Dealing With Medicaid-Integrated or "Dual Complete" Type Policies

Certain unified or "dual complete" policies, which unite Medicaid secondary coverage with Medicare or HMO primary coverage in a single policy, issue X12.835 EOBs that cause difficulties during processing and billing. This guide explains the situation and how AngelTrack handles it.

The problem is also observed in the EOBs of some standalone Medicaid policies when adjudicating as secondary.

The Problem: Dual Adjudications Under a Single Policy

The problem with these policies is that they return EOBs as though they are two separate carriers, yet both the primary and the secondary adjudication claim to be primary. It is clearly a hybrid situation that the X12.835 spec cannot handle gracefully.

For example, these policies will typically return a pair of EOBs like this:

To make matters worse, the pair of EOBs are often muddled together:

AngelTrack Requirements

Because such EOBs behave like a primary adjudication forwarded to a secondary, AngelTrack requires them to be filed in payment events in this manner. That is to say: AngelTrack requires the primary adjudication to be filed as from the primary, and the secondary adjudication to be filed as from the secondary... even though the patient does not technically have a secondary policy.

AngelTrack's EDI Import is aware of the problem and attempts to identify these secondary EOBs. When it finds one, AngelTrack displays it as "Processed as secondary (falsely reported as primary)." It will then raise a yellow warning icon, and suggest that the adjudication be imported as a secondary, rather than as the primary it claims to be.

AngelTrack will thereafter be able to properly calculate the patient responsibility, which will usually be zero.

Medicaid Carriers Do It Too

Some Medicaid carriers issue similarly ambiguous EOBs, even when the patient has distinct Medicare and Medicaid policies on file. The Medicaid EOBs claim to be "Processed as primary" (CLP02='1'), creating the exact same problem as with dual-complete/integrated policies.

When AngelTrack recognizes that the carrier is doing this, it will react as above: It will display the EOB's claim status as "Processed as secondary (falsely reported as primary)," raise a yellow warning icon, and suggest importing it as from the secondary.

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