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New Provider EOB message for QMB program claims

August 3, 2018

The Qualified Medicare Beneficiary (QMB) program is a state Medicaid benefit that pays Medicare premiums and cost-sharing for certain low-income Medicare beneficiaries. Federal law states that Medicare providers may not collect Medicare Part A and Medicare Part B cost-sharing (i.e., copayments, coinsurance, or deductibles) from those enrolled in the QMB program. Please remember that when billing Independence for services rendered to these members, you must accept our reimbursement, according to your Agreement with Independence, as payment in full. All Original Medicare and Medicare Advantage providers ? not only those who accept Medicaid ? must abide by these billing prohibitions.

Unfortunately, the Centers for Medicare & Medicaid Services (CMS) have found that improper billing issues persist. Therefore, we have taken steps to assist with member education and provider compliance by adding specific messaging related to member cost-sharing when claims are processed.

Provider notification

Below are new messages that will appear on claims submitted for members in the QMB program.

Provider EOB

The following message will appear on your Provider Explanation of Benefits (EOB):

    The patient is a CMS Qualified Medicare Beneficiary. Do not bill for any deductible, coinsurance, or copay amounts.
835 transaction

One of the following Remittance Advice Remark Codes (RARC) will appear in the MIA or MOA segments of the 835 transaction:

  • N781: No deductible may be collected as patient is a Medicaid/Qualified Medicare Beneficiary. Review your records for any wrongfully collected coinsurance, deductible or co-payments.
  • N782: No coinsurance may be collected as patient is a Medicaid/Qualified Medicare Beneficiary. Review your records for any wrongfully collected coinsurance, deductible or co-payments.
  • N783: No co-payment may be collected as patient is a Medicaid/Qualified Medicare Beneficiary. Review your records for any wrongfully collected coinsurance, deductible or co-payments.

Member notification

To help our members understand the QMB program?s billing restrictions, the following message will appear on the Member EOB:

    Providers may not bill you for deductibles, coinsurance, or copay amounts as long as you remain a CMS Qualified Medicare Beneficiary.

These messages will appear on QMB program claims processed on or after July 20, 2018.

For more information on the QMB program, read the updated Prohibition Billing Dually Eligible Individuals Enrolled in the QMB Program article on CMS?s website.


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