1. Medicare-Related Institutional Claim Filing
HP Provider Relations
May 2010
HP Confidential
1 April 2017

2. 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

3. 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

4. MEDICARE EXHAUST CLAIMS

5. 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

6. 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

7. 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

8. Billing Information

9. Coordination Of Benefits

10. Coordination Of Benefits

11. Claim Note Information

12. Attachment Information

13. Attachment Cover Sheet

14. Benefits Exhausted

15. PAPER MEDICARE EXHAUST CLAIMS

16. 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

17. 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

18. Medicare Exhaust Claim Address
Paper claims should be submitted to the regular IHCP claims address:
HP Institutional Claims
P. O. Box 7271
Indianapolis, IN

19. 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:
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

20. Benefits Exhausted

21. Benefits Exhausted

22. Benefits Exhausted

23. MEDICARE REPLACEMENT CLAIM

24. 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

25. How Medicare Replacement Plans Work
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

26. 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

27. 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

28. Medicare Replacement Plans – TPL or Crossover?
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

29. 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

30. 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

31. Web interChange Claims Processing Menu

32. Billing Information

33. Coordination Of Benefits

34. Coordination Of Benefits

35. Attachment Information

36. Claims Attachment Cover Sheet

37. PAPER REPLACEMENT CLAIMS

38. 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

39. 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

40. UB-04 Billing – Medicare Replacement Plans
Paper claims should be submitted to the regular IHCP claims address
HP Institutional Claims
P. O. Box 7271
Indianapolis, IN
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

41. 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:
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

42. Replacement Claim

43. Replacement Claim

44. Replacement Claim

45. MEDICARE CROSSOVER CLAIM

46. 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

47. 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

48. 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

49. Claims Partially Paid By Medicare
When 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

50. Web interChange – Claims Processing Menu

51. Institutional Claim

52. Coordination Of Benefits

53. Coordination Of Benefits

54. PAPER CROSSOVER CLAIMS

55. 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

56. Crossover Claim

57. HELPFUL TOOLS
Avenues of resolution

58. Helpful Tools Avenues of resolution
IHCP Web site at
IHCP Provider Manual (Web, CD- ROM, or paper)
Customer Assistance
Local (317)
All others
Written Correspondence
HP Provider Written Correspondence P. O. Box Indianapolis, IN
Provider field consultant

59. Q&A
HP Confidential
1 April 2017