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Medicaid will not pay a crossover claim if:


Medicare has paid the claim in an amount that equals or exceeds Medicaid’s fee for the specified service;

The combined amount received from Medicare and any other third party exceeds Medicaid’s fee for the service;

The Medicaid program limitations for the service have already been met for a recipient who has no Qualified Medicare Beneficiary (QMB) coverage and who is not eligible for Supplemental Security Income;

Both Medicare and Medicaid cover the service, and Medicare has determined that the service is not medically necessary. If Medicare determines that a service that Medicaid also covers is not medically necessary, it is also considered to be not medically necessary by Medicaid. This does not apply to services that Medicare does not cover, but Medicaid covers such as dental care;

The recipient is eligible as SLMB (Special Low Income Medicare Beneficiary) only or QI1 (Qualifying Individuals) only.

See also: How Medicaid Receives Crossover Claims


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