Medicare-Related Institutional Claim Filing HP Provider Relations May 2010

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

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

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

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

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

Billing Information

Coordination Of Benefits

Claim Note Information

Attachment Information

Attachment Cover Sheet

Benefits Exhausted

PAPERMEDICAREEXHAUSTCLAIMS

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

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

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

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

Benefits Exhausted

MEDICAREREPLACEMENTCLAIM

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

– 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

– 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

– 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

– 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?

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

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

Web interChangeClaims Processing Menu

Billing Information

Attachment Information

Claims Attachment Cover Sheet

PAPERREPLACEMENTCLAIMS

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

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

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

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

Replacement Claim

MEDICARECROSSOVERCLAIM

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

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

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

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

Web interChange – Claims Processing Menu

Institutional Claim

PAPERCROSSOVERCLAIMS

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

Crossover Claim

HELPFUL TOOLS

Avenues of resolution

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

Medicare-Related Institutional Claim Filing HP Provider Relations May 2010

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