Dual-Eligible Special Needs Plan (D-SNP) billing
PriorityMedicare D-SNP is Priority Health's dual-eligible special needs plan. Members with this plan are eligible for both Medicare and full Medicaid benefits. If you provide services to PriorityMedicare D-SNP members, review the below billing information. Note that this information applies to all dual-eligible beneficiaries, not just those enrolled in PriorityMedicare D-SNP.
Billing prohibitions for dual-eligibles
Certain billing prohibitions apply to the dual eligible beneficiaries you serve. Federal law prohibits all Medicare providers and suppliers from billing dual-eligible beneficiaries (also known as Qualified Medicare Beneficiaries or QMBs) for Medicare Part A and Part B cost-sharing (i.e. copays, coinsurance or deductibles) under any circumstances. These beneficiaries have Medicaid coverage of Medicare Part A and Part B premiums and cost-sharing.
Providers and suppliers may bill State Medicaid agencies (Michigan Department of Community Health) for Medicare cost-sharing amounts. However, as permitted by Federal law, States can limit Medicare cost-sharing payments, under certain circumstances. Regardless, individuals enrolled in the QMB program have no legal liability to pay Medicare providers for Medicare Part A or Part B cost-sharing. Medicare providers who do not follow these billing prohibitions are violating their Medicare Provider Agreement and may be subject to sanctions.
For more information, see MLN Matters SE1128.
Billing & payment topics
- Status claims
- Claims Inquiry tool guide
- Edits Checker tool guide
- Claim deadlines
- Set up electronic payments
- BH provider billing
- Facility billing
- Advanced practice professional billing
- Professional billing
More billing topics:
- ACA non-payment grace period
- Balance billing
- Clinical edits
- Check reissue procedure
- COB: Coordination of benefits
- Correcting claims
- Correcting overpayments & underpayments
- Diagnosis coding
- Dual-eligible members
- Front-end rejections
- Gender-specific services
- Medicaid billing
- NDC numbers on drug claims
- Office-based procedures billing
- Risk adjustment
- Unlisted codes, drugs & supplies