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What are guidelines for filing a Medicare claim as a non-participating provider when patient has Medicaid as secondary?


All Medicare providers, participating or non-participating, are required to file insurance for Medicare beneficiaries. Participating providers must accept assignment on all Medicare claims. A non-participating provider has the choice to accept or not accept assignment on a claim by claim basis.

If assignment is accepted by a non participating provider, payment is made by Medicare directly to the practice. Reimbursement is 80% of the non-par allowed fee (the non-par allowed fee is 95% of the par allowed fee). The claim should automatically cross over to Medicaid. If the provider is a Medicaid participating provider (either full provider status or Medicare only status), Medicaid also pays the provider directly for the coinsurance and deductible portion of the claim. If the provider is not a participating Medicaid provider, the claim will be rejected by Medicaid without adjudication. The patient must stay in the system to get secondary benefits.

If the provider chooses not to accept Medicare assignment, Medicare makes this payment directly to the Medicare beneficiary. Medicaid does not pay secondary benefits on non assigned Medicare claims. The provider may receive payment of the Medicare deductible and coinsurance on behalf of special classes of Medicare beneficiaries, known as Qualified Medicare Beneficiaries (QMBs) who qualify for Medicare catastrophic benefits. Some of these patients may also qualify for Medicaid benefits. These are classified as Medicaid Qualified, Medicare Beneficiaries (MQMB).

Therefore to insure your secondary payment from Medicaid, as a non participating provider, you must accept assignment from Medicare. Medicare will pay you directly for 80% of the allowed amount less any deductible. The claim will cross over to Medicaid and if you are a participating provider with Medicaid they will pay you directly for coinsurance and deductibles.


Russ B. Still
Executive Vice President

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