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December 2016 Texas Medicaid Provider Procedures Manual

Section 6: Claims Filing : 6.12 Filing Medicare Primary Claims : 6.12.2 Paper Crossovers Claims : 6.12.2.1 Deductible or Coinsurance Amount Balancing

6.12.2.1
The Texas Medicaid claims processing system validates that the total Medicare deductible and coinsurance amounts on the claim header match the sum of the detail Medicare deductible and coinsurance amounts.
For paper crossover claims, providers must submit the same information to Texas Medicaid that was received from Medicare.
Texas Medicaid will reimburse Medicare crossover claims up to the Texas Medicaid allowed amount for Medicaid-covered services. System enhancements have been identified to ensure appropriate age restrictions are enforced applicable to the services rendered.
Example:
For a Medicare service provided to an adult client, if that service is only payable to Medicaid for clients who are 20 years of age and younger, the age restriction will be applied and the Medicaid allowed amount will be zero. Since the Medicare payment exceeds the Medicaid allowed amount or encounter payment for the service, Texas Medicaid will not make a payment for coinsurance liabilities.
Because Medicare reimbursed more than Medicaid allowed, the client has no liability for any balance or Medicare coinsurance related to the rendered services.

Texas Medicaid & Healthcare Partnership
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