- (FCRC) Only count the part of a bill that is the client's responsibility, towards spenddown. Require written proof of the client's responsibility for medical costs from the provider or from the TPL resource of the medical service.
- (FCRC) Consider the adjudication date as the date of billing for any part of the bill which is the client's responsibility.
Example: The total medical expense (doctor) is $200. The service date was 02/10. The bill is submitted to the client's insurance company.
On 04/01 the insurance company pays $125 to the doctor, leaving $75 as the client's responsibility. When determining if the client meets spenddown, consider the bill as incurred on 02/10 and the billing date as 04/01. Allow $75 towards spenddown.
- (FCRC) Enter an adjudicated bill in IES.
- Enter the total amount of the service in the "Total Amount Billed" field.
- Enter the client's responsibility, after adjudication, in the "Client Liability Amount" field.
- (FCRC) Enter unadjudicated bills on Form 360C generated by the system.
Hospital Inpatient and Renal/Hemo Dialysis Charges
For renal/hemo dialysis charges the provider must provide:
- a written statement of charges showing the amount of the dialysis charges,
- the amount billed or to be billed to Medicare, and
- a written estimate of the client's liability for medical costs.
For inpatient hospital charges, accept as proof the hospital's written estimate of the amount that a Medicare and/or non-Medicare TPL resource is expected to pay towards a person's medical care costs.
Hospitals may provide a written estimate of the client's liability for medical costs directly to the FCRC.
The statement must show monthly liability incurred by an enrolled client. When this occurs make a determination if spenddown has been met.