Medicare Secondary Claims Processing Incorrectly, TR 41671

May 19, 2014

Some Medicare secondary claims are processing incorrectly. This issue affects claims that are processing after Medicare for providers who are eligible to receive coinsurance and deductible. These claims are for members who are dual eligible (they have both MaineCare and Medicare). Claims submitted for QMB-only members are not affected by this issue.

Instead of processing the coinsurance/deductible amount, the system is using lesser than logic. For providers who receive Provider Incentive Payments (PIP), this error can cause a negative balance, which results in the claims being held in a “waitpay” status.

We will notify you when this issue has been corrected. Affected claims will be reprocessed and no provider action is needed.