The Qualified Medicare Beneficiary (QMB) program put in place by the Centers for Medicare and Medicaid Services (CMS) assists low-income Medicare beneficiaries with Medicare Part A and Part B premiums and cost-sharing, including deductibles, coinsurance, and copayments. As a reminder, under the QMB program enrollees are exempt from cost-sharing liability, so all providers are prohibited from charging QMB members for Medicare cost-sharing for covered Parts A and B services.
Identifying members with QMB status
Harvard Pilgrim provides the necessary information to our members and providers regarding QMB eligibility. When we are aware that a Harvard Pilgrim claim is for a member who is a qualified Medicare beneficiary, a message appears on the member’s Explanation of Benefits statement, as well as the provider’s Explanation of Payment, to identify this status.
In addition, CMS’s HIPAA Eligibility Transaction System (HETS) provides Medicare eligibility data to providers and their authorized billing agents (including clearinghouses and third-party vendors) to help verify a patient’s QMB status and exemption from cost-sharing charges. Contact your third-party eligibility verification vendor to ask how their products reflect the new QMB information from HETS. Alternatively, you can contact Harvard Pilgrim’s Medicare Advantage Provider Service Center at 888-609-0692 to learn the best way to identify the QMB status of your patients.
For more detailed information about CMS’s QMB program, please refer to this document from the Medicare Learning Network, as well as the Billing Members policy in Harvard Pilgrim’s Medicare Advantage Provider Manual.
Director, Provider Relations & Communications