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ARMHS Billing Question

John-Debbie Trunk 4 years ago in Billing/Electronic Modules updated by anonymous 3 years ago 3

Hi Community,


I'm hoping someone out in the community has an answer to this question.


If an ARMHS client has Medicare as their primary insurance payer and PMAP/MA as their secondary payer and is seeing a NON-Medicare provider, how to we bypass Medicare and bill the PMAP plan or the MA plan as the primary insurance plan? Do we need a modifier to do so?If a modifier is required, what is the modifier code used bypassing Medicare, billing PMAP/MA as the primary payer.


I'm advised we should bill Medicare first and get the denial then send the claim to the secondary plan, PMAP/MA.


Does anyone have experience with this? I'd love to hear from someone. Thank you for your time.

+1

What are the credentials of the provider? You are correct that a modifier is needed and that is GY. Additionally if your provider is not an eligible Medicare provider I believe you have to send an attachment that states why they are not (I can check with my office colleague tomorrow).

+2

You will want to check with your network reps for the PMAPS/MA but we have been told that anytime the primary payer does not cover a service (which in this case Medicare would not cover non Medicare providers), that we should send it to the PMAP/MA secondary with COB info from Medicare PR 96, meaning non covered service. I also know that we can't even bill Medicare to get a denial for non Medicare providers bc it won't get through the clearing house bc Medicare knows which NPI's are Medicare, so for Medicare it's almost impossible to submit a claim to them to get a denial.

I've also had issues with the GY modifier. Last year for UCare for Seniors plans (that are Medicare related/Medicare replacement plans) I had to add the GY modifier for our clients who were seeing non Medicare providers. As of the end of 2015, UCare changed things bc we got a bunch of denials for the same clients who we were receving payments for and I finally confirmed recently with a UCare rep that if a non Medicare provider sees a UCare for Seniors client, they just need to be credentialed with UCare and we do not need to send the GY modifier. I've tried GY for other payers and it's kind of hit and miss. Good luck.

We have not had a problem not billing Medicare first for our PMAP's and MA. We don't have any of the ARMHS billing codes available for Medicare, so it skips Medicare completely and bills the secondary payer.