TMPPM 2010 > Volume 1, General Information > Section 6: Claims Filing > Medicare Claims


6.13 Medicare Claims

When a service is a benefit of Medicare and Medicaid, the claims must be filed with Medicare first. Providers should not file a claim with Medicaid until Medicare has dispositioned the claim. The payment received from Medicare and the coinsurance or deductible payment from Medicaid must be considered payment in full. Medicaid pays the beneficiary's Part A and B deductibles and coinsurance liabilities on valid Medicare claims. These guidelines exclude clients living in a nursing facility.

Providers must accept Medicare assignment to received coinsurance and deductible amounts from Medicaid services provided to clients. If a provider has accepted a Medicare assignment, the provider may receive payment of the Medicare deductible and coinsurance from TMHP on behalf of the qualified Medicare beneficiary (QMB) or Medicaid qualified Medicare beneficiary (MQMB) client.

Providers accepting Medicare or Medicaid assignment cannot legally require the client to pay the Medicare coinsurance or deductible amounts.

Medicare primary claims filed to Medicare Administrative Contractors (MACs) may be transferred electronically to TMHP through a Coordination of Benefits Contractor (COBC) for claims processed as assigned. Providers should contact their MAC for more information. This benefit allows providers to receive disposition from both carriers while only filing the claim once. Providers allow 60 days from the date of Medicare's disposition for a claim to be shown on the Medicaid R&S Report. Claims totally denied by Medicare are not automatically transferred to TMHP.

For crossover claims that are not transferred electronically, providers must submit a paper claim to TMHP.

Refer to: Subsection 2.6, "Medicare Crossover Reimbursement" in Section 2, Texas Medicaid Reimbursement (Vol. 1, General Information).

Texas Medicaid & Healthcare Partnership
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