Deseret Alliance Claims Information

Submitting a Claim

Providers must send claims directly to Medicare first. The only exception is foreign claims (services rendered outside the United States, including services received on a cruise ship, in the U.S, territories, or on any military base outside the United States), which should be submitted directly to DMBA. After Medicare has processed the claim, the claim and Medicare’s payment information will be forwarded electronically to DMBA. This is known as crossover billing. DMBA will then process the claim. The provider may bill the member for any remaining charges, such as the copayment or coinsurance.

Claims Processing

DMBA will have the claim information only after Medicare has processed the claim. It’s sent electronically to us the next day by Group Health Incorporated (GHI), the designated coordination-of-benefits contractor for Medicare claims.

Please note, Medicare delays processing claims in an effort to help prevent fraud. EDI (electronic) claims are held for 14 days before they’re processed, while paper claims are held for 29 days before they’re processed.

Claims Payment

When Medicare processes claims, they will send a Medicare Summary Notice (MSN) to the member every three months. The MSN details all of the claims processed during the previous three-month period. The member can view their Medicare claims and print the MSN anytime at www.mymedicare.gov. Also, they can view their DMBA claims at www.dmba.com

If the member’s Deseret Alliance copayment for any service is more than the remaining balance after Medicare has paid, DMBA will make no additional payment. But the copayment will still apply toward the member’s annual out-of-pocket maximum and an Explanation of Benefits (EOB) will still be sent to the member.

Sometimes the combined payments of Medicare and DMBA will be more than the total billed charges. When this occurs, it’s because Medicare has contracted with the provider to base their payment on a preset amount, regardless of the amount actually billed. And the “Over Allowed Amount” column on the EOB will show a negative number. To find the Medicare allowed amount, add this number to the billed amount.