Third Party Liability. Presented by EDS Provider Field Consultants

Transcription

1 Third Party Liability Presented by EDS Provider Field Consultants OCTOBER 2007

2 Agenda Session Objectives TPL Responsibilities Identifying TPL Resources Updating TPL Information Reporting Casualty Cases to TPL Submitting Claims with and without TPL Managed Care and TPL TPL Payments After IHCP Payments Health Management Systems Cost Avoidance and TPL Resource Information Disallowance Project Medicare Buy-In Helpful Tools Questions 2 / OCTOBER 2007

3 Session Objectives Ensure the IHCP is the payer of last resort, with the exception of: Victims Assistance First Steps Children's Special Health Care Services Hospital Care for the Indigent (HCI) Coordinate benefits with other payers Recover funds due the IHCP Explain HMS role 3 / OCTOBER 2007

4 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 Recover money for paid Medicaid claims where third party insurance carriers are liable for the claims 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 4 / OCTOBER 2007

5 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 Insurance, such as a homeowners plan, or compensation resulting from an accident or injury (car accident) This type of insurance is used only for casualty recovery, not cost avoidance 5 / OCTOBER 2007

6 Identifying TPL Resources Verify TPL member eligibility using one of the following verification options: Automated voice-response Omni swipe card BT includes download instructions for the Omni machine for the addition of the NPI number Web interchange What is the best option for TPL information? EDS Web interchange offers expanded TPL detail including: Primary insurance name, address, and telephone number Policy holder information Show More button for expanded information 6 / OCTOBER 2007

7 Identifying TPL Resources If member eligibility reads QMB (Only), Medicaid is only liable for the Medicare co-insurance and deductible If member eligibility reads QMB (Also), Medicaid will reimburse for Medicare non-covered services Verify eligibility for Medicare at the following numbers: Part A Part B / OCTOBER 2007

8 Updating TPL Information What is needed to update the member s insurance information (choose one)? 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 IHCP Web site at 8 / OCTOBER 2007

9 Updating TPL Information What if a member has an indemnity policy that pays the member only? Indemnity policies should not be loaded into IndianaAIM When providers or others notify EDS, the TPL unit will terminate the indemnity policy in IndianaAIM 9 / OCTOBER 2007

10 Updating TPL Information Providers should always ask members for a copy of their other insurance card and keep a copy of the card in the member s file Providers should always ask members to sign an assignment of benefits form to submit to the other insurance with the claim 10 / OCTOBER 2007

11 Reporting Casualty Cases to TPL Providers should notify the Casualty Unit if they receive a request for medical records due to an accident or illness that may have resulted from the negligent act of another person Contact the Casualty Unit By at INXIXCasualty@eds.com By telephone at (317) By U.S. mail at: EDS TPL Casualty Unit P.O. Box 7262 Indianapolis, IN / OCTOBER 2007

12 Submitting Claims with TPL Billing the IHCP for Insurer Co-payments Providers may not collect insurer co-payments 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 Note: State-mandated co-payments are not the same as TPL co-payments, and may be collected from the member 12 / OCTOBER 2007

13 Submitting Claims with TPL Blanket Denial 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 non-coverage of the service When does a blanket denial expire? Blanket denial EOBs are good until the end of the calendar year and must list the same procedure code(s) as those billed on the claim 13 / OCTOBER 2007

14 Submitting Claims with TPL 90-Day Provision 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 IHCP Provider Manual, Chapter 5, contains billing instructions 14 / OCTOBER 2007

15 Submitting Claims with TPL Helpful Hints When submitting TPL claims: Include member identification on the claim attachment Clearly state the reason for non-coverage 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 top of the claim form and EOB, if applicable If the TPL carrier pays the claim, no EOB is necessary (except Medicare replacement policies) If the TPL carrier denies the claim for any reason than an EOB is necessary with claim submission Submit TPL claims to the appropriate claim P.O. Box P.O. Box 7269 for CMS-1500 claims P.O. Box 7271 for UB-92/UB-04 claims 15 / OCTOBER 2007

16 Submitting Claims with TPL Member Receives Services Outside the Commercial Network Did the member receive service out of 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 16 / OCTOBER 2007

17 Medicare & Commercial Bypass Tables Bypass Tables Updating of the TPL bypass tables: EDS reviews the 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. This is cross referenced with the CMS file received by EDS EDS updates the commercial bypass tables based on information received from outside sources such as other carriers and providers 17 / OCTOBER 2007

18 Managed Care and TPL 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). 18 / OCTOBER 2007

19 TPL Payments After IHCP Payments What if a third party 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 NL For additional questions, call / OCTOBER 2007

20 Health Management Systems Health Management Systems (HMS) is contracted by EDS to perform retro-recovery (or pay and chase ) of Medicaid claims from commercial insurance carriers and Medicare HMS performs data matches with commercial carriers to determine member eligibility and provides IndianaAIM with this insurance resource information 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 20 / OCTOBER 2007

21 Cost Avoidance and TPL Resource Information Updates When a member s TPL insurance information is listed in IndianaAIM, the member s claim will deny unless it is first submitted to the TPL carrier EDS receives insurance updates from: Indiana Client Eligibility System (ICES) HMS claims data members providers insurance carriers caseworkers 21 / OCTOBER 2007

22 Cost Avoidance and TPL Resource Information Updates EDS verifies third party insurance information and performs 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 22 / OCTOBER 2007

23 TPL: Disallowance Project Effective May 23, 2007, Medicaid cannot bill directly for Medicare Part B claims paid that should be paid by Medicare as primary HMS identified Medicaid paid claims that should have been billed to Medicare Part B as primary HMS sent listings with these identified claims to the providers affected, instructing them to bill Medicare for the services Providers have been requested to submit a Credit Balance Worksheet to HMS within 60 days with the status of paid/denied claims from Medicare Reference BR for more information 23 / OCTOBER 2007

24 TPL: Disallowance Project Credit Balance Corrections Credit Balance Worksheet EDS will process adjustments to the claims Direct Refunds Mail refunds to HMS at: Fifth Third Bank Indiana Medicaid/EDS P.O. Box 2303 Dept. 132 Indianapolis, IN / OCTOBER 2007

25 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 and Medicaid Services (CMS) are conducted monthly to identify, update, resolve differences, and monitor new and ongoing Medicare buy-in cases Advantages of Medicare Buy-In: 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 with Social Security Income (SSI) Qualified Individual (QI-1) 25 / OCTOBER 2007

26 Helpful Tools Avenues of Resolution IHCP Web site at IHCP Provider Manual (Web, CD-ROM, or paper) Customer Assistance , or (317) in the Indianapolis local area Written Correspondence P.O. Box 7263 Indianapolis, IN Provider Relations Field Consultant 26 / OCTOBER 2007

27 Questions EDS Provider Field Consultants EDS 950 N. Meridian St., Suite 1150 Indianapolis, IN EDS and the EDS logo are registered trademarks of Electronic Data Systems Corporation. EDS is an equal opportunity employer and values the diversity of its people Electronic Data Systems Corporation. All rights reserved. OCTOBER 2007