Guidance for Submitting Claims for Dually Eligible Beneficiaries

These guidelines assist with claim submissions for dually eligible beneficiaries. This information addresses situations known to affect a significant number of claims. It is not feasible to provide an all-inclusive list due to the variable nature of the programs.

1. Institutional claims submitted by hospital outpatient departments or outpatient clinics should include the National Drug Code (NDC) associated with the HCPCS code.
2. It is not necessary to alter (remove or change) the HCPCS code prior to submission to Medicaid if Medicaid does not require a HCPCS code. For example, revenue codes for emergency room (045X) and clinic (051X) do not require a HCPCS code for Medicaid claims processing. The revenue codes for laboratory services (030X, 031X) and pharmacy (025X, 063X) do require a HCPCS code for Medicaid claims processing. Refer to the appropriate clinical policy for additional program specific guidelines.
3. Modifiers submitted on Medicare Part B claims do not need to be removed before submitting the claim to Medicaid. For example, a Medicare primary claim containing modifier JW, JG, TB, GY or PO (a sample set of modifiers for example purposes only) can be processed in NCTracks without removal of the modifiers required by Medicare. They are identified as “Crossover” modifiers in NCTracks, which means they are accepted for crossover claims but there is no impact on Medicaid claims processing. In addition, modifiers that Medicare does not require should be included on the Medicare claim; Medicare will pass the modifiers to Medicaid for processing, such as with modifier UD (see May 2018 bulletin article).

While the above represents existing submission requirements, guidelines can change. Providers must stay up to date by regularly checking the North Carolina Medicaid and NCTracks websites for updates, reminders and notices.