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HP Provider Relations October 2010 UB-04 Billing Medicare Replacement Plans.

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Presentation on theme: "HP Provider Relations October 2010 UB-04 Billing Medicare Replacement Plans."— Presentation transcript:

1 HP Provider Relations October 2010 UB-04 Billing Medicare Replacement Plans

2 UB-04 Billing Medicare Replacement PlansOctober Agenda –Session Objectives –Definition of Medicare Replacement Plans –How Medicare Replacement Plans Work –Contrast of Medicare Crossover and Replacement Plans –Billing Requirements for Crossovers and Replacement Plans –ANSI version 5010 –Most Common Denials –Helpful Tools –Questions

3 UB-04 Billing Medicare Replacement PlansOctober Session Objectives –Provide a clear definition of Medicare Replacement Plans and how they work –Explain the critical differences between Medicare Crossovers and Medicare Replacement Plans –Clearly define the UB-04 electronic and paper billing requirements for crossovers and replacement plans –Understand upcoming implementation of ANSI version 5010 –Provide the knowledge necessary for providers to improve their billing processes with respect to crossovers and replacement plans

4 Learn Medicare Replacement Plans

5 UB-04 Billing Medicare Replacement PlansOctober 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

6 UB-04 Billing Medicare Replacement PlansOctober How 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 –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

7 UB-04 Billing Medicare Replacement PlansOctober 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

8 UB-04 Billing Medicare Replacement PlansOctober 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, for both crossovers and replacement plans –The excess of the providers charges over the combined Medicare and Medicaid payments must be written off; it cannot be charged to the member

9 UB-04 Billing Medicare Replacement PlansOctober 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

10 UB-04 Billing Medicare Replacement PlansOctober 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 Noncovered claims, should be billed separately to Medicaid as a TPL Attach copies of the Medicare Remittance Notice –Medicare Replacement Plans, and all other insurances, other than the original Medicare Part A and Part B plans, are considered TPL

11 Bill Electronic Claims

12 UB-04 Billing Medicare Replacement PlansOctober 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 required 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 Replacement Policy must be written on the attachment The words Replacement Policy should be entered in the Notes section of the attachment window

13 UB-04 Billing Medicare Replacement PlansOctober 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

14 UB-04 Billing Medicare Replacement PlansOctober Web interChange – Claims Processing Menu

15 UB-04 Billing Medicare Replacement PlansOctober Institutional Claim

16 UB-04 Billing Medicare Replacement PlansOctober Coordination of Benefits

17 UB-04 Billing Medicare Replacement PlansOctober Coordination of Benefits

18 UB-04 Billing Medicare Replacement PlansOctober Attachment Information

19 UB-04 Billing Medicare Replacement PlansOctober Claims Attachment Cover Sheet

20 Bill Paper Claims

21 UB-04 Billing Medicare Replacement PlansOctober UB-04 Billing – Medicare Replacement Plans –Paper claims should be submitted to the regular IHCP claims address P.O. Box 7271 Indianapolis, IN –Enter the words Replacement Policy 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 Policy in the Prior Payments field 54B

22 UB-04 Billing Medicare Replacement PlansOctober UB-04 Billing – Medicare Replacement Plans –Submit a copy of the Medicare Remittance Notice –The words Replacement Policy 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 No filing limit for Medicare crossovers

23 Update ANSI version 5010

24 UB-04 Billing Medicare Replacement PlansOctober HIPAA 5010 –The mandatory compliance date for ANSI version 5010 and the National Council for Prescription Drug Programs (NCPDP) version D.0 for all covered entities is January 1, 2012 –If submitting claims to the IHCP, you need to prepare for these upgrades to prevent delay in payment –The IHCP and HP will test transactions on a scheduled basis –Specific transaction testing dates will be provided at a future date

25 UB-04 Billing Medicare Replacement PlansOctober HIPAA 5010 –Transactions affected by this upgrade: Institutional claims (837I) Dental claims (837D) Medical claims (837P) Pharmacy claims (NCPDP) Eligibility verifications (270/271) Claim status inquiry (276/277) Electronic remittance advices (835) Prior authorizations (278) Managed Care enrollment (834) Capitation payments (820)

26 UB-04 Billing Medicare Replacement PlansOctober Testing Information –All Trading Partners currently approved to submit 4010A1 and NCPDP 5.1 versions will be required to to be approved for 5010 and D.0 transaction compliance All software products used to submit 4010 and NCPDP 5.1 versions must be tested and approved for 5010 and D.0. –Testing will begin January 2011 and include: Clearinghouses, Billing services, software vendors, individual providers, provider groups –Providers that exchange data with the IHCP using an IHCP- approved software vendor will not need to test –Each trading partner will be required to submit a new Trading Partner Agreement

27 UB-04 Billing Medicare Replacement PlansOctober What You Need To Do –If you bill IHCP directly Begin the process to upgrade to the ANSI 5010 or NCPDP D.0 versions –If you are using a billing service or clearinghouse Find out if they are preparing for the HIPAA upgrades to ANSI v5010 and NCPDP vD.0 IHCP Companion Guides will be available during the fourth quarter of 2010 –Questions should be directed to OR –Call the EDI Solutions Service Desk or (317) –Watch for additional information on the testing process, revised IHCP Companion Guides, and the schedule for transaction testing on this mandated initiative in bulletins, banner pages, and newsletters at

28 Deny Common Denials

29 UB-04 Billing Medicare Replacement PlansOctober 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 Policy 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 Replacement Policy is written at the top of the claim and the attached Medicare Remittance Notice

30 UB-04 Billing Medicare Replacement PlansOctober Most Common Denial Codes 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 Policy 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 Replacement Policy is written at the top of the claim and the attached Medicare remittance notice

31 Find Help Resources Available

32 UB-04 Billing Medicare Replacement PlansOctober Helpful Tools Avenues of resolution –IHCP Web site at –Provider Enrollment –Customer Assistance , or (317) in the Indianapolis local area –Written Correspondence P.O. Box 7263 Indianapolis, IN –Provider Relations field consultant

33 Q&A


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