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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
6
Step 1: Other Insurance (TPL)
at the header
7
Step 2: Other Insurance (TPL) header
8
Step 3: Other Insurance (TPL) header
9
Step 4: Other Insurance (TPL) header
10
Step 1: Other Insurance (TPL) detail
11
Step 2: Other Insurance (TPL) detail
12
Step 3: Other Insurance (TPL)
additional details
13
Step 4: Other Insurance (TPL)
additional details
14
When is the primary Medicare or Medicare
Replacement Plan EOB required?
• When Medicare or the Medicare Replacement Plan denies the service
15
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
16
How to complete Medicare or
Medicare replacement plans on the
Provider Healthcare Portal
17
Step 1: Other Insurance (TPL)
at the header
18
Step 2: Medicare or Medicare replacement
plan header
19
Step 3: Medicare or Medicare replacement
plan header
20
Step 4: Medicare or Medicare replacement
plan header
21
Step 5: Medicare or Medicare replacement
plan header
22
Step 6: Medicare or Medicare replacement
plan header
23
Step 1: Medicare or Medicare replacement
plan at detail
24
Step 2: Medicare or Medicare replacement
plan at detail
25
Step 3: Medicare or Medicare replacement
plan at detail
26
Step 4: Medicare or Medicare replacement
plan at detail
27
Step 5: Medicare or Medicare replacement
plan at detail
28
Step 6: Medicare or Medicare replacement
plan at additional details
29
Step 7: Medicare or Medicare replacement
plan at additional details
30
Step 8: Medicare or Medicare replacement
plan at additional details
31
Step 9: Medicare or Medicare replacement
plan at additional details
32
Step 10: Medicare or Medicare
replacement plan at additional detail
33
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.
34
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
35
How to complete Other Insurance on the
Provider Healthcare Portal
Copy the ENTIRE CLAIM
36
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
37
Submit the claim adding claim
attachments
38
Adding claim attachments
When the primary EOB is required, use the “Attachments” feature
39
Submit the claim
40
Submit the claim
41
Submitting Secondary
Paper Claims
42
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.
43
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
44
Medicare or Medicare Replacement Plan
Paper Claim
45
Medicare or Medicare Replacement Plan
Paper Claim
Medicare is always listed as Payer Seq 1 on the IHCP TPL/Medicare Special
Attachment Form.
46
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.
47
TPL Paper Claim
48
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.
49
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.
50
Medicare and TPL Paper Claim
51
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
52
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.
53
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.
54
How to submit Other Insurance
(TPL) updates on the
Provider Healthcare Portal
55
How to submit Other Insurance (TPL)
updates
56
How to submit Other Insurance (TPL)
updates
57
How to submit Other Insurance (TPL)
updates
58
How to submit Other Insurance (TPL)
updates
59
How to submit Other Insurance (TPL)
updates
Add any available attachments to support the request.
60
Helpful tools
61
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
62
QuestionsFollowing this session please review your schedule for the next session you
are registered to attend
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