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Medicare-Related Institutional Claim Filing

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

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Medicare-Related Institutional Claim Filing

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

  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 EXHAUSTCLAIMS

  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. PAPERMEDICAREEXHAUSTCLAIMS

  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 46207-7271

  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: • “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. Benefits Exhausted

  21. Benefits Exhausted

  22. Benefits Exhausted

  23. MEDICAREREPLACEMENTCLAIM

  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 ReplacementPlans 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 MedicarePart 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 interChangeClaims Processing Menu

  32. Billing Information

  33. Coordination Of Benefits

  34. Coordination Of Benefits

  35. Attachment Information

  36. Claims Attachment Cover Sheet

  37. PAPERREPLACEMENTCLAIMS

  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 46207-7271 • 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: • “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. Replacement Claim

  43. Replacement Claim

  44. Replacement Claim

  45. MEDICARECROSSOVERCLAIM

  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

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