UB-04 Medicare Crossover and Replacement Plans. HP Provider Relations October 2012

Transcription

1 UB-04 Medicare Crossover and Replacement Plans HP Provider Relations October 2012

2 Agenda Objectives Medicare crossover claim defined Medicare replacement plan claims Electronic billing of crossovers Paper billing of crossovers Helpful tools Questions 2 UB-04 Medicare Crossover and Replacement Claims October 2012

3 Session Objectives At the end of this session, providers will: Understand what constitutes a Medicare crossover claim Learn changes for Medicare replacement plan billing Know the correct claim filing procedures for crossover claims Become skilled at determining the correct documentation requirements 3 UB-04 Medicare Crossover and Replacement Claims October 2012

4 Understand Medicare Crossover Claims

5 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 or a Medicare replacement plan (date of service August 9, 2012, and after) Medicare issued a payment of any amount, or the entire payment was applied to the deductible and coinsurance A claim is not a crossover claim when: Medicare denied the entire claim It is a Medicare benefit exhaust claim 5 UB-04 Medicare Crossover and Replacement Claims October 2012

6 Medicare Replacements to Process as Crossovers Effective for dates of service August 9, 2012 (BT201225) Claims submitted to the IHCP for reimbursement will no longer be processed as third-party liability (TPL) Claims will no longer require the Medicare Replacement Plan explanation of benefits (EOB) to be attached to the claim when a payment has been made by the Medicare Replacement Plan The words Medicare Replacement must not be written on the claim form; however, Medicare Replacement is required on the attachment when the replacement plan denies the claim This change includes claims paid at zero when the amount allowed has been allocated to the member s deductible Medicare replacement claims will be processed as Medicare crossover claims 6 UB-04 Medicare Crossover and Replacement Claims October 2012

7 Claims Denied by Medicare Replacement Plan When services are denied on an institutional claim: The replacement plan EOB must be attached to the claim with Medicare Replacement written on the top of the attachment Note: Medicare Replacement Plan claims that have been paid at zero and the dollars allocated to the member s coinsurance or deductible are considered paid and must be submitted to the IHCP as crossover claims 7 UB-04 Medicare Crossover and Replacement Claims October 2012

8 Part A and C Crossover claims UB-04 claims may be submitted via the following methods: 837I transaction Web interchange Paper UB-04 claim form 8 UB-04 Medicare Crossover and Replacement Claims October 2012

9 Answer Common Questions

10 Common Questions Why do I receive zero dollars for payment on my crossover claims? The IHCP reimburses covered services for Medicare crossover claims only when the Medicaid-allowed amount exceeds the amount paid by Medicare If the Medicaid-allowed amount exceeds the Medicare paid amount, the IHCP reimburses using the lesser of the coinsurance plus deductible or the total Medicaid-allowed amount minus the Medicare paid amount See IHCP Provider Manual Chapter 7 for details on crossover payment calculation 10 UB-04 Medicare Crossover and Replacement Claims October 2012

11 Common Questions Why do some claims require manual billing instead of automatically crossing over? Following are some of the reasons why claims fail to cross over from Medicare automatically: National Provider Identifier (NPI) one-to-one match cannot be accomplished Medicare billing procedures differ from Medicaid, such as: Ambulatory surgical center (ASC) claims billed to Medicare on a CMS-1500 claim form with the SG modifier Medicare replacement plan claims do not automatically cross over 11 UB-04 Medicare Crossover and Replacement Claims October 2012

12 Common Questions What is the 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 12 UB-04 Medicare Crossover and Replacement Claims October 2012

13 Common Questions How do I file claims partially paid by Medicare? When Medicare allows only some of the services on a nonsurgical 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 for services Medicare has paid Only the Medicare-allowed services are exempt from the one-year filing limit AND prior authorization 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 or the Medicare Replacement Plan EOB 13 UB-04 Medicare Crossover and Replacement Claims October 2012

14 Learn Electronic Crossover Claims

15 Web interchange Claims Processing Menu 15 UB-04 Medicare Crossover and Replacement Claims October 2012

16 Institutional Claim 16 UB-04 Medicare Crossover and Replacement Claims October 2012

17 Coordination of Benefits UB-04 Medicare Crossover and Replacement Claims October 2012

18 Coordination of Benefits UB-04 Medicare Crossover and Replacement Claims October 2012

19 Crossover Claims via Web interchange Crossover information required in the Benefit Information window To report information, perform the following steps: Click Benefit Information on the Claim Submission window 1. Payer ID = Payer Name = Wisconsin Physician Services (WPS) OR the name of the Medicare Replacement plan billed (no spaces) 3. TPL/Medicare Paid Amount = The total amount paid by Medicare or the Replacement Plan for the claim 4. Group code = Choose appropriate code reason 5. Reason Code = Choose appropriate reason code (example 1 = deductible amount) 6. Amount = Enter amount for deductible, coinsurance 7. Subscriber Name 8. Primary ID = Medicare number with alpha character 9. Relationship Code = 18 (self) 10. Claim Filing Code = MA Click Save Benefits at the bottom of the screen Scroll to the top of the screen and click Save and Close 19 UB-04 Medicare Crossover Claims October 2012

20 Claim filing help 20 UB-04 Medicare Crossover and Replacement Claims October 2012

21 Learn Paper Crossover Claims

22 How to Bill a Crossover Claim Identify Medicare Remittance Notice (MRN) or Medicare Replacement policy EOB information in field 39 as follows: Value Code A1 Medicare deductible amount Value Code A2 Medicare coinsurance amount Value Code 06 Medicare blood deductible amount Value Code 80 IHCP covered days 22 UB-04 Medicare Crossover Claims October 2012

23 How to Bill a Crossover Claim Field 50A must indicate Medicare as the payer Field 54A must contain the Medicare/Replacement Plan paid amount (actual dollars received from Medicare) Do not include the Medicare-allowed amount or contractual adjustment amount in field 54A TPL payments will continue to be reported in field 54B 23 UB-04 Medicare Crossover Claims October 2012

24 Claim Filing Instructions Where do I find documented claim filing instructions for UB-04 paper claims? Refer to IHCP Provider Manual Chapter 8, Section 2 24 UB-04 Medicare Crossover and Replacement Claims October 2012

25 Deny Common Denials

26 Common Denials 0558 Coinsurance and deductible amount is missing indicating that this is not a crossover claim 2501 This recipient is covered by Medicare Part A; therefore, you must first file claims with Medicare Cause: No coinsurance or deductible information is present on the claim and no Medicare paid amount is entered in field 54 Resolution: Electronic Complete the Benefit Information window on the Web interchange indicating the Medicare payment and the Medicare coinsurance or deductible Paper Add A1 or A2 and amount in field locator 39 and the word Medicare in field 50A and the Medicare paid amount in field UB-04 Medicare Crossover and Replacement Claims October 2012

27 Common Denials 2055 The claim has been denied. Please resubmit the Medicare Replacement Plan claim as a crossover claim for reimbursement consideration Cause: Claim has not been submitted indicating the coinsurance and deductible amount in field 39 no Medicare paid amount in field 54A and no attachment Resolution: Electronic Complete the Benefit Information window on Web interchange indicating the Medicare payment and the Medicare coinsurance or deductible Paper Add A1 or A2 and amount in field locator 39 and the Medicare paid amount in field 54A 27 UB-04 Medicare Crossover and Replacement Claims October 2012

28 Common Denials 2007 Qualified Medicare Beneficiary (QMB) recipient Please bill Medicare first Cause: Member is a QMB ONLY or ALSO and no Medicare payment is indicated on the claim Resolution: QMB claims require proof that the Medicare has been billed Claims denied by Medicare must have the Medicare EOB submitted with the claim QMB ALSO can be adjudicated if Medicare denies QMB ONLY will be denied by the IHCP if Medicare denied the claim Electronic Complete the Benefit Information window on Web interchange indicating the Medicare payment and the Medicare coinsurance or deductible Paper Add A1 or A2 and amount in field locator 39 and the word Medicare in field 50A and the Medicare paid amount in field UB-04 Medicare Crossover and Replacement Claims October 2012

29 Find Help Resources Available

30 Helpful Tools Avenues of resolution IHCP website at indianamedicaid.com IHCP Provider Manual, Chapter 8, Section 2 Web interchange HELP feature Provider Enrollment Customer Assistance , or (317) in the Indianapolis local area Written Correspondence P.O. Box 7263 Indianapolis, IN Locate area consultant map on: indianamedicaid.com (provider home page> Contact Us> Provider Relations Field Consultants) or Web interchange > Help > Contact Us 30 UB-04 Medicare Crossover Claims October 2012

31 Q&A