UB-04 Billing Medicare Replacement Plans

HP Provider Relations

October 2011

UB-04 Billing Medicare

Replacement Plans

UB-04 Billing Medicare Replacement Plans October 20112

Agenda

– Session Objectives

– Medicare Replacement Plans• Definition of a Medicare Replacement Plan

• The concept of the replacement plan

• Definition of the difference between a Medicare crossover and a replacement plan

– Billing Requirements (electronic/paper)• Supporting documentation

– Most Common Denials

– Helpful Tools

– Questions


Session Objectives

– Define what a Medicare Replacement Plan is and how it processes

– Clarify the difference between a Medicare crossover and a Medicare Replacement Plan

– Billing requirements for UB-04 electronic and paper claims submission

– What supporting documentation is required

– How to identify and notate the supporting documentation when necessary

LearnMedicare Replacement Plans


What Is a Medicare Replacement Plan?

– 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, Medicare Advantage Plan, or Medicare HMO


How Replacement Plans Work

– Plans are approved by Medicare but administered by private carriers

– Some plans require referrals to see specialists

– Premiums, copays, and deductibles often lower

– Covers 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


Medicare Replacement Plans

– Health Maintenance Organizations (HMOs)

– Preferred Provider Organizations (PPOs)

– Private Fee-for-Service Plans (PFFS)

– Medicare Medical Savings Account (MSA)

– Medicare Special Needs Plans


Reimbursement

– Reimbursement is the Medicaid allowed amount minus the payment from the Medicare Replacement Plan

– Reimbursement is based on the aggregate (totals), not line-by-line calculations

– The excess of the provider’s charges over the combined Medicare and Medicaid payments must be written off, the balance cannot be charged to the member


Eligibility Verification

– 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


Common Misconceptions about Replacement Plans – Crossover or TPL?

– Replacement plans are regarded as Third Party Liability (TPL) claims, not as Medicare crossovers

– This is a critical distinction, as billing requirements and reimbursement are different for TPL vs. crossover claims

– A Medicare crossover is defined as a claim billed to traditional Medicare Part A or Part B for a covered service

• Noncovered claims should be billed separately to Medicaid as a TPL

• Attach copies of the Medicare Remittance Notice if services are Medicare noncovered


Common Misconceptions about Medicare Replacement Plans

– Standard Medicaid prior authorization rules apply • Medicare Replacement Plan claims are subject to prior authorization (PA)

guidelines

−Reminder: A Medicare Replacement is processed as a TPL secondary claim and not as a Medicare crossover; therefore, all PA criteria must be satisfied

– Standard Medicaid timely filing limits apply• Medicare Replacement Plans are subject to the 365-day filing limit

• If claims past the 365-day filing are submitted, past filing documentation must be included with the claim

BillElectronic Claims


Electronic Billing – 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 at the “detail” level

• Must use the “Attachment” feature and mail the Medicare Remittance Notice (EOB) as an attachment, along with an Attachment Cover Sheet

• The words “Medicare Replacement Plan” must be written on the top of the attachment

• The words “Replacement Plan” should be entered in the Notes section of the attachment window


UB-04 Billing – Medicare Replacement Plans

– The following slides illustrate how to access the Web interChange screens to enter benefit information at the header Medicare Replacement Plans, and to enter Attachment and Note information


Web interChange – Claims Processing Menu


Institutional Claim


Coordination of Benefits


Coordination of Benefits


Attachment Information


Claims Attachment Cover Sheet

BillPaper Claims



– Paper claims should be submitted to the regular IHCP claims address• P.O. Box 7271Indianapolis, IN 46207-7271

– Enter the words “Replacement Plan” in the Payer Name field 50B

– Do not enter any reference to Medicare in Payer Name field, as this causes the claim to be treated as a crossover claim

– Enter the payment received from the Medicare Replacement Plan in the Prior Payments field 54B


UB-04 Paper Claim Submission Requirements



– Submit a copy of the Medicare Replacement plan EOB

– The words “Medicare Replacement Plan” must be written at the top of the claim form and on the attachment

– Standard Medicaid prior authorization rules apply to these claims

– Standard Medicaid timely filing limits apply to these claims

DenyCommon Denials


Most Common Denial Codes

Edit 2502 – Recipient Covered by Medicare Part B or D (with attachment)

– Cause

• The member is covered by Medicare Part B and has a Medicare Replacement Plan, but the attachment does not adequately document the replacement plan

– Resolution• Electronic

−Verify “Replacement Plan” is entered in the Notes section of the attachment window

−Verify the name of the replacement/HMO is entered in the Benefit Information window

• Paper

−Verify the Medicare Replacement Plan payment is indicated in field 54B

−Verify “Medicare Replacement Plan” is written at the top of the claim and the attached replacement plan EOB



Edit 2501 – Recipient Covered by Medicare Part A (with attachment)

– Cause

• The member is covered by Medicare Part A and has a Medicare Replacement Plan, but the attachment does not adequately document the replacement plan

– Resolution• Electronic

−Verify “Replacement Plan” is entered in the Notes section of the attachment window

−Verify the name of the replacement/HMO is entered in the Benefit Information window

• Paper

−Verify the Medicare Replacement Plan payment is indicated in field 54B

−Verify “Medicare Replacement Plan” is written at the top of the claim and the attached the replacement plan EOB


Most Common DenialCodes

– Cause• Coinsurance and deductible amount is missing indicating this is not a

crossover claim. The claim processed as a cross over due to a Medicare indicator on the claim

– Resolution• Remove any formatting of a Medicare payment from claim.

Remove coinsurance and/or deductible amounts in field 39 a-d

Write “Replacement Plan” in field 50 B

Do not write “Medicare” in field 50 A or B

Edit 0558 Coinsurance and deductible amount missing


Edit 5001 – Exact Duplicate

– Cause

– A claim being submitted that has the same recipient number, rendering provider number, dates of service and procedure code of a claim that is in a current paid status

– Resolution

– Review Remittance Advices and/or Web Interchange to see if there is a claim in a paid status



Edit 0512 Claim Past Filing Limit

– Cause• When the days between the last date of service and the ICN date are greater than the filing limit

– Resolution • The provider should attach evidence of prior claim submission or inquiries

−Retroactive Eligibility

−Previous Submission History

−Late Third Party Liability Notification

−Retroactive Prior Authorization

Most Common Denials

Find HelpResources Available


Helpful ToolsAvenues of resolution

– IHCP Web site at indianamedicaid.com

– Provider Enrollment• 1-877-707-5750

– Customer Assistance• 1-800-577-1278, or

• (317) 655-3240 in the Indianapolis local area

– Written Correspondence

• P.O. Box 7263

Indianapolis, IN 46207-7263

– Provider Relations field consultant

http://www.indianamedicaid.com/

Q&A

Documents

UB-04 Billing Medicare Replacement Plans