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Medicare-Related Institutional Claim Filing HP Provider Relations May 2010.

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Presentation on theme: "Medicare-Related Institutional Claim Filing HP Provider Relations May 2010."— Presentation transcript:

1 Medicare-Related Institutional Claim Filing HP Provider Relations May 2010

2 Medicare-Related Institutional Claim FilingMay 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 Medicare-Related Institutional Claim FilingMay 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 Medicare-Related Institutional Claim FilingMay 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 Medicare-Related Institutional Claim FilingMay 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 Medicare-Related Institutional Claim FilingMay 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 Medicare-Related Institutional Claim FilingMay Billing Information

9 Medicare-Related Institutional Claim FilingMay Coordination Of Benefits

10 Medicare-Related Institutional Claim FilingMay Coordination Of Benefits

11 Medicare-Related Institutional Claim FilingMay Claim Note Information

12 Medicare-Related Institutional Claim FilingMay Attachment Information

13 Medicare-Related Institutional Claim FilingMay Attachment Cover Sheet

14 Medicare-Related Institutional Claim FilingMay Benefits Exhausted

15 PAPER MEDICARE EXHAUST CLAIMS

16 Medicare-Related Institutional Claim FilingMay 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 Medicare-Related Institutional Claim FilingMay 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-Related Institutional Claim FilingMay 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 Medicare-Related Institutional Claim FilingMay 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

20 Medicare-Related Institutional Claim FilingMay Benefits Exhausted

21 Medicare-Related Institutional Claim FilingMay Benefits Exhausted

22 Medicare-Related Institutional Claim FilingMay Benefits Exhausted

23 MEDICARE REPLACEMENT CLAIM

24 Medicare-Related Institutional Claim FilingMay 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 Medicare-Related Institutional Claim FilingMay – 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 Replacement Plans Work

26 Medicare-Related Institutional Claim FilingMay – 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

27 Medicare-Related Institutional Claim FilingMay – 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

28 Medicare-Related Institutional Claim FilingMay – 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?

29 Medicare-Related Institutional Claim FilingMay 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 Medicare-Related Institutional Claim FilingMay 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 Medicare-Related Institutional Claim FilingMay Web interChange Claims Processing Menu

32 Medicare-Related Institutional Claim FilingMay Billing Information

33 Medicare-Related Institutional Claim FilingMay Coordination Of Benefits

34 Medicare-Related Institutional Claim FilingMay Coordination Of Benefits

35 Medicare-Related Institutional Claim FilingMay Attachment Information

36 Medicare-Related Institutional Claim FilingMay Claims Attachment Cover Sheet

37 PAPER REPLACEMENT CLAIMS

38 Medicare-Related Institutional Claim FilingMay 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 Medicare-Related Institutional Claim FilingMay 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 Medicare-Related Institutional Claim FilingMay 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 Medicare-Related Institutional Claim FilingMay 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

42 Medicare-Related Institutional Claim FilingMay Replacement Claim

43 Medicare-Related Institutional Claim FilingMay Replacement Claim

44 Medicare-Related Institutional Claim FilingMay Replacement Claim

45 MEDICARE CROSSOVER CLAIM

46 Medicare-Related Institutional Claim FilingMay 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 members primary insurance is not traditional Medicare – Medicare denied the entire claim – It is a Medicare benefit exhaust claim

47 Medicare-Related Institutional Claim FilingMay 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 Medicare-Related Institutional Claim FilingMay 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 Medicare-Related Institutional Claim FilingMay 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 Medicare-Related Institutional Claim FilingMay Web interChange – Claims Processing Menu

51 Medicare-Related Institutional Claim FilingMay Institutional Claim

52 Medicare-Related Institutional Claim FilingMay Coordination Of Benefits

53 Medicare-Related Institutional Claim FilingMay Coordination Of Benefits

54 PAPER CROSSOVER CLAIMS

55 Medicare-Related Institutional Claim FilingMay 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 Medicare-Related Institutional Claim FilingMay Crossover Claim

57 HELPFUL TOOLS Avenues of resolution

58 Medicare-Related Institutional Claim FilingMay 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 7263 Indianapolis, IN Provider field consultant

59 59 Q&A


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