1. October 2009 Third Party Liability Presented by EDS Provider Field Consultants

2. 2/ October 2009 Third Party Liability Agenda Session Objectives TPL Responsibilities Identifying TPL Resources Updating TPL Information TPL Policies Casualty Cases Submitting TPL Claims and Attachments Managed Care and TPL TPL Payments After IHCP Payments Health Management Systems Cost Avoidance and TPL Resource Information Disallowance Project Medicare Buy-In Common Denials Helpful Tools Questions

3. 3/ October 2009 Third Party Liability Session Objectives Following this session, providers will better understand the following: IHCP is the payer of last resort Coordination of benefits with other payors Recovery of funds due the IHCP The role of HMS

4. 4/ October 2009 Third Party Liability Identifying TPL Resources What is TPL? TPL stands for third-party liability. It is a term used to refer to insurance other than the IHCP, including: –A commercial group health or medical plan –An individually purchased health or medical plan –Casualty insurance, such as a homeowners or automobile liability policy, or compensation resulting from an accident or injury This type of insurance is used only for casualty recovery, not cost avoidance

5. 5/ October 2009 Third Party Liability TPL Responsibilities Identify Medicaid member third-party insurance coverage; verify and update insurance information Maintain TPL insurance information by accepting adds, updates, or deletes from various external entities Maintain Medicare and other TPL insurance information by accepting adds, updates, or deletes from various external entities File and pursue Medicaid liens in casualty cases Provide Medicaid member birth expenditure information to county prosecutor’s office Pay private health insurance premiums for Medicaid members when it is deemed cost-effective to do so Meet federal and State TPL reporting requirements

6. 6/ October 2009 Third Party Liability Identifying TPL Resources Verify TPL member eligibility using one of the following verification options: –Automated Voice Response –Omni swipe card BT200711 includes download instructions for the Omni machine for expanded NPI information –Web interChange What is the best option for TPL information? –Web interChange offers expanded TPL detail including: Primary insurance name, address, and telephone number Policy holder information

7. 7/ October 2009 Third Party Liability Identifying TPL Resources QMB (Qualified Medicare Beneficiary) – Medicare Premiums are paid by the state. This is referred to as Buy-in coverage. Discussed later in the presentation If member eligibility reads QMB-Only, Medicaid is only liable for the Medicare coinsurance and deductible only There is no Medicaid reimbursement when Medicare does not allow a service –Dental –Hearing Aids –Vision Refraction Verify eligibility for Medicare at the following numbers: –Part A – 1-866-580-5987 –Part B – 1-866-250-5665 Impact of QMB-Only Members

8. 8/ October 2009 Third Party Liability Updating TPL Information – Via Paper What is needed to update the member’s insurance information? A copy of the member’s medical insurance card A copy of the explanation of benefits (EOB) stating coverage is terminated A letter on company letterhead from the insurance carrier or the employer stating what date the member’s coverage terminated A copy of the Medicaid Third Party Liability Questionnaire form –Download this form from the Forms link at www.indianamedicaid.com www.indianamedicaid.com

9. 9/ October 2009 Third Party Liability Updating TPL Information – Electronically Submit an electronic request to the EDS TPL Unit to update a member’s insurance information The TPL Unit receives the request, researches, confirms the information, and updates the eligibility screen with corrected information –Updates are usually made within 20 days Confirm that eligibility has been updated by reviewing the Eligibility Inquiry feature

10. 10/ October 2009 Third Party Liability Updating TPL Information

11. 11/ October 2009 Third Party Liability TPL Policies that Pay the Member What if a member has a health insurance policy that pays the member only? Attempt to retrieve the funds from the payor via an assignment of benefits form –Providers should always ask members to sign an assignment of benefits form to submit to the other insurance with the claim –Providers create their own assignment forms If carrier refuses to honor the assignment of benefits form, request that member forward TPL payment to the provider –If the member refuses to forward the TPL payment to the provider, submit the claim to EDS following the 90-Day Provision procedure (discussed later in this presentation) Indemnity policies are not loaded as a TPL resource. When providers or others notify EDS, the TPL unit will terminate the indemnity policy in IndianaAIM Note: Reference Chapter 5, Section 3 of the IHCP Provider Manual for more information

12. 12/ October 2009 Third Party Liability Reporting Casualty Cases to TPL Providers should notify the Casualty Unit within the TPL Unit if they receive a request for a member’s medical records due to an accident or illness resulting from the negligent act of another person Contact the Casualty Unit –By e-mail at INXIXTPLCasualty@eds.comINXIXTPLCasualty@eds.com –By telephone local (317) 488-5046 or toll-free at 1-800-457-4510 –By U.S. mail at: EDS TPL Casualty Unit P.O. Box 7262 Indianapolis, IN 46207-7262

13. 13/ October 2009 Third Party Liability Providers may not collect insurer copayments from the member Providers must bill Medicaid for the usual and customary charges and report the TPL payment –The usual and customary charge includes the copay amount –Do not include write-off amounts on the claim Note: State-mandated copayments are not the same as TPL copayments, and may be collected from the member Billing the IHCP for Insurer Copayments Submitting Claims with TPL

14. 14/ October 2009 Third Party Liability Submitting Claims with TPL What is a blanket denial? When a healthcare service is not a covered benefit for the insured, the IHCP accepts an EOB from the other insurer showing that the service is not covered What must the blanket denial EOB include? Name of primary insurance carrier Information sufficient to identify the member Description of healthcare service Statement of noncoverage of the service When does a blanket denial expire? Blanket denial EOBs are valid until the end of the calendar year Blanket Denial

15. 15/ October 2009 Third Party Liability What if the third-party insurance does not respond? When a third-party payer fails to respond within 90 days of the provider’s billing date, the claim may be submitted to the IHCP for payment consideration How to submit claims under the 90-Day Provision: Indicate 90-Day Provision Include attachments to support previous attempts to file with the primary carrier –Web interChange users may insert a claim note to invoke the 90-Day Provision. Provider should write 90-day rule no response, insurance carrier, and dates sent to carrier IHCP Provider Manual, Chapter 5, contains billing instructions 90-Day Provision Submitting Claims with TPL

16. 16/ October 2009 Third Party Liability Submitting Claims with TPL When submitting TPL claims: Include member identification (name and RID number) on the claim attachment Clearly state the reason for noncoverage on the TPL attachment Ensure that the primary insurance company name on the attachment matches the information in the member’s file Hand write “Medicare Replacement Policy” on the claim form and EOB for Medicare HMO claims Hand write the procedure code(s) on the EOB if not already indicated Submit TPL claims to the appropriate claim P.O. Box –P.O. Box 7269 for CMS-1500 claims –P.O. Box 7271 for UB-04 claims Note: No attachments are required when TPL has made a payment Helpful Hints

17. 17/ October 2009 Third Party Liability Submitting Claims with TPL Did the member receive service outside a commercial network? The member must follow the rules of his or her commercial plan first If a provider is not in a member’s primary plan network, the provider should check with the primary plan before rendering service The IHCP does not reimburse for services rendered out-of- network of another plan unless the policy reimburses for out-of-network services –If the plan makes payment, it is business as usual Member Receives Services outside the Commercial Network

18. 18/ October 2009 Third Party Liability Submitting Claims without TPL If the IHCP has a TPL resource for a member on file and a claim is submitted for payment with zero dollars in the TPL field and no EOB is sent, the claim will deny for TPL The TPL edits are: –2500 – Recipient covered by Medicare A – no attachment –2501 – Recipient covered by Medicare A – with attachment –2502 – Recipient covered by Medicare B – no attachment –2503 – Recipient covered by Medicare B – with attachment –2504 – Recipient covered by Private insurance – no attachment –2505 – Recipient covered by Private Insurance – with attachment –2510 – Recipient covered by Medicare D TPL Edits

19. 19/ October 2009 Third Party Liability Submitting Claims without TPL Claims that bypass TPL edits: Claims from a state psychiatric hospital Claims with principal diagnosis code of: –Prenatal care –Pregnancy –Preventive pediatric –Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) Services for dually eligible Medicare and Medicaid members, when the service is always noncovered by Medicare (program excluded) –Services sometimes covered by Medicare will not bypass TPL TPL Edits

20. 20/ October 2009 Third Party Liability Submitting Claims without TPL Updating the TPL bypass tables: –EDS reviews the Medicare bypass tables annually –EDS uses the Medicare Covered and Non-Covered Manual to be sure the Medicare bypass tables are up-to-date with codes that are never covered by Medicare –EDS updates the commercial bypass tables based on information received from outside sources such as other carriers and providers TPL Bypass Tables

21. 21/ October 2009 Third Party Liability Managed Care and TPL Insurance questions concerning members who are enrolled in the risk-based managed care (RBMC) delivery system should be directed to the appropriate managed care organization (MCO)

22. 22/ October 2009 Third Party Liability TPL Payments After IHCP Payments What if a third party or the member makes payment after IHCP has paid the claim? –The provider should submit a replacement claim via Web interChange, or use the paper adjustment form or –The provider can use the credit balance reporting process administered by Health Management Systems (HMS) Additional information was published in IHCP provider newsletter NL200604 For additional questions, call 1-877-264- 4854

23. 23/ October 2009 Third Party Liability Health Management Systems HMS is contracted by EDS to perform retro-recovery (or “pay and chase”) of Medicaid claims from commercial insurance carriers and bills the carriers monthly HMS performs data matches with commercial carriers to determine member TPL eligibility and provides IndianaAIM with this insurance resource information Beginning in May 2009, EDS and HMS have increased the frequency of TPL updates to the IndianaAIM system from bimonthly to biweekly updates, in an effort to provide the most up to date TPL information

24. 24/ October 2009 Third Party Liability Health Management Systems HMS conducts disallowance projects where it looks for claims that should have been paid by Medicare or the Federal Employee Program (FEP) and notifies the provider to submit the claim to Medicare or FEP –Once the claim is paid by Medicare or FEP, the Medicaid claim is adjusted to show this payment and the funds recouped by Medicaid HMS conducts provider self-audits for providers to report credit balances Beginning in 2008, HMS conducts commercial insurance disallowance projects focused on hospital providers where it looks for claims covered by commercial carriers and notifies the provider to bill the carrier

25. 25/ October 2009 Third Party Liability Cost Avoidance and TPL Resource Information Updates When a member’s TPL insurance information is listed in IndianaAIM, the member’s claim will be cost avoided (or denied) unless it was first submitted to the TPL carrier EDS receives insurance information updates from the Indiana Client Eligibility System (ICES), HMS, claims data, members, providers, insurance carriers, and caseworkers EDS verifies third-party insurance information and adds updates to IndianaAIM within 20 business days of receipt Update requirements are as follows: –Copy of the member’s medical insurance card –Copy of the EOB stating coverage is terminated –Letter on company letterhead from the insurance carrier or the employer stating what date the member’s coverage terminated –Copy of the Medicaid Third Party Liability Questionnaire form This form can be downloaded from the IHCP Web site

26. 26/ October 2009 Third Party Liability TPL: Disallowance Project Effective May 23, 2007, Medicare carriers can only be billed by the provider of services –Because Medicaid can no longer bill TPL claims directly to Medicare carriers, the billing of TPL claims through the provider of service is the only viable method of recovery –Consequently, in addition to the Medicare Part A and FEP disallowance projects, HMS will also conduct a Medicare Part B disallowance project on a quarterly basis How the disallowance projects work: –HMS identifies Medicaid paid claims that should have been billed to Medicare/FEP as primary –HMS will send listings of paid Medicaid claims to providers with instructions asking them to bill Medicare/FEP for the claims paid by Medicaid and respond within 60 days –Providers are to report back to HMS within 60 days by submitting a Credit Balance Worksheet and notify Medicaid as to which claims have been paid by Medicare/FEP and which have been denied Medicare

27. 27/ October 2009 Third Party Liability How the Commercial Insurance disallowance projects work: –Focused on hospital providers –HMS identifies Medicaid paid claims that should have been billed to commercial carriers –HMS will send listings of paid Medicaid claims to providers with instructions asking them to bill the commercial carriers for the claims paid by Medicaid and respond within 60 days –Providers are to report back to HMS within 60 days and notify Medicaid as to which claims have been paid by the commercial carrier and which have been denied Commercial Insurance TPL: Disallowance Project

28. 28/ October 2009 Third Party Liability Credit Balance Worksheet –EDS will process adjustments to the claims –Instructions can be located at www.indianamedicaid.com Web site under Forms, TPL www.indianamedicaid.com Direct Refunds –Mail refunds to HMS at: Fifth Third Bank Indiana Medicaid/EDS P.O. Box 2303 Dept. 132D Indianapolis, IN 46206-2303 Credit Balance Corrections TPL: Disallowance Project

29. 29/ October 2009 Third Party Liability Medicare Buy-In Overview Allows states to pay Part B Medicare premiums for dually eligible members (members eligible for both Medicaid and Medicare) Automated data exchanges between EDS and the Centers for Medicare & Medicaid Services (CMS) are conducted monthly to identify, update, resolve differences, and monitor new and ongoing Medicare buy-in cases The state is responsible for initiating Medicare buy-in for eligible members and EDS coordinates Medicare buy-in resolution with CMS Medicare is generally the primary payer –Payment of Medicare premiums, coinsurance, and deductibles cost less than Medicaid benefits –States receive Federal Financial Participation (FFP) for premiums paid for members eligible as: Qualified Medicare beneficiaries (QMB) Qualified disabled working individual (QDWI) Specified low-income Medicare beneficiaries (SLMB) Money grant members Social Security Income (SSI) Qualified individual (QI-1)

30. 30/ October 2009 Third Party Liability Top Denials

31. 31/ October 2009 Third Party Liability Edit 0558 Cause –Coinsurance and deductible amount is missing on the claim showing payment from Medicare Resolution –Bill Medicare First for payment –CMS-1500 Field 22 Left = The sum of Medicare Coinsurance, Deductible, and Psych Reduction Right – Medicare paid amount -UB-04 Field 39a-41d Value code A1 – Medicare deductible amount Value code A2 – Medicare coinsurance amount Value code 06 – Medicare blood deductible amount Field 54A – Medicare paid amount Coinsurance and Deductible Amount Missing

32. 32/ October 2009 Third Party Liability Cause –Occurs when Medicare denies a detail line and are included with the paid detail lines Resolution –Refile new claim with Medicare Remittance Notice (MRN) electronically –Do not include paid detail lines on the new claim –These claims are processed as TPL claims Medicare Denied Detail Edit 0593

33. 33/ October 2009 Third Party Liability Cause –Claim was billed to Medicare Replacement or HMO policy but was never indicated on claim as a replacement or HMO policy Resolution –Bill To Medicare Replacement or HMO Plan as primary –If payment was made from other plan, indicate payment on claim and write “Medicare Replacement” or “Medicare HMO” –If no payment from other plan write “Medicare Replacement” or “Medicare HMO” on claim and submit EOB from other plan with claim to non- crossover address QMB-Recipient – Bill Medicare First Edit 2007

34. 34/ October 2009 Third Party Liability Cause –If a physician or outpatient claim is submitted for a Medicare Part B covered service and recipient is covered by Medicare Part B –The claim will deny if no attachment indicating Part B has been billed Resolution –Bill Medicare Part B first –Bill Medicaid with claim with Medicare Remittance Notice (MRN) or electronically using the attachment (ACN) process Recipient Covered by Medicare Part B (No Attachment) Edit 2502

35. 35/ October 2009 Third Party Liability Cause –This member has private insurance, which must be billed prior to Medicaid Resolution –Add the other insurance payment to the claim electronically –CMS-1500 Add other insurance excluding Medicare payments to field 29 –UB-04 Add other insurance excluding Medicare payments in field 54B Recipient Covered by Private Insurance Edit 2505

36. 36/ October 2009 Third Party Liability IHCP Web site at www.indianamedicaid.comwww.indianamedicaid.com IHCP Provider Manual (Web, CD-ROM, or paper) HCBS Waiver Provider Manual (Web) 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 Avenues of Resolution Helpful Tools

37. 37/ October 2009 Third Party Liability Questions

38. October 2009 Office of Medicaid Policy and Planning (OMPP) 402 W. Washington St, Room W374 Indianapolis, IN 46204 EDS, an HP Company 950 N. Meridian St., Suite 1150 Indianapolis, IN 46204 EDS and the EDS logo are registered trademarks of Hewlett-Packard Development Company, LP. HP is an equal opportunity employer and values the diversity of its people. © 2009 Hewlett-Packard Development Company, LP.