Third Party Liability (TPL) Simplified

Transcription

1 Third Party Liability (TPL) Simplified Spring 2018 Agenda What is Third Party Liability (TPL)? How do I know if a member has TPL? Eligibility Commercial Traditional, PPO, HMO Medicare primary, supplements, replacements Adding/removing TPL from a member s profile 2 Third Party Liability Simplified 1

2 Agenda (cont.) Submitting TPL claims Electronic Data Interchange/Provider Portal/paper Primary paid/denied Attachments What is required HMS overview Resources TPL page on the OHCA public site OHCA Call Center Field Reps Questions 3 Disclaimer SoonerCare policy is subject to change. The information included in this presentation is current as of May 1, Current information can be found on the OHCA public website: 4 Third Party Liability Simplified 2

3 What is TPL? TPL means another party is responsible for paying health care costs before SoonerCare pays. All other available third-party resources must meet their legal obligation to pay claims first. SoonerCare is the payer of last resort. Exceptions to this policy include: Indian Health Services (IHS) Crime victims compensation 5 TPL Third Party Liability How does OHCA determine a member s TPL? Providers, members and HMS notify OHCA if a member has TPL or if the policy has termed. HMS does data matches with the insurance carriers to verify the coverage start and end dates. Pursuant to 63 OS , any insurance company doing business in Oklahoma is required to match with OHCA. 6 Third Party Liability Simplified 3

4 TPL Third Party Liability HMS does most of this coordination and varies how often they exchange data with a carrier. OHCA has direct data feed with Oklahoma Child Support Services, Workers Compensation and HealthChoice. 7 TPL Examples Medicare Private health insurance TRICARE Casualty/tort settlements Worker s compensation 8 Third Party Liability Simplified 4

5 Reminder TPL and Patient-Centered Medical Home (PCMH) Policy was amended to make individuals with other forms of credible health insurance coverage ineligible for SoonerCare Choice (effective 2014). Additionally, members currently enrolled in SoonerCare Choice who have or gain other forms of creditable insurance will be unenrolled from SoonerCare Choice. 9 Eligibility 1x23sas12: Status A3 PCMH CLINIC Third Party Liability Simplified 5

6 TPL 11 Adding TPL 12 Third Party Liability Simplified 6

7 TPL1 - Form Be very specific with request, either adding or removing. 13 SoonerCare Supplemental Eligibility B Bob Computer Third Party Liability Simplified 7

8 SoonerCare Supplemental Eligibility (cont.) 15 Medicare HMOs Third Party Liability Simplified 8

9 Medicare HMOs HMO replaces Medicare as primary SoonerCare is secondary OHCA pays only the copay 17 Medicare HMOs (cont.) Examples: GHS Health Maintenance Organization, Inc. AARP Medicare Complete Secure Horizons Global Health/Generations Healthcare Classic Coventry Advantage Humana Gold Plus Aetna Medicare Value Plan Arcadian Health Plans Community Care Senior Oklahoma Superior Select, Inc./Tribute 18 Third Party Liability Simplified 9

10 Medicare HMOs (cont.) Submission available on Provider Portal Paper claims for HMOs must be sent to: DXC Administrative Services PO Box Oklahoma City, OK HMO claims have been processed correctly if the ICN number begins with 92/94 Do NOT bill for any charges other than the copay on the claim Do NOT enter payment in any TPL field 19 Claim Submission Third Party Liability Simplified 10

11 Electronic Data Interchange (EDI) Submission If the primary payer paid: Under Other Subscriber Information, in loop 2320, send the SBR segment, AMT segment and IO segment with the amount paid. All CAS segments at the line level. No attachment is required. 21 EDI Submission (cont.) If the primary denied the claim or applied it to deductible: The same procedure is followed, with 0.00 entered in the AMT segment. You will then add an attachment to the claim. Add PWK segment with Attachment Control Number (ACN). 22 Third Party Liability Simplified 11

12 EDI Submission (cont.) Provider indicates attachment required for claim and creates the attachment control number. Clearinghouse creates a PWK segment, which includes the attachment control number created by the provider. Once an electronic (EDI) claim is submitted, provider prints and completes the HCA-13 (attachment cover sheet). Provider faxes/mails attachments. 23 Attachment Cover Sheet (HCA-13) 24 Third Party Liability Simplified 12

13 EDI Instructions for Crossovers Note: Crossovers process directly from Medicare to Medicaid. To reconcile crosswalk failure: contact EDI Help Desk Opt 2,2. Submission through clearing house: add CAS segments at the line level. add MA or MB at the end of SBR segment. 25 Portal Submission Third Party Liability Simplified 13

14 TPL Submission 27 Primary Paid FIXEM UP MEDICINE A Include 28 Third Party Liability Simplified 14

15 TPL Amount B Fee Lingbetter 29 Primary Denied B Lingbetter Fee 30 Third Party Liability Simplified 15

16 Step 2 31 Adding Attachments 32 Third Party Liability Simplified 16

17 Insurance Denied 33 OR Fax Cover Sheet HCA13 Attachment Cover Sheet Required 34 Third Party Liability Simplified 17

18 Medicare Crossovers 35 Medicare Crossovers (cont.) 36 Third Party Liability Simplified 18

19 Medicare Crossovers (cont.) 37 Institutional Crossover 38 Third Party Liability Simplified 19

20 HMO Copay 39 HMS Provider Relations Team and Portal HMS Third Party Liability Service Center Phone: Fax: Provider Portal 40 Third Party Liability Simplified 20

21 HMS Provides cost containment solutions for health care payers. Helps ensure that claims are paid correctly (program integrity) and by the responsible party (coordination of benefits). Overall Goal - To ensure that Medicaid remains the payer of last resort and spends more of its health care dollars on individuals entitled to them. 41 Background HMS is the third party liability (TPL) contractor for the OHCA. HMS has been conducting TPL projects on behalf of OHCA for more than 10 years. HMS creates and oversees the TPL projects from start to finish and reports the findings to OHCA. 42 Third Party Liability Simplified 21

22 Identifying TPL OHCA provides HMS their Medicaid eligibility and paid claims. Commercial insurance carriers and Medicare provide HMS with their eligibility. HMS performs data match to identify claims where Medicaid paid as primary but a third party was liable. 43 Disallowance Projects HMS notifies providers of claims selected, instructing provider to bill claim to third party and provide results within 60 days. Projects performed on quarterly basis: Commercial Insurance (CI) Medicare Part A Medicare Part B Based on TPL policy identified, CI or Medicare Part A/B should pay the claim as primary. 44 Third Party Liability Simplified 22

23 45 Disallowance Project Details HMS Provider Relations Team Works with provider during 60-day cycle to ensure all questions are answered and process documentation is submitted, if specific claims should not be recouped. Provider Letter Includes step-by-step instructions for provider to bill claims. Claims Listing is also included, indicating specific claims and TPL identified. 46 Third Party Liability Simplified 23

24 Disallowance Project (cont.) Claims Listing Provider should only submit claims included on HMS Claims Listing to TPL. Other claims may be pursued under other HMS projects, on behalf of OHCA. CI Timely Filing Appeal Letter Provider must include CI Timely Filing Appeal Letter, which is included in the letter packet, when billing the claim to the commercial insurer. If letter was not originally included when billing the CI, HMS will instruct provider to supply letter to the CI. 47 Disallowance Project (cont.) Outcome of Billing Provider must supply HMS Provider Relations team with supporting documentation before close of 60-day cycle, if claim should not be recouped. Otherwise, claim will be recouped by OHCA. Extensions Providers must request in writing that additional time is needed before the close of the 60-day cycle. One 30-day extension will be granted. 48 Third Party Liability Simplified 24

25 Disallowance Project (cont.) Recoupment Process Provider should not void claim during cycle. OHCA will recoup claim after cycle close. Checks not accepted. Provider Refunds Provider has 60 days from date of OHCA recoupment to request refund in writing to HMS Provider Relations, if claim was recouped in error. 49 HMS Letter 50 Third Party Liability Simplified 25

26 HMS Provider Relations Team and Portal HMS Third Party Liability Service Center Phone: Fax: Provider Portal 51 TPL Carriers Third Party Liability Simplified 26

27 OHCA Public Site 53 OHCA Public Site (cont.) 54 Third Party Liability Simplified 27

28 OHCA Public Site (cont.) 55 Resources OHCA Public Site: OHCA Provider Forms: TPL-1 form Billing Manual (Chapter 14) OHCA Provider Helpline (toll free) or (OKC area) Option 3,2 for Third Party Liability 56 Third Party Liability Simplified 28

29 Evaluations 57 Questions 58 Third Party Liability Simplified 29