PM 15-08-06-a: Adjudicated Bills

WAG 15-08-06-a.

For community, LTC, and SLF cases, for each bill submitted, determine whether a third party resource may be responsible for any part of the bill. A bill with a third party resource must be adjudicated. The treatment of a bill subject to adjudication depends on the type of service and third party coverage. Treat bills subject to adjudication as follows:

• Hospital Inpatient and Renal/Hemo Dialysis Charges

  Renal/hemo dialysis services are considered incurred on the date provided, not the first day of the month.

  For hospital inpatient bills and renal/hemo dialysis charges with Medicare coverage and/or private insurance coverage, accept the provider's estimate of the client's share of the charges once the service is provided. The provider's estimate of these expenses is acceptable unless there is other information that indicates the estimate is not accurate.

  If it is later learned that the client's estimated share was not correct, adjust the spenddown met day and/or the amount of the client's expenses. 

• Medicare Covered Services, Part B (SMIB)

  For Medicare covered services other than inpatient hospital and renal/hemo dialysis, accept the provider's estimate of client share of the charges. If the provider does not provide an estimate, allow 20% of the private charges towards spenddown. 

• Private Insurance Coverage

  For services covered by private insurance accept the provider's estimate of client's share of the charges. Allow the provider's estimate towards spenddown.