405 IAC 1-18-1 Definitions

Sec. 1. (a) The definitions in this section apply throughout this rule. (b) "Cross-over claim" means a Medicaid claim filed on behalf of a Medicare beneficiary who is also eligible for Medicaid. The term includes claims filed on behalf of beneficiaries who are eligible for Medicaid in any category, including, but not limited to, qualified Medicare beneficiaries (QMBs) and beneficiaries who are eligible for full Medicaid coverage. (c) "Medicaid allowable amount" means the reimbursement rate for a Medicaid claim as determined under state and federal law and policies. This reimbursement rate shall be the most recent rate on file with the office of Medicaid policy and planning or its contractor at the time a cross-over claim is processed. (d) "Medicare payment amount" means the amount of payment made by Medicare to the provider for a given claim. It does not include coinsurance amounts or deductibles.