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.