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2012 Texas Medicaid Provider Procedures Manual

Volume 1, General Information : Section 4: Client Eligibility : 4.11 Medicare and Medicaid Dual Eligibility : 4.11.2 Medicare Part B Crossovers

Based on Medicare determination of the beneficiary’s eligibility and the status of the annual deductible, the Medicare intermediary pays the provider a percentage of the allowed amount for covered Part B services. Medicaid pays the deductible if any is applied to the Medicare claim. Medicaid also pays the coinsurance liabilities according to Medicaid benefits and limitations.
Federal regulations require that Texas Medicaid pay all Medicare deductible and coinsurance payments to nursing facilities, regardless of whether the provider has filed the claims as assigned to Medicare. The following qualify as Medicare Part B crossover claims: QMB, MQMB, and client TPs 13 or 14, with base plan 10, and category R.
Therefore, even if the provider has not accepted Medicare assignment, the provider may receive payment of the Medicare deductible and coinsurance on behalf of the QMB, MQMB, client TPs 13 or 14, base plan 10, and category R client. If the provider has collected money from the client and also received reimbursement from TMHP, the provider is required to refund the client’s money.
The Social Security Act requires that Medicaid payment for physician services under Medicare Part B be made on an assignment-related basis.
If Medicaid does not reimburse or does not reimburse the full deductible or coinsurance, the provider is not allowed to bill the client.

Texas Medicaid & Healthcare Partnership
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