Medicaid/Medicare Billing and Insurance Search

[pharmalt82]

If a ptn has both medicare-D and medicaid, you bill their PART D first, right? No COB at all.
Most things are paid for by part D and medicaid picks it up if medicare does not cover something.
At WAGS, you can use FINDMPD to lookup part D information.
However, what scenarios FINDINS be useful for? Finding private insurance?

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[ravingrabbid]

For dual coverage - bill medicare part D first, then if it's not covered, try medicaid. Medicaid will usually reject you anyway if you try to bill before part D. Medicaid has its own formulary posted online (or Medi-cal), so no, you technically wouldn't need to bill Part D first to see if it's ok to bill Medicaid (but you would need to know if it's covered)

COB - this can be done but I believe there's special exceptions in order to fall into that category e.g., disability/transplant/etc. Usually, the patient should/would tell you that or at give you some sort of letter.

FINDINS - only good for finding private insurance (that's why FINDMPD is used exclusively for finding their medicare coverage)

 

[pharmalt82]

For dual coverage - bill medicare part D first, then if it's not covered, try medicaid. Medicaid will usually reject you anyway if you try to bill before part D.

FINDINS - only good for finding private insurance (that's why FINDMPD is used exclusively for finding their medicare coverage)

Do you need to have Medicaid see the Part D reject in order for you to bill Medicaid for something that isn't covered by Medicare?
COB?

 

[Lnsean]

Do you need to have Medicaid see the Part D reject in order for you to bill Medicaid for something that isn't covered by Medicare?
COB?

DOUBLE CHECK YOUR STATE. in new jersey..medicaid no longer picks up things that are not covered by medicare D. all things must go through medicare part D (their copays will be 0...1.15...or 3.50). In the past, if medicare part D didn't cover....you could SDL it to medicaid with reject code "primary insurance exist, claim not covered" and bill the entire cost to medicaid...and YES medicaid had to see rejection from Part D in order for you to put in this reject code and bill them directly....otherwise you will aways get "BILL OTHER PRIMARY PROCESSOR" as the rejection when straight billing medicaid.

 

[pharmalt82]

DOUBLE CHECK YOUR STATE. in new jersey..medicaid no longer picks up things that are not covered by medicare D. all things must go through medicare part D (their copays will be 0...1.15...or 3.50). In the past, if medicare part D didn't cover....you could SDL it to medicaid with reject code "primary insurance exist, claim not covered" and bill the entire cost to medicaid...and YES medicaid had to see rejection from Part D in order for you to put in this reject code and bill them directly....otherwise you will aways get "BILL OTHER PRIMARY PROCESSOR" as the rejection when straight billing medicaid.

I'm in NY. This makes sense. For example, for COCs, NYMED must see a rejection from the medicaid managed care plan in order to pick up the tab for it. This has to be done via SDL after a TPR has been created. This only applies to those managed care plans that don't pay for COCs.

 

[BidingMyTime]

In Illinois, 99.99% of drugs will not be covered by Medicaid, once the person is Medicare eligible (and if they don't sign up on their own, Medicaid will do the sign-up for them.) As far as I'm aware, there is no COB billing at the pharmacy level....any COB'ing is set up behind the scenes with the Medicare Part D plan--the pharmacy will see the subsidized co-pay when they bill the part D plan (if they aren't, then the pt needs to contact their caseworker to set that up with the Medicare Part D) Drugs which are excluded by law from being in any Medicare Part D plan, can be billed directly to Medicaid (for practical purposes, benzodiazepines & BCP's are the only excluded drugs that are covered, most of the other excluded drugs Viagra, weight loss drugs, etc. will not be covered by Medicaid because Medicaid provides no coverage for those drugs. Drugs which aren't covered just because they aren't on the Part D's formulary, will not be covered by Medicaid)