Indiana Health Coverage Programs

DXC Technology

Submitting Secondary

CMS-1500 Claims

October 2017

2

Session Objectives• When is the primary EOB required for other

insurance (TPL)?

• Completing Other Insurance (TPL)

• When is the primary Medicare or Medicare

replacement plan EOB required?

• Completing Medicare or Medicare replacement

plans

• Adding claim attachments

• Submit Secondary Paper claims

• How to submit Other Insurance (TPL) updates

• Helpful tools

• Questions

3

When is the primary EOB required for

Other Insurance (TPL)?

• When the TPL has denied the service as non-covered

Exception – If the TPL primary EOB contains an acceptable denial ARC code, the secondary windows can be completed with the ARC code, and no EOB is required

• When TPL has applied the entire amount to the copay, coinsurance, or deductible

Services that are NON-COVERED by the primary

insurance are NOT filed as a secondary claim.

The secondary windows may be completed to bypass

the need for the primary EOB attachment for TPL

CLAIMS only

4

When is the primary EOB for Other

Insurance information (TPL) not needed?

• The primary insurance COVERS the service and has PAID on the

claim

• Actual dollars were received

5

How to complete Other Insurance

(TPL) on the

Provider Healthcare Portal

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Step 1: Other Insurance (TPL)

at the header

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Step 2: Other Insurance (TPL) header

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Step 3: Other Insurance (TPL) header

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Step 4: Other Insurance (TPL) header

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Step 1: Other Insurance (TPL) detail

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Step 2: Other Insurance (TPL) detail

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Step 3: Other Insurance (TPL)

additional details

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Step 4: Other Insurance (TPL)

additional details

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When is the primary Medicare or Medicare

Replacement Plan EOB required?

• When Medicare or the Medicare Replacement Plan denies the service

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When is the primary EOB for Medicare or

Medicare replacement plans not needed?

• The Medicare or Medicare Replacement Plan COVERS the service.

Actual dollars were received

Entire or partial amount was applied to deductible, coinsurance or copay

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How to complete Medicare or

Medicare replacement plans on the

Provider Healthcare Portal

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Step 1: Other Insurance (TPL)

at the header

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Step 2: Medicare or Medicare replacement

plan header

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Step 3: Medicare or Medicare replacement

plan header

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Step 4: Medicare or Medicare replacement

plan header

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Step 5: Medicare or Medicare replacement

plan header

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Step 6: Medicare or Medicare replacement

plan header

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Step 1: Medicare or Medicare replacement

plan at detail

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Step 2: Medicare or Medicare replacement

plan at detail

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Step 3: Medicare or Medicare replacement

plan at detail

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Step 4: Medicare or Medicare replacement

plan at detail

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Step 5: Medicare or Medicare replacement

plan at detail

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Step 6: Medicare or Medicare replacement

plan at additional details

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Step 7: Medicare or Medicare replacement

plan at additional details

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Step 8: Medicare or Medicare replacement

plan at additional details

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Step 9: Medicare or Medicare replacement

plan at additional details

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Step 10: Medicare or Medicare

replacement plan at additional detail

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How to copy an existing claim to add other

insurance

Search for claim by Member ID and dates of service to see if the claim is in the

system. If it is not, complete the required claim information.

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How to complete Other Insurance on the

Provider Healthcare Portal

Look at the EOB code to make sure the claim is denying only for primary

insurance

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How to complete Other Insurance on the

Provider Healthcare Portal

Copy the ENTIRE CLAIM

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How to complete Other Insurance on the

Provider Healthcare Portal

If the primary insurance PAID the claim – even if it was applied to a deductible – check the

box to Include Other Insurance

If the primary insurance DENIED as non-covered:

• Include Other Insurance is BLANK – Do not add insurance information. ATTACH THE

PRIMARY EOB, or

• For TPL claims only, check Include Other Insurance and add the APPROPRIATE ARC

code to bypass the need for the EOB

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Submit the claim adding claim

attachments

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Adding claim attachments

When the primary EOB is required, use the “Attachments” feature

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Submit the claim

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Submit the claim

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Submitting Secondary

Paper Claims

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Medicare/Medicare Replacement Plans and

TPL secondary paper claims

• The IHCP encourages providers to use electronic transactions or the

Portal for submitting claims that contain TPL or Medicare information.

• For providers that choose to submit claims on paper, the Third-Party

Liability (TPL)/Medicare Special Attachment Form must be submitted to

provide detail-level TPL and Medicare information.

www.indianamedicaid.com > Forms > Claim Forms (Nonpharmacy)

• Paper claim forms require this form be attached.

− Claims received without this form will deny for explanation of benefits

(EOB) 655 ̶ Missing/Invalid other payer reject code.

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Medicare or Medicare Replacement Plan

Paper Claim

Indicate total of coinsurance, copayment and deductible

on the LEFT side of field 22 (resubmission code).

Indicate ACTUAL DOLLARS received on the RIGHT side

of field 22 (original ref. no)

The paid amounts and coinsurance, copayment and

deductible must be listed for each DETAIL on the IHCP

TPL/Medicare Special Attachment Form

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Medicare or Medicare Replacement Plan

Paper Claim

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Medicare or Medicare Replacement Plan

Paper Claim

Medicare is always listed as Payer Seq 1 on the IHCP TPL/Medicare Special

Attachment Form.

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TPL Paper Claim

TPL (Commercial Insurance) Primary

Commercial insurance payment amount (ACTUAL

DOLLARS received) should be entered in field 29 on the

CMS-1500 claim form.

Detail-level commercial insurance payments are entered

on the IHCP TPL/Medicare Special Attachment Form

form and attributed to the appropriate details.

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TPL Paper Claim

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TPL Paper Claim

Commercial insurance is always listed as Payer Seq 2 on the IHCP

TPL/Medicare Special Attachment Form.

The Deductible (PR1),

Coinsurance (PR2),

Copayment (PR3) and

Psych Red (PR122)

fields are used only for

Medicare claims; these

fields are left blank for

commercial insurance.

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Medicare and TPL Paper Claim

Medicare payment and a commercial insurance payments

The total Medicare payment amount and coinsurance,

deductible, and similar amounts should be entered in field

22 (right and left, respectively).

The commercial insurance payment amount should be

entered in field 29.

Detail Medicare and commercial amounts are entered on the

form and attributed to the appropriate details.

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Medicare and TPL Paper Claim

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Medicare and TPL Paper Claim

The fields should be completed on the IHCP TPL/Medicare Special Attachment FormMedicare Entered as Payer Seq 1 and Commercial Insurance Entered as Payer Seq 2

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Tips for completing the IHCP

TPL/Medicare Special Attachment

form

Detailed instructions for completing the IHCP

TPL/Medicare Special Attachment Form are on the

Forms page at indianamedicaid.com.

A Quick Reference Guide on the Billing and Remittance

web page at indianamedicaid.com provides additional

assistance in completing the form correctly.

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Red-and-white claim form requirement

• Effective January 1, 2018 the IHCP will require the below claim types to be submitting for processing on the appropriate red and white forms.

– CMS-1500 (02-12) – professional claims

– UB-04 (CMS-1450) – institutional claims

• The IHCP will no longer accept copied (black and white) claim forms on or after January 1, 2018.

• Claims not received on the red-and-white claim form on or after January 1, 2018, will be returned to the provider.

Note: This requirement does not effect the ADA Form 1260

as that form is only available only in black and white.

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How to submit Other Insurance

(TPL) updates on the

Provider Healthcare Portal

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How to submit Other Insurance (TPL)

updates

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How to submit Other Insurance (TPL)

updates

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How to submit Other Insurance (TPL)

updates

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How to submit Other Insurance (TPL)

updates

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How to submit Other Insurance (TPL)

updates

Add any available attachments to support the request.

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Helpful tools

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Helpful Tools

• IHCP website at indianamedicaid.com

– IHCP Provider Reference Modules

– Medical Policy Manual

• Customer Assistance available 8am-6pm EST Monday –

Friday

– 1-800-457-4584

• IHCP Provider Relations Field Consultants

– See the Provider Relations Field Consultants page at

indianamedicaid.com

• Secure Correspondence via the Provider Healthcare

Portal

• Written Correspondence

– DXC Technology Provider Written Correspondence

P.O. Box 7263

Indianapolis, In 46207-7263

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QuestionsFollowing this session please review your schedule for the next session you

are registered to attend