if necessary, by February 15, 2014 to ensure that payment is made in accordance with State law and the North Carolina State Plan approved by CMS.  No action is required by providers.