medicare-related institutional claim filing hp provider relations may 2010
TRANSCRIPT
Medicare-Related Institutional Claim Filing
HP Provider Relations
May 2010
Medicare-Related Institutional Claim Filing May 20102
Agenda
– Objectives
– What is a Medicare Benefit Exhaust Claim
– Billing Part B Charges
– What is a Medicare Replacement Claim
– What is a Medicare Crossover Claim
– Billing Electronically
– Paper Billing Locators 50 through 54
– Paper Billing Locator 39
– Supporting Documentation
– Helpful Tools
– Questions
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Session Objectives
At the end of this session, providers will understand:
– What constitutes a Medicare benefit exhaust claim
– How to bill the Part B charges
– What constitutes a replacement claim
– What constitutes a Medicare crossover claim
– What supporting documentation is required
– How to identify and notate the supporting documentation
MEDICARE EXHAUSTCLAIMS
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What Constitutes A Medicare Exhaust Claim– Dually eligible member (Medicare and
Medicaid coverage)
– IHCP member has exhausted his or her Medicare Part A benefits
– Benefits exhaust prior to the admission for an inpatient stay
– Medicare Remittance Notification (MRN) or online Florida Shared System (FSS) printout indicating exhaust status must accompany the claim to Medicaid
DO NOT BILL THE IHCP FOR PARTIAL INPATIENT STAYS
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Part B Charges
– Part B charges must be billed to Medicare before billing the exhaust inpatient claim to IHCP
– Medicare Part B claims automatically crossover
– Medicare B crossover claim must be voided before billing the exhaust claim
• Inpatient claim will deny as a duplicate claim if Part B claim is not voided
– Part B payment must be listed as a third-party liability (TPL) payment
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Electronic Billing Of Medicare Benefit Exhaust Claim?
– Medicare benefit exhaust claims may be submitted electronically via Web interChange using the Attachment feature
– “Benefits Exhausted” must be typed in the Notes field of the claim submission screen
– The supporting documentation required for the electronic claim is the same as for the paper claim
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Billing Information
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Coordination Of Benefits
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Coordination Of Benefits
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Claim Note Information
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Attachment Information
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Attachment Cover Sheet
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Benefits Exhausted
PAPERMEDICAREEXHAUSTCLAIMS
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Paper Billing Of Medicare Exhaust Claims Locators 50 Through 55
– Providers must verify member eligibility to determine if the patient is enrolled in Traditional Medicaid including Care Select
– These claims are billed on the UB-04 claim form
– Part B payments are indicated by entering the word, “Exhaust” in locator 50 on lines a or b
• Do not enter the word “Medicare” on the claim in line 50
– The payment is entered in field 54
– Other commercial payments are entered in the same manner on line b fields 50 through 55
– Use line c in fields 50 through 55 for the Medicaid billing
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Paper Billing Locator 39
– Using value code 80, enter the covered days
– Do not enter value codes for deductible and coinsurance or blood deductible
•A1, A2, or 06
– These claims are TPL claims
– All other UB-04 billing policies apply
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Medicare Exhaust Claim Address
– Paper claims should be submitted to the regular IHCP claims address:
HP Institutional Claims
P. O. Box 7271
Indianapolis, IN 46207-7271
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Supporting Documentation
– In the top or bottom margin of the UB-04 claim form boldly write the words: • “Benefits Exhausted”
– On the top of the MRN or FSS screen print boldly print:• “Benefits Exhausted”
– The information on the supporting documentation must match the information presented for Medicaid claim
– Claims are Medicaid primary; all filing limit and prior authorization rules apply to these claims
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Benefits Exhausted
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Benefits Exhausted
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Benefits Exhausted
MEDICAREREPLACEMENTCLAIM
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What Is A Medicare Replacement Claim?
– Created by the Balanced Budget Act of 1997
– Medicare beneficiaries given the option to receive Medicare benefits through private health insurance plans
– Replacement of original Part A and Part B plan
– Sometimes referred to as Medicare+Choice, Part C, Medicare Advantage Plan, or Medicare HMO
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– Plans are approved by Medicare but run by private companies
– Some plans require referrals to see specialists
– Premiums, copays, and deductibles often lower
– Cover all Part A and Part B services
– Often have networks requiring member to use certain doctors and hospitals
– Offer extra benefits, such as prescription drug coverage
How Medicare ReplacementPlans Work
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– Health Maintenance Organizations (HMOs)
– Preferred Provider Organizations (PPOs)
– Private Fee-for-Service Plans (PFFS)
– Medicare Medical Savings Account (MSA)
– Medicare Special Needs Plans
Medicare Replacement Plans
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– For a member with a Medicare Replacement Plan, the Web interChange Eligibility Inquiry screen will indicate that the member has Medicare Part A and Medicare Part B
– No information will appear about the Medicare Replacement Plan in the Third Party Carrier section
Eligibility Verification
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– Replacement plans are considered TPL (Third Party Liability); not Medicare Crossovers
– This is a critical distinction, as billing requirements and reimbursement are different for TPL vs. Crossover
– A Medicare crossover is defined as a claim billed to the original Part A and Part B plan, which is covered
– Medicare Replacement Plans, and all other insurances, other than the original Medicare Part A and Part B plans, are considered TPL
Medicare Replacement Plans – TPL or Crossover?
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Electronic Billing Of Medicare Replacement Plans
– Medicare Replacement Plans will not automatically cross over from the Medicare carrier to Medicaid
– Medicare Replacement Plans can be submitted via Web interChange
• Coordination of Benefits information must be entered at the “header” level, but not required at the “detail” level
• Must use the “Attachment” feature, and mail the replacement policy EOB as an attachment, along with an Attachment Cover Sheet
• The words “Medicare Replacement Policy” must be written on the attachment and mailed to HP with an Attachment Cover Sheet
• The words “Medicare Replacement Policy” should be entered in the Notes section
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Electronic Billing Of Medicare Replacement Plans
– Submit a copy of the Private Insurance EOB
– Standard Medicaid prior authorization rules apply to these claims
– Standard Medicaid timely filing limits apply to these claims
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Web interChangeClaims Processing Menu
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Billing Information
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Coordination Of Benefits
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Coordination Of Benefits
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Attachment Information
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Claims Attachment Cover Sheet
PAPERREPLACEMENTCLAIMS
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Paper Billing Of Replacement Claims Locators 50 Through 55
– Providers must verify member eligibility to determine if the patient is enrolled in Traditional Medicaid including Care Select
– These claims are billed on the UB-04 claim form
– The private insurer name or the word “Replacement” is indicated by entering the information in locator 50 on lines A or B
• Do not enter the word “Medicare” on the claim
– The payment is entered in field 54
– Other commercial payments are entered in the same manner on line B in fields 50 through 55
– Use line C in fields 50 through 55 for the Medicaid billing
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Paper Billing Locator 39
– Using value code 80, enter the covered days
– Do not enter value codes for deductible and coinsurance or blood deductible• A1, A2, or 06
– These claims are TPL claims
– All other UB-04 billing policies apply
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UB-04 Billing – Medicare Replacement Plans
– Paper claims should be submitted to the regular IHCP claims address
HP Institutional ClaimsP. O. Box 7271Indianapolis, IN 46207-7271
– Enter the payment received from the Medicare Replacement Plan in the Prior Payments field 54 A or B
– Enter the replacement plan name or the word “replacement” in the Payer Name field 50 A or B
– Do not enter any reference to Medicare in Payer Name field, as this causes the claim to be treated as a crossover claim
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Support Documentation
– In the top or bottom margin of the UB-04 claim form boldly write the words:
• “Medicare Replacement Policy”
–On the top of the Commercial EOB boldly print:
• “Medicare Replacement Policy”
• IHCP Member ID number
– The information on the supporting documentation must match the information presented on the Medicaid claim
– Claims are Medicaid primary; all filing limit and prior authorization rules apply to these claims
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Replacement Claim
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Replacement Claim
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Replacement Claim
MEDICARECROSSOVERCLAIM
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Medicare Crossover Claim Defined
The term, “crossover claim” applies when a member has Medicare as the primary insurance, and:
–The Medicare coverage is from traditional Medicare, not one of the Medicare Replacement (or Medicare HMO) plans
–Medicare issued a payment of any amount, or the entire payment was applied to the deductible
A claim is not a crossover claim when:
–The member’s primary insurance is not traditional Medicare
–Medicare denied the entire claim
–It is a Medicare benefit exhaust claim
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Why Claims Do Not Automatically Cross Over
Following are some of the reasons why claims fail to cross over from Medicare automatically
– The Medicare intermediary is not National Government Services (NGS) or is not an intermediary that has a partnership agreement with HP
– Ambulatory surgical center (ASC) claims billed to Medicare on a CMS-1500 claim form with the SG modifier
– Data errors on the crossover file
• Examples include incorrect Social Security number (SSN) or spelling of member name
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Claim Filing Limit
– The standard filing limit for Medicaid claims is one year from the date of service
– Crossover claims are not subject to the one-year filing limit
• Crossover claims may be submitted and processed irrespective of the age of the claim
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Claims Partially Paid By MedicareWhen Medicare allows only some of the services on a non-surgical outpatient claim:
– Only the Medicare-allowed services apply to crossover logic
• These services should be billed to Medicaid separately from the Medicare-denied services
• Providers should not send the Medicare Remittance Notice (MRN) to Medicaid when billing these services
– Only the Medicare-allowed services are exempt from the one-year filing limit
– Services denied by Medicare are subject to the one-year filing limit
• These services should be billed separately to Medicaid with a copy of the MRN
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Web interChange – Claims Processing Menu
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Institutional Claim
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Coordination Of Benefits
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Coordination Of Benefits
PAPERCROSSOVERCLAIMS
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How To Bill A Crossover Claim– Identify Medicare Remittance Notice (MRN) information in field 39 as
follows:• Value Code A1 – Medicare deductible amount
• Value Code A2 – Medicare coinsurance amount
• Value Code 06 – Medicare blood deductible amount
• Value Code 80 – IHCP covered days
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Crossover Claim
HELPFUL TOOLS
Avenues of resolution
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Helpful ToolsAvenues of resolution
– IHCP Web site at www.indianamedicaid.com
– IHCP Provider Manual (Web, CD-ROM, or paper)
– Customer Assistance
• Local (317) 655-3240
• All others 1-800-577-1278
• Written Correspondence
• HP Provider Written CorrespondenceP. O. Box 7263Indianapolis, IN 46207-7263
• Provider field consultant
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Q&A