Coordination of Benefits : Medicare

Dual-Eligibility During Inpatient Stay

If a member becomes eligible for both Medicare and Wisconsin Medicaid during an inpatient stay, submit the claim to Medicare first.

Use the following billing instructions for dual-eligibles whose Medicare Part A benefits are exhausted prior to or during an inpatient hospital stay or when a member gains Medicare Part A benefits mid-stay.

Part A Benefits Exhausted Prior to Admission (No Part A)

• Bill Medicare for all Medicare Part B billable ancillaries for the noncovered Medicare Part A days. Wisconsin Medicaid allows and pays the coinsurance and any deductible on those Medicare-approved services through the outpatient crossover claim.
• Bill Wisconsin Medicaid for all inpatient charges including the Medicare Part B charges.
• In Form Locators 39–41 a–d of the UB-04 Claim Form, use the value code "AB" and state the total Medicare allowed amount for Medicare Part B services (not the Medicare payment amount).
• Indicate the Medicare disclaimer code "M-7" or "7" on the Explanation of Medical Benefits form. Wisconsin Medicaid pays the straight Wisconsin Medicaid inpatient claim deducting the amount shown with value code AB from the DRG reimbursement since this amount was already paid through the outpatient crossover claim.
• Do not attach the Medicare RA to this claim.
• Bill Medicare for the Professional Component charges on the 1500 Health Insurance Claim Form. Wisconsin Medicaid allows and pays the coinsurance and any deductible on those Medicare-approved services through the professional crossover claim.

Part A Benefits Exhausted or Gained Mid-Stay (Partial Part A)

• Bill Medicare for all charges for the entire stay. Medicare approves and pays the Medicare Part A covered days. Wisconsin Medicaid allows and pays the coinsurance and any deductible on those Medicare-approved days through the inpatient crossover claim.
• Bill Medicare for all Medicare Part B billable ancillaries for the noncovered Medicare Part A days. Wisconsin Medicaid allows and pays the coinsurance and any deductible on those Medicare-approved services through the outpatient crossover claim.
• Bill Wisconsin Medicaid for all inpatient charges for the entire stay, including the Medicare Part B charges.
• In Form Locators 39–41 a–d of the UB-04 Claim Form, use value code "AB" to indicate the Medicare paid amount for both Medicare Part A and Medicare Part B services. Wisconsin Medicaid pays the straight Wisconsin Medicaid inpatient claim deducting the total amounts shown with value code AB from the DRG reimbursement since these amounts were already paid through the outpatient and inpatient crossover claims.
• In Form Locators 31–34 of the UB-04 Claim Form, indicate occurrence code "C3" and the date that Medicare Part A benefits were exhausted.
• On the Explanation of Medical Benefits form, within Section IV (Header Adjudication Information):
  • Enter the date Medicare processed the claim in Element 8 (Date Payer Processed).
  • Enter only the dates Medicare covered the service in Element 9 (From Date of Service) and Element 10 (To Date of Service).
  • Enter Medicare disclaimer code "M-7" or "7" in Element 11 (Paid/Deny).
  • Enter the amount billed to Medicare in Element 12 (Billed Amount).
  • Enter the amount paid by Medicare in Element 14 (Paid).
  • Leave Elements 15–21 blank.
• Leave Section V (Detail Adjudication Information) blank of the Explanation of Medical Benefits form.
• Do not attach the Medicare RA to this claim.