CMS 1500 Secondary Claims: Dual Eligible Filing Instructions for Medicare to Medicaid Billing

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Step-by-Step Guide: Filing CMS 1500 Claims with Medicare Primary and Medicaid Secondary

This comprehensive guide provides detailed instructions for healthcare providers navigating the complex process of filing CMS 1500 secondary claims when Medicare is the primary payer and Medicaid is secondary. Understanding the specific requirements for dual-eligible claim filing is crucial for accurate reimbursement and avoiding common billing errors.

Table of Contents

Understanding Dual Eligibility for Medicare & Medicaid

When medical services are provided to a client who is entitled to both Medicare benefits under the Social Security Act and Medicaid benefits, they are considered "dual eligible." In these scenarios, Medicare is almost always the primary payer. It is therefore necessary that you file a claim with Medicare first. After you receive payment from Medicare, you may then file a claim to the appropriate state Medicaid agency or its current contractor or fiscal agent for reimbursement consideration of any remaining patient liability or services covered by Medicaid but not Medicare.

Filing Your Primary Medicare Claim (CMS 1500)

Each performing provider’s services must be billed on a separate CMS 1500 claim form to Medicare as the primary payer. Once Medicare processes the claim, they will issue a payment and a statement. For providers, this statement is typically known as a Remittance Advice (RA) or Electronic Remittance Advice (ERA). For beneficiaries, it is a Medicare Summary Notice (MSN). It is essential for providers to utilize the RA or ERA to obtain Medicare payment information when preparing secondary claims for Medicaid.

Key Adjustments for Medicaid Secondary Claims on CMS 1500

In order to submit a Medicare/Medicaid secondary claim to your state’s Medicaid agency, you must submit an original CMS-1500 claim with specific fields altered from your primary Medicare claim. These alterations ensure that Medicaid can correctly process the claim as secondary to Medicare.

Specific Field Modifications for Secondary Medicaid Claims

  • Field 1a – Insured's ID Number: Complete this field with the client’s Medicaid Identification (ID) number. This is crucial as it correctly identifies the patient within the state Medicaid system for benefit eligibility and claims processing, distinct from their Medicare ID.
  • Field 24J – Rendering Provider ID: Complete this field with the performing (rendering) provider’s National Provider Identifier (NPI) or their Atypical Provider Number if applicable. This ensures Medicaid can accurately identify the individual clinician who delivered the services.
  • Field 29 – Amount Paid: This field requires careful attention for secondary Medicaid claims. While you should not enter the Medicare paid amount directly here, it’s vital to ensure Medicaid understands the Medicare payment. For secondary Medicaid claims, Field 29 should generally indicate the total amount of funds received from other third-party insurance sources excluding Medicare. The Medicare payment information itself is typically conveyed to Medicaid through the attached Remittance Advice (RA) or Medicare Summary Notice (MSN), allowing Medicaid to calculate the remaining patient liability or covered amount. Consult your specific state’s Medicaid guidelines; some states may require a specific override code or a zero value if no other third-party payments exist, with the expectation that Medicare payment details are clearly outlined in attachments.
  • Field 31 – Signature of Physician or Supplier: Each paper claim form must bear an original signature, dated by the physician or supplier, or their authorized representative. This certifies the accuracy and completeness of the claim and serves as a legal attestation for Medicaid processing.
  • Field 33a – Billing Provider NPI: Complete this field with the National Provider Identifier (NPI) of the billing provider (the entity submitting the claim), or their Atypical Provider Number if applicable. This ensures proper identification of the entity responsible for the billing for Medicaid.

Handling Multiple Service Lines and Preventing Detail Errors

Each performing provider’s services must be billed on a separate claim form to ensure clarity and proper processing, especially when filing secondary claims. When dealing with the CMS 1500 form, be aware of the limitation to a maximum of six service lines per claim. If a single patient encounter involves more than six distinct services, you will need to utilize multiple CMS-1500 forms or a continuation sheet, clearly indicating that it’s a multi-page claim. The instruction "no double details in one box" means that each data field on the CMS 1500 form should contain only one piece of specific, relevant information. For example, do not combine two different diagnosis codes or service dates into a single field. This attention to detail prevents processing delays and potential denials from Medicaid.

Avoiding Common Denials in Dual Payer Billing

To facilitate smooth processing, you must include a copy of the Medicare Remittance Advice (RA) or Medicare Summary Notice (MSN) with the secondary Medicaid claim, with the client’s name clearly circled on the document. Each dual-eligible client listed on the RA/MSN must have a separate claim filed with the appropriate documentation. It is important to note that generally, charges denied outright by Medicare will not be paid by Medicaid. However, exceptions exist for services: (1) not covered by Medicare but within Medicaid’s scope of covered benefits, or (2) covered by both programs but with differing limits, criteria, or medical necessity determinations. In these specific instances, Medicaid will assess coverage based solely on its own state policies and regulations. Always refer to Common Medicaid Coverage Policies specific to your state.

Medicaid Timely Filing Limits: State-Specific Guidance

A critical aspect of successful Medicaid secondary billing is adhering to timely filing limits. These limits are set by each individual state’s Medicaid program and can vary significantly. Failure to submit claims within the specified timeframe will result in denial of payment, regardless of medical necessity or eligibility. It is imperative to consult your specific state’s Medicaid provider manual or website for the most current and accurate information on timely filing requirements. Proactive tracking of Medicare payment dates and prompt submission of secondary claims are essential practices.

Important Disclaimer: Consult Official Guidelines

It is crucial to remember that healthcare billing regulations, especially for complex dual-payer scenarios involving Medicare and Medicaid, are subject to frequent changes and can vary significantly by state. The information provided in this guide is for general informational purposes only and should not be considered legal or professional advice. Always consult the most current official CMS (Centers for Medicare & Medicaid Services) guidelines and your specific state’s Medicaid provider manuals, bulletins, or fiscal agent communications for the latest and most accurate billing instructions. For specific questions or challenging claims, contact your Medicare Administrative Contractor (MAC) or state Medicaid contractor directly.


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