CMS to Reinstate QMB Indicator in Medicare FFS Claims Processing System

February 2018 ~

CMS has issued a notice announcing the agency will reinstate the Qualified Medicare Beneficiary (QMB) Indicator in the Medicare Fee-For-Service (FFS) Claims Processing System in an effort to prevent providers from illegally billing some Medicare beneficiaries for cost-sharing.

The agency states in the notice that effective July 1st it will begin sending communications alerting providers when certain beneficiaries should not be billed for cost-sharing.

As stated in the notice: “Effective with Change Request (CR) 10433, the Centers for Medicare & Medicaid Services (CMS) will reintroduce Qualified Medicare Beneficiary (QMB) information in the Medicare Remittance Advice (RA) and Medicare Summary Notice (MSN). CR 9911 modified the Fee-For-Service (FFS) systems to indicate the QMB status and zero cost-sharing liability of beneficiaries on RAs and MSNs for claims processed on or after October 2, 2017. On December 8, 2018, CMS suspended CR 9911 to address unforeseen issues preventing the processing of QMB cost-sharing claims by States and other secondary payers outside of the Coordination of Benefits Agreement (COBA) process. CR 10433 remediates these issues by including revised “Alert” Remittance Advice Remark Codes (RARC) in RAs for QMB claims without adopting other RA changes that impeded claims processing by secondary payers. CR 10433 reinstates all changes to the MSNs under CR 9911. Please make sure your billing staff is aware of these changes.”

The QBM program was initially launched in 2017 following reports that providers were billing coinsurance costs to patients dually eligible for Medicare and Medicaid enrolled in a savings program. CMS then announced that it would attach an alert on billing notices that would indicate a person is in the QMB program and thus has zero cost-sharing liability.

However, the agency later announced it would be halting the effort after it was reported that changing the notices had created a technical issue in which claims for QMB beneficiaries were not paid by state Medicaid agencies and other payers secondary to Medicare such as Tricare. At that time, CMS made the decision to return to the previous display of the billing notices that did not contain QMB information.

The agency states the necessary technical and procedural changes have since been made to ensure payments would by Medicaid and other payers for QMB enrollees.

The programs re-launch is scheduled to begin on July 1stand will apply to claims processed on or after July 2nd, 2018.



Source(s): Modern Healthcare; MLN Matters;