Library: Policy

317:30-5-44. Medicare eligible individuals

Revised 9-1-15

     Payment is made to hospitals for services to Medicare eligible individuals as set forth in this section.

• (1) Claims filed with Medicare automatically cross over to OHCA.  The explanation of Medicare Benefits (EOMB) reflects a message that the claim was referred to SoonerCare.  If such a message is not present, a claim for coinsurance and deductible must be filed with the OHCA within 90 days of the date of Medicare payment and within one year of the date of service in order to be considered timely filed.

• (2) If payment is denied by Medicare and the service is a SoonerCare covered service, mark the claim "denied by Medicare" and attach the Medicare EOMB showing the reason for denial.

• (3) In certain circumstances, some claims do not automatically "cross over". Providers must file a claim for coinsurance and/or deductible to SoonerCare within 90 days of the Medicare payment and within one year from the date of service.

• (4) For individuals who have exhausted Medicare Part A benefits, claims must be accompanied by a statement from the Medicare Part A intermediary showing the date benefits were exhausted.