QMB Indicator in the Medicare fee-for-service claims processing system

Under federal law, Medicare providers may not bill individuals enrolled in the QMB program for Medicare deductibles, coinsurance, or copayments, under any circumstances.  State Medicaid programs may pay providers for Medicare deductibles, coinsurance, and copayments. However, as permitted by Federal law, states can limit provider reimbursement for Medicare cost-sharing under certain circumstances. Nonetheless, Medicare providers must accept the Medicare payment and Medicaid payment (if any, and including any permissible Medicaid cost sharing from the beneficiary) as payment in full for services rendered to an individual enrolled in the QMB program.

To more clearly identify QMB members, Medicare will begin providing Remittance Advice Remark Codes (RARC) to providers indicating a members QMB status.  The indicators are:

  • 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.

When the RARC is included on a providers remittance advice, the provider billing staff is responsible for ensuring no collections are attempted for coinsurance and deductibles as indicated.

The new rules are scheduled to go into effect October 2, 2017.  Billing staff of providers and suppliers should be aware of this change.

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