Agenda Objectives Benefit Plans Clarification Medicare Advantage Plans General Billing Information Common Denials Interactive Voice Response System (IVRS) Overview Session Review Closing, Questions & Answers
Objectives The information presented will enable participants to: –Explain Benefit Plans and related program. –Review and resolve common crossover issue problems relating to claim denials –Perform functions using the IVRS and Web Portal –Explain where to send crossover claim forms –Identify general billing information
Benefit Plan Clarification Qualified Medicare Beneficiaries (QMB – Aid category 660) –Medicare beneficiaries with income up to 100% of the Federal Poverty Level (FPL). –Pays an individual’s Medicare premiums Part A & B – coinsurance and deductibles only. –This program does not pay for prescription drugs.
Benefit Plan Clarification (continued) Specified Low Income Medicare beneficiaries (SLMB – Aid category 661) –Medicare beneficiaries with income up to 120% of the FPL. –Pays the monthly premium for Medicare Supplemental Insurance (Part B). –This program has no Medicaid benefits.
Benefit Plan Clarification (continued) Qualified Individuals (1) – (QI-1 – AID CATEGORY 662) –This is a Medicaid program for beneficiaries who need help paying for Medicare Part B premiums. –Beneficiary must have Medicare Part A and limited income and resources and not be otherwise eligible for Medicaid. –The Medicaid program pays full Medicare Part B premiums only. Beneficiaries have no Medicaid benefits.
Benefit Plan Clarification (continued) Qualified Individuals (2) – (QI-2s – AID CATEGORY 663) –This is a Medicaid program for beneficiaries who need help paying for Medicare Part B premiums. –The beneficiary must have Medicare part A and limited income and resources and not be otherwise eligible for Medicaid. –For those who qualify, Medicaid pays a percentage of Medicare Part B premiums only – they have no Medicaid benefit.
Medicare Advantage Plans Medicare Advantage plans / Medicare Part C: This combines parts Part A and Part B and sometimes the Medicare prescription program (Medicare Part D). –These plans cover the same benefit as the Original Medicare plans; however, they are administered by private health insurance payers. –Some of these plans offer additional services beyond what the original Medicare plans offer. –These claims do not automatically cross-over to Medicaid; the provider must submit the claim to Medicaid along with the EOMB from the Medicare Advantage Plan. Please write “Attachment 06”.
Medicare Advantage Plans (continued) A Medicare Advantage Plan claim that was submitted by the provider by paper and denied can be corrected on the Web Portal. The provider will need to review the EOB reason on the Remittance Advice (RA) and correct the appropriate information on the Web Portal and resubmit.
General Billing Information Effective July 1, 2011 crossover claims with dates of service July 1, 2010 and forward must be received by the Department of Community Health within 12 months of the month of service. Medicaid providers must accept Medicare assignment in order to submit claims to Medicaid for consideration of payment.
General Billing Information (continued) If Medicare denies the claim, providers have 90 days from the Medicare denial date to submit the Medicaid primary claim. NOTE: Medicare denied claims are straight Medicaid claims, not crossovers. All Medicaid billing requirements must be followed.
Edit 0481 – Medicare paid date is less than 45 days from ICN date. If the remittance Advice (RA) indicates Remark Code MA07, the claim has been forwarded to (crossover) Medicaid for adjudication. If the forwarded claim is not processed by the Department within forty-five (45) days from the receipt of Medicare payment; a claim may be submitted directly to the Department’s third party administrator (paper or electronic). If providers do not wait the allotted 45 days, the claims will be returned without further processing. NOTE: There is no 45 day waiting period if the RA does not show the MA07.
Common Denials (continued) Edit 0438 - Medicare allowed or paid amount is zero or missing. These claims can be corrected on the Web Portal only if there is deductible, co-insurance, or HMO sub co-pay. Provider should correct “Other Payer Claims Data;” only fields with an asterisk (*) are required. Provider should make sure that correct information is showing in “Detail Other Payer Claims Data.”
Option 1Member Eligibility Option 2Claims Status Option 3Payment Information Option 4Provider Enrollment Option 5Prior authorization and Georgia Better Healthcare member referrals Option 6Web Portal password reset, Pharmacy Benefits, the Nurse Aide Registry or Nurse Aide Training program, PeachCare for Kids TM, EDI submission or electronic claim submission, or a system overview 1.800.766.4456 Options for the IVRS IVRS Overview
Session Review You should now be able to: –Explain Benefit Plans and related programs. –Review and resolve common crossover issues problems relating to claim denials. –Perform functions using the IVRS and Web Portal. –Explain where to send crossover claim forms. –Identify general billing information.