CMS Clarifies QMB Beneficiary Payment Advice

Date: May 11, 2019

CMS recently sent a MLN (MedLearn Matters) article (link here) advising of a change in the notifications that are received on the Medicare Summary Notice (MSN) when the patient is a QMB-status beneficiary.  The change takes place on claims with dates of service on or after October 7, 2019, to allow for MACs to make the system changes needed.

CMS notes that “Federal law bars Medicare providers and suppliers from billing an individual enrolled in the QMB program for Medicare Part A and Part B cost sharing for covered items and services.”  The existing QMB remittance advice codes (N781 and N782) that you currently receive are unchanged – but the MSN messages have new information.  CMS notes that “ … claims processing systems … [did] not differentiate between paid and fully denied claims or denied service lines [and]… to show accurate patient payment liability amounts for beneficiaries enrolled in QMB.”

  • When a QMB claim is paid:
  • If an MSN includes at least one detail line for a QMB that contains an allowed amount greater than zero, page one (the summary page), will … briefly explain the QMB billing protections (in the “Be Informed!” section).
  • Also, on page one, the patient’s total liability amount (in the “Total You May Be billed” field) will omit the deductible and coinsurance amounts for details lines that are for a QMB and include an allowed amount greater than zero.
  • Further, in the claims detail section of the MSN, if the detail line is for a QMB and includes an allowed amount greater than zero, such detail line will reflect $0 (in the “Maximum You May Be Billed” field) and include [a message that] informs the beneficiary of her/his QMB status and billing protections.
  • When a claim is denied and also rejected for Fiscal Intermediary Standard System (FISS) edits:
  • In the claim detail pages of the MSN, if a detail line is for a QMB and contains an allowed amount of zero, the MSN:
    • Will reflect the beneficiary’s total liability amount in the “Maximum You May Be Billed” field and
    • Include new MSN … message to inform the beneficiary that even though Medicare has denied the claim, Medicaid may pay for the care.
  • Since most QMBs also have full Medicaid coverage, it’s important to convey that their full Medicaid coverage may cover care that Medicare has denied.

It is vitally important to know whether or not you are able to bill QMB patients.  Don’t get it wrong!

We are happy to assist with claims issues as well as other coverage topics, which include proper code selection, chart reviews, and payer actions.  We can also provide training on these or other subjects.  You can also download our “App”, Corcoran 24/7, which can be separately accessed via one of the links below.

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