CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Dual-eligible cost sharing and payment coordination

Governs how payment and cost sharing are coordinated for members who are dual eligible for Medicare Advantage and Rhode Island Medicaid, and rules for provider billing practices affecting these members.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyDual-eligible cost sharing and payment coordination

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionBill Medicare Advantage first; do not bill members with full Medicaid for Medicare Parts A and B cost sharing.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

20%Member coinsurance example

S80BCBSRI paid example

No member billingProvider billing prohibition

ProhibitedMissed appointment fees

Dual-Eligible Payment Coordination Rules

Duals payment coordination and provider billing rules

Payment coordination examples and provider billing rules for dual eligibles with RI Medicaid:

Medicare Advantage billed first before Rhode Island Medicaid for dual eligible members.

Participating Medicare providers are not allowed to bill members who have full Medicaid for cost sharing related to any Medicare Parts A and B.

Participating Medicaid providers must accept the Medicare Advantage payment plus Rhode Island Medicaid payment as 'paid in full' for covered services that are not Medicare Part A or B (for example, dental).

Participating providers are prohibited from charging missed appointment fees for any service.

Illustrative payment scenarios:

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyDual-eligible cost sharing and payment coordination

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionBill Medicare Advantage first; do not bill members with full Medicaid for Medicare Parts A and B cost sharing.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Examples and Code Placeholders

Example payment placeholdersmixed

S100	BCBSRI Allowed, Unlikely/Likely Scenario: Medicaid Rate Close to or Significantly Lower than BCBSRI's Rate = S100
S80	BCBSRI Paid (typically 80%): Unlikely/Likely Scenario = S80
S20	Member Coinsurance (20%): Unlikely/Likely Scenario = S20 (Medicaid enrollees should not be billed this)
S90	Medicaid Allowed, Unlikely Scenario = S90
S60	Medicaid Allowed, Likely Scenario = S60
S10	Medicaid Paid (Medicaid Allowed BCBSRI Paid), Unlikely Scenario = S10
SO	Medicaid Paid (Medicaid Allowed BCBSRI Paid), Likely Scenario = SO
S0	Total Paid to Provider, Likely Scenario = S0 (document indicates total paid examples such as S80 or S0)
S20	Gap in Payment Experienced by Provider, Likely Scenario = S20

Member coinsurance example

Member coinsurance20% — Medicaid enrollees should not be billed this

Billing Order and Prohibitions for Providers

Billing Rule

Billing order and prohibitions for dual eligibles

For members dually eligible for Medicare Advantage and Rhode Island Medicaid, bill the Medicare Advantage plan first; Medicaid coordinates payment thereafter. Do not bill members who have full Medicaid for cost sharing related to any Medicare Parts A and B. For covered services that are not Medicare Part A or B (for example, dental), participating Medicaid providers must accept the Medicare Advantage payment plus the RI Medicaid payment as payment in full. Participating providers are also prohibited from charging missed appointment fees for any service.

Medicare Advantage must be billed before Medicaid for dual-eligible members.
Providers may not bill members with full Medicaid for Medicare Parts A and B cost sharing.
For non–Medicare Part A/B services, participating Medicaid providers must accept MA payment plus RI Medicaid payment as paid in full.
Participating providers may not charge missed appointment fees for any service.

Key Definitions

Dual eligible members

DefinitionMembers eligible for both Medicare Advantage and Rhode Island Medicaid whose covered services costs are coordinated between payers; Medicare Advantage is billed first before Medicaid.

Participating providers

Billing obligationsParticipating Medicare providers may NOT bill members with full Medicaid for cost sharing related to any Medicare Parts A and B.

Acceptance of paymentParticipating Medicaid providers must accept the Medicare Advantage payment plus RI Medicaid payment as 'paid in full' for covered services that are not Medicare Part A or B (e.g., dental).

Missed appointment feesParticipating providers are prohibited from charging missed appointment fees for any service.