Since July 1, 1991, the MO HealthNet Division (MHD) has been re-pricing Medicare Part A inpatient hospital crossover claims for the possible payment of Medicare deductible and co-insurance amounts. This Hot Tip is a reminder that the re-pricing policy also applies to Medicare Part C/Advantage plans for inpatient hospital services for deductible, co-insurance and co-pay amounts for participants who are QMB eligible. The following information is taken from Section 12.5.A of the Hospital Provider Manual.
MO HealthNet is responsible for deductible and coinsurance amounts for Medicare Part A crossover claims only when the MO HealthNet applicable payment schedule exceeds the amount paid by Medicare. In those situations where MO HealthNet has an obligation to pay a crossover claim, the amount of MO HealthNet’s payment is limited to the lower of the actual crossover amount or the amount the MO HealthNet fee exceeds the Medicare payment. The hospital’s remittance advice will show the amount to be paid for each re-priced Part A/Part C crossover claim. The system will post claim adjustment reason code OA-045 (charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement) and remittance advice remark code N-59 (please refer to your provider manual for additional program and provider information) for those claims where Medicare has paid more than MO HealthNet would.
Amounts not reimbursed by MO HealthNet for allowable crossover claims may not be billed to the MO HealthNet participant.
The Part A Medicare deductible for inpatient services is always applied to the day of admission or the first day in the hospital stay that the individual becomes Medicare eligible. If the patient is not MO HealthNet eligible on the day the deductible is applied, MO HealthNet does not pay the deductible and it becomes the responsibility of the patient to pay for the deductible.