For helpful resources regarding claims for ConnectiCare members, see Billing and Claims and Our Policies. For EmblemHealth members, see Claims Corner and the Claims chapter of the EmblemHealth Provider Manual.
Contracted time frames in provider agreements will supersede time frames in this guide. For facility time frames, see the Provider Manual or applicable agreement.
Clinic Visit Policy
If you provide clinic visits to our Medicare members, and are owned and operated by a hospital, please review our clinic visit policy and correct coding requirements. ConnectiCare will monitor compliance with this policy and may recoup payment from providers for not following it.
Reminder: For services rendered in place of service (POS) 19, off-campus hospital-owned location, claims billed with the G0463 clinic code should include the Modifier PO.
Medicare/Medicaid and Qualified Medicare Beneficiaries (QMBs)
ConnectiCare offers two plans to members who have Medicaid (Choice Dual and Choice Dual Vista). In addition, many Qualified Medicare Beneficiaries (QMBs) enroll in our Medicare Advantage plans. Members with full Medicaid or QMBs are not responsible for paying any member cost-share for their plan-covered benefits.
Do Not Bill Dual Eligible and QMB Members for Any Medicaid Cost-Sharing
Medicare-Medicaid full dual eligible and QMB individuals who qualify to have their Medicare Parts A and B cost-share covered by their state Medicaid are not responsible for paying their Medicare Advantage plan cost-shares for Medicare-covered Part A and Part B services. Please do not balance bill these members.
Federal and State laws prohibit providers from balance billing Medicare-Medicaid dual eligible individuals for any Medicare deductibles, coinsurance, or copayments. All Medicare and Medicaid payments, if any, received for services provided to dual eligible individuals must be accepted as payment in full. To comply with this requirement, providers treating dual eligible and QMB individuals enrolled in ConnectiCare Medicare Advantage plans must do the following:
- Verify plan and Medicaid/QMB eligibility prior to providing a service.
- Do not bill the member or collect cost-sharing during the visit.
- Bill Connecticut State Medicaid for the member’s cost-share.
- Consider the claim as “paid in full,” regardless of the Medicaid or plan payment.
- Notify member in writing if you do not accept Medicaid and member is not a QMB.
Federal law and provider contracts prohibit Medicare (ConnectiCare) providers from balance billing beneficiaries with Medicare and QMB, and Medicaid providers from balance billing dual eligibles. Providers may reference Section 1902(n)(3)(B) of the Social Security Act, as modified by Section 4714 of the Balanced Budget Act of 1997.
For ConnectiCare members, you can contact the Connecticut Department of Social Services at 800-842-8440 or visit their website.
For EmblemHealth members, you can use eMedNY to check whether the member has full or partial Medicaid benefits. For more detail, see our EmblemHealth Medicare Advantage webpage or call the New York State eMedNY Call Center at 800-343-9000.