QMB (Qualified Medicare Beneficiary)
Qualified Medicare Beneficiary
A category of dual-eligible whose Medicare cost-sharing (deductibles, coinsurance, premiums) is paid by Medicaid.
1 min read · Last reviewed May 23, 2026
At a glance
- Category
- Payer
- Acronym for
- Qualified Medicare Beneficiary
- Primary sources
- 1
- Workspace handoff
- denial workbench →
Where this comes up
Front-office and billing both hit this term — eligibility before the visit, prior auth before the procedure, contract terms during fee-schedule negotiation, and credentialing whenever a new provider joins or a payer roster lapses. Misses here become denials downstream.
Full definition
What it is in practice
Section 1902(n) of the Social Security Act prohibits providers from billing QMBs for Medicare cost-sharing. The remittance advice typically flags QMB status.
How it shows up in your practice
Suppress patient statements for Medicare cost-sharing on QMB encounters. Misbilling is a CMS-investigated issue.
Sources
- CMS — Medicare Secondary Payerhttps://www.cms.gov/medicare/coordination-benefits-recovery/medicare-secondary-payer
Suppress QMB patient billing in the Denial Workbench
Open denial workbench →Related terms
- PayerDual-EligibleAn individual enrolled in both Medicare and Medicaid.
- PayerMedicaidJoint federal-state program providing health coverage to certain low-income individuals, families, pregnant women, elderly, and people with disabilities.
- Denials & AppealsMedicare Secondary Payer (MSP)Statutory rules at 42 USC 1395y(b) requiring other insurance to pay before Medicare in defined situations.
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Related across the archive
- GlossaryDual-EligibleAn individual enrolled in both Medicare and Medicaid.
- GlossaryMedicare Secondary Payer (MSP)Statutory rules at 42 USC 1395y(b) requiring other insurance to pay before Medicare in defined situations.
- GlossaryMedicaidJoint federal-state program providing health coverage to certain low-income individuals, families, pregnant women, elderly, and people with disabilities.
- GlossaryCoordination of Benefits (COB)The rules and processes that determine which of two or more insurance plans pays first when a patient is covered by multiple plans.
- GlossaryOA (Other Adjustment)An X12 adjustment group code used when no other group code applies — frequently for coordination of benefits and other payer adjustments.
- ComplianceOIG LEIE Monthly Exclusion Screening: Process + Audit-Ready LogsMonthly OIG LEIE and SAM.gov exclusion screening for every workforce member and vendor: the workflow, the log fields auditors require, and the escalation path.
- CompliancePECOS Provider Enrollment Verification (2026) — Quarterly ChecklistQuarterly PECOS provider enrollment verification workflow: who to check, the exact lookup steps, the audit log columns, and the revalidation escalation path.
- Glossary270/271 Eligibility Inquiry/ResponseThe HIPAA standard EDI transactions used to verify patient insurance eligibility (270 query, 271 response).
This glossary entry is a research aid for billing and compliance staff. It does not provide legal, medical, or financial advice and does not replace counsel. References cited link to primary sources at HHS, OCR, CMS, eCFR, NIST, and the relevant payer or industry body.