N.H. Medicaid Hospice Provider Manual, Vol. II, § 9

Under federal law, the Medicaid Program is the payer of last resort. All third party obligations must be

exhausted before claims can be submitted to Xerox in accordance with 42 CFR 433.139, except for

Medicaid only services and claims for prenatal care of pregnant women or claims for preventive pediatric

services, including EPSDT (this includes dental and orthodontic services in New Hampshire). Additional

information on exclusions is outlined in this section or in the General Billing Manual – Volume 1.

Providers who receive payment in full from a third party are not required to file zero-payment claims with

the NH Medicaid Program.

A provider must first submit a claim to the third party within the third party’s time limitations. If a third

party or primary insurance plan does not pay at or in excess of the applicable NH Medicaid

reimbursement level, a provider may submit a claim to NH Medicaid which is processed based on the

applicable reimbursement rate minus any payment received from all other resources. Commercial health

insurance coverage often provides a higher payment than does NH Medicaid.

When a third party denies a claim, for any reason, a copy of the notice of denial from the third party must

be included behind the claim submitted to NH Medicaid. When Medicare denies a claim, a copy of the

Explanation of Medicare Benefits must be attached behind the claim that is submitted. For claims not

submitted on paper, the Medicare or third-party denial is considered a claim attachment.

Detailed Medicare/Third Party Liability (TPL) information is found in the General Billing Manual,

including handling discrepancies in TPL resource information, correcting erroneous TPL information, and

exceptions to third party filing requirements.

When a member is also covered by Medicare, the provider must bill Medicare for all services before

billing NH Medicaid. The provider must accept assignment of Medicare benefits in order for the claim to

“crossover” to NH Medicaid. The crossover process works only for Medicare approved services;

Medicare denied services and Medicare non-covered services are addressed in this section. NH Medicaid

pays crossover claims only if the service is covered by NH Medicaid.

Certain services that are not covered by Medicare may be covered by NH Medicaid for dually eligible

members. Services identified in the Medicare billing manual and HCPCS coding manuals as non-covered

by Medicare may be billed directly to NH Medicaid who will determine whether or not the service is

covered and can be reimbursed by NH Medicaid.

This does not apply to QMB Only members whose benefits are limited to the Medicare premiums and

payment toward the Medicare deductible and coinsurance. Therefore, if Medicare does not cover the

service, there is no NH Medicaid payment available for QMB members.

When a member elects or revokes the Medicaid hospice benefit, the member shall also elect or revoke the

hospice benefit under Medicare and/or other insurance, as applicable.

Detailed Medicare/Third Party Coverage guidelines are found in the General Billing Manual – Volume I.