14 CLAIM SUBMISSION AND ADJUDICATION PROCEDURES
14.17 Cost Sharing
Billing Members & Balance Billing
An important protection for beneficiaries when they obtain plan-covered services in an HMO, PPO, or RPPO is that they do not pay more than plan-allowed cost-sharing. Providers who are permitted to balance bill must obtain this balance billing from the MAO. Providers may not collect any additional payment for costsharing obligations from Medicare members other than those specified in a member’s plan Summary of Benefits.
Under Original Medicare rules, an Original Medicare participating provider (hereinafter referred to as a participating provider) is a provider that signs an agreement with Medicare to always accept assignment. Participating providers may never balance bill because they have agreed to always accept the Medicare allowed amount as payment in full. An Original Medicare nonparticipating provider (hereinafter referred to as a nonparticipating, or non-par, provider) may accept assignment on a case-by-case basis and indicates this by checking affirmatively field 27 on the CMS 5010 claims form; in such a case, no balance billing is permitted.
In the case of dual-eligible members covered by both Medicare and Medicaid, federal law requires providers to bill only the member’s Medicaid health plan or the state Medicaid agency for copays or other cost-sharing amounts. Providers may not bill such members for cost sharing. The chart below indicates how cost sharing is paid, either by IntegraNet or the state Medicaid agency. IntegraNet processes the claim for reimbursement when IntegraNet has an arrangement with state Medicaid to pay Medicare cost sharing for dual-eligible members in its Special Needs Plans (SNP). The state retains responsibility for cost sharing when IntegraNet does not have an arrangement with the state Medicaid agency. In states where IntegraNet pays cost sharing, claims will be processed under the member’s account for both Medicare and Medicaid benefits. In the states where IntegraNet does not have an arrangement with the state Medicaid agency, providers should bill cost sharing to the appropriate Medicaid carrier or state Medicaid agency for payment once the claim has been processed by IntegraNet. Please check your EOP upon claims adjudication.