EOMBs: Stay on top of it...it's your money

Wednesday, November 30, 2005

Q. I just received some EOMBs following a favorable ALJ ruling on a number of claims that our DMERC initially denied to pay. There was, however, no notation that the claims were crossed over, and I know these were Medicaid patients. What gives?
A. They probably did not get forwarded to the appropriate Medicaid state for you. Under the Coordination of Benefits Agreement (COBA), carriers and DMERCs are required to cross claims over to any approved Medicare supplemental insurance company, including state Medicaid. This crossover happens automatically on almost all initial claims.
Unfortunately, that doesn't happen if the initial determination or redetermination (formerly carrier review) is unfavorable and the supplier is forced to pursue further appeal. If the supplier wins the appeal--either redetermination (formerly carrier hearing) or at the ALJ level--the decision is effectuated but there is no automatic crossover.
What should you do? Check the original EOMB issued with the unfavorable initial determination for the indication of a Medicare supplemental insurance company. Send a copy of that EOMB and the one showing the effectuation with no crossover indicated to the DMERC asking them to correct the error.
If you don't have an answer in a reasonable period of time, forward everything to the CMS Regional Office and ask them to intercede on your behalf. Stay on top of it...it's your money.
Michael Watson is vice president of government affairs for American Medical Technologies. Reach him at michaelwatson207@sbcglobal.net or (707) 542-0330.