Claims Adjustments to Capture the Elusive 12.5%!

November 09, 2021

Based on the training this morning that we offered to share “how to adjust” claims in fee-for-service services (DD Waiver), we want to share the following:

  • There is (and always has been) a difference between “co-pays” and “patient pay.”  The former is a fixed amount – generally small – charged for specified services or by classes of providers to have the Medicaid member share the cost of the service.  The federal Public Health Emergency prompted a decision by CMS to suspend the collection of co-pays for the duration.   DD Waiver providers have never charged co-pays for services they provide! 


  • Patient pay is the specific amount (as determined by DSS) that an individual must contribute to the cost of their care.  It applies only to those individuals who have excess Federal benefits (see the most recent Medicaid memo on the subject dated 9/2/2015).  Please note that it is the designated provider’s responsibility to show (as “amount paid”) the patient pay on the first claim of each month.  And note the collection of patient pay was not suspended  during the public health emergency.  Providers who have not been properly collecting and managing patient pay should promptly adjust claims appropriately!

And for the MCOs!  The attached may be helpful in sorting out the nuances of each MCO.  We didn’t say this was going to be easy.