Medicare /Medicaid patients


(Daniel) #1

When an ERA is uploaded to OpenEMR and there are patients that have secondary insurance, shouldn’t the encounter be marked as ‘unbilled’ and the secondary insurance populates? I’ve been having a tough time with Medicare /Medicaid patients. It seems to mark the encounter as billed even after the ERA is posted. I dn’t think this is happening with other insurances. Any ideas?


(Stephen Waite) #2

are they crossover claims?


(Daniel) #3

stepping through the code they are getting a value of 1 for crossover. Is that supposed to happen? When I upload the ERA with update, I get the following message:

This claim is processed by Insurance 1 and automatically forwarded to Insurance 2 for processing.

but when we do a search for unbilled, none of the encounters that we want to send to Medicaid appear.


(Daniel) #4

They have to send the claims to Medicaid themelves, it doesn’t happen automatically when they send claims to Medicare. Maybe the cross-over is what is the game stopper.


(Stephen Waite) #5

in the era there’s a TT segment that indicates the claim was crossed over to the secondary payer and one usually waits 30 days before sending the secondary claim which would most likely be a duplicate


(Daniel) #6

Just to clarify, when the TT is placed in the NM1 segment, this indicates the clearing house sent the payment to Medicaid for payment. If the clinic resends the claim to Medicaid, you are saying that it would be a duplicate.


(Stephen Waite) #7

yes, medicare sends the claim to medicaid (clearinghouse or network service vendor sends claim to medicare originally) then they forward the details of the claim’s payment to the crossover. The crossover can also be a medigap, aka commercial medicare supplement.


(Daniel) #8

Are there any occasions where Medicare / Medicaid claims are not crossover?


(Stephen Waite) #9

sure, then there won’t be the TT record and the billing manager will show them for you, hopefully :slight_smile:
and there are times when it doesn’t crossover even when the TT comes along so you’ll have to find them in the collections report pending


(Daniel) #10

This is where I am confused. According to the billing department, when a Medicare claim was processed, they would fall into the secondary billing queue as a unbilled Medicaid claim. They would then process the X12 and send it to Medicaid. Now, this doesn’t happen and they are several months behind in getting paid.

Now this behavior of claims not going to secondary billing as unbilled started happening in October. I’m wondering if something in the clearing house end changed.


(Daniel) #11

When they hit collections report pending, is there a way that I can quickly mark them as unbilled so we can send the batch?

I’m wondering if I should make changes to an existing report or create a new one that allows me to choose multiple Medicare/Medicaid claims so we can send them to medicaid.

Here is a statement directly from my customer: " Also, I have already reached out to Medicare and their response is that they que the claims to crossover, but they do not always crossover. It is the Provider’s responsibility to make sure their claims are getting to the Secondary"


(Stephen Waite) #12

no, it would have to be a custom report afaik