Physician visit limit lifted for dually-eligible beneficiaries

Effective May 1, 2016, the Medicaid-imposed 12 visit limit on physician visits is no longer applicable to individuals covered by both Medicare and Medicaid, who are eligible for Medicaid payment of crossover claims. These individuals are dually-eligible beneficiaries, who receive some type of health-care coverage from Medicare and Medicaid.

This change means that Medicaid providers may be reimbursed for physician visits deemed medically necessary, which exceed the previous 12 visit limit for dually-eligible beneficiaries.

Submitted claims may still deny until the appropriate system modifications are made. System modifications are tentatively scheduled to be implemented by July 1, 2016.

Providers currently seeking reimbursement for denied claims for visits which exceed the12 visit limit for dually-eligible beneficiaries must follow the standard reconsideration process during this interim system modification period. The Claim Reconsideration Form is available on the Mississippi Division of Medicaid’s (DOM) website on the Forms webpage (https://medicaid.ms.gov/resources/forms/).

This change will apply to all claims previously denied for Claim Exception Code 3708, Physician Office Visit Service Limit Exceeded, and that fall within timely filing requirements as of the effective date of this change. Medicare crossover claims for coinsurance and/or deductibles must be filed with DOM within 180 days of the Medicare Pay Date. The 180-day filing limitation will be determined using the Medicare payment register date as the date of receipt by DOM. Claims filed after the 180-day timely filing limitation will be denied.

Please be advised that this change will not affect claims denied for Claim Exception Code 3708, Physician Office Visit Service Limit Exceeded, for individuals covered only by DOM.

If you have questions, please contact us toll-free at 800-421-2408 or 601-359-6050. Learn more about the Mississippi Division of Medicaid at https://medicaid.ms.gov.