SDMGMA Third Party Payer Day. Chelsea King, Policy Analyst

Transcription

1 SDMGMA Third Party Payer Day Chelsea King, Policy Analyst

2 Agenda Medicaid Overview Third Party Liability Common TPL Errors NDC Claims Processing Anesthesia Claims Online Portal Q & A

3 Medicaid Overview

4 Medicaid Overview Medicaid is one of the largest healthcare insurers in South Dakota. Federal-State partnership governed by Medicaid State Plan (agreement with federal government on who is served and what services are covered). Each state s plan is different. Makes comparisons between states difficult. Different than Medicare - 100% federal coverage for older and some disabled adults.

5 Claims Processing South Dakota Medicaid pays for covered health care services that are medically necessary. The program meets or exceeds Federal timely payment requirements. Processing and adjudication are completed by South Dakota Medicaid staff. There were approximately 5.3 million claims processed in SFY16. Over 83% of the claims are submitted electronically.

6 Who We Serve Most of the recipients serviced through the Medicaid program are children - 31% are adults All foster care children Low income children, pregnant women, adults and families Adult coverage is limited to: The elderly or disabled Parents or caregivers of low income children at or below 52% of the Federal Poverty Level (FPL) Family of three $10,560 annual income limit

7 Medicaid Overview SFY 2016 Average Monthly Eligible South Dakotans Elderly/Blind 6,991 Disabled 16,161 Pregnant Women (pregnancy only) 1,221 Low-income Adults 13,021 Children of Low-income Families 67,664 Children covered by CHIP 13,925 Total Average Monthly 118,983

8 Medicaid Participation SFY 2016 Monthly Average = 118,983 Aged/Blind 6% Adults, 31% Children- Medicaid and CHIP, 69% CHIP 12% LIF Children 57% Disabled 13% Low Income 11% Pregnant 1%

9 Who Uses Medicaid Now In SFY16 there were 118,983 average monthly individuals enrolled in South Dakota Medicaid. Nearly 1 of every 7 persons in any given month will have health coverage through Medicaid or CHIP. 1 of every 3 persons under the age of 19 in South Dakota has health coverage through Medicaid or CHIP. 50 percent of the children born in South Dakota will be on Medicaid or CHIP during the first year of their life.

10 Health Care Services Must be medically necessary and physician ordered Medicaid Mandatory Services Inpatient hospital services Outpatient hospital services Early and Periodic Screening, Diagnostic and Treatment (EPSDT) services All medically necessary care for eligible children under the age of 21 Nursing facility services Home health services Physician services Rural health clinic services Federally qualified health center services Laboratory and X-ray services Nurse Midwife services Certified Pediatric and Family Nurse Practitioner services Transportation to medical care Tobacco cessation counseling for pregnant women South Dakota Optional Services Physician assistants Psychologists and independent mental health practitioners Intermediate Care Facilities for the Mentally Challenged (ICF/MR) Podiatry Prescription drugs Optometry Chiropractic services Durable medical equipment Dental services Physical, occupational, speech therapy, audiology Prosthetic devices and eyeglasses Hospice care, nursing services Personal care services and home health aides

11 Third Party Liability

12 Third Party Liability Third Party Liability (TPL) is the obligation of an entity other than Medicaid to pay for either part or all of the medical costs of an injury, disease, or disability. The most common sources of TPL are Medicare and private health insurance plans such as DakotaCare, Blue Cross/Blue Shield, etc. TPL can also come from worker s compensation, disability insurance, or automobile insurance. When a recipient becomes eligible for Medicaid, they assign their right to TPL payments to Medicaid.

13 Reporting of Third Party Liability By Federal law, Medicaid is the payer of last resort. When a Medicaid recipient has a third party payment source, such as private health insurance, the insurance company must pay the claim before Medicaid. SD Medicaid requires all providers to submit claims to TPL before billing Medicaid. Claims not submitted to TPL first will be denied. Exception: Absent parent insurance and auto insurance SD Medicaid requires proof of TPL denials to be submitted with all paper claims. Electronic claims are preferred when there is a TPL payment reported on the claim

14 Third Party Source ARSD 67:16:26:05 Provider must collect from third-party source before submitting a claim to the Department Medical assistance program payer of last resort. The provider is eligible to receive the recipient s TPL responsibility amount, or the amount allowed under the department s payment schedule, less the TPL amount, whichever is less.

15 Third Party Liability Terms Explanation of Benefits (EOB): A statement sent by a health insurance company identifying the patient and services rendered, the amount charged by the provider, the amount of charges covered and not covered by the insurance company, including any contractual write-off amounts, and the patient responsibility amount. Alternate Terms: Summary of Benefits, Remittance Advice, Coverage Determination, Beneficiary Notice Usual and Customary Charge (UCC): The amount charged by the provider for the service. This amount should not contain any deductions. Alternate Terms: Billed Charges

16 Third Party Liability Terms Patient Responsibility: The amount of the UCC the patient is responsible for paying, usually the co-payment, co-insurance, and/or deductible amount. Contractual Obligation: The amount of the UCC that neither the insurance company or the patient is responsible for paying. This amount is usually specified in a contract between the provider and the insurance company or network. Alternate Terms: Network Savings, Not-Allowed Amount, Write-Off, Adjustment, CTR True Payment: The dollar amount that the private health insurance company paid for the service.

17 TPL Information on Claim Form Block 9 Other Insured s Name Block 11 Insured s Policy Group or FECA Number Block 24 (Shaded) If commercial insurance enter the contractual obligation/network savings amount with the prefix CTR. If after Medicare do not enter CTR. Block 9 Block 11 Block 24 Shaded Block 24 F Block 28, 29, 30

18 TPL Information on Claim Form Block 24 (Shaded) If commercial insurance enter the true payment for each service in the shaded portion. If after Medicare enter payment plus contractual obligation. Block 24 F The Usual and Customary Charge will be entered in the unshaded portion. Block 9 Block 11 Block 24 Shaded Block 24 F Block 28, 29, 30

19 TPL Information on Claim Form Block 28 Enter the Total UCC amount. Block 29 Enter the dollar amount paid by TPL. This should equal the sum of the true payments in 24 Shaded. Do not include any network savings or contractual obligation amounts unless billing after Medicare. Block 30 Enter the Balance Due. Block 9 Block 11 Block 24 A Block 24 F Block 28, 29, 30

20 Explanation of Benefits Example Claim Submitted to Private Health Insurance Usual & Customary Charge: $240 Contractual Obligation: $ Insurance Payment: $72.39 Balance Due from SDMA: $ $ = $12.77

21 Third Party Liability Example UB TRICARE 999 MEDICAID

22 After Medicare Example UB TRICARE 999 MEDICAID

23 Common TPL Errors

24 Medicare Crossovers Ensure that the information sent to Medicare matches the information that is in South Dakota Medicaid s SDMEDX Provider Enrollment Record Zip+4 Servicing and Billing NPI Taxonomy Check the Medicare Box on the claim form If you do not receive a response from South Dakota Medicaid within 4 weeks of submitting a crossover claim, please contact the Telephone Service Unit

25 Adjustment and Void Errors Adjustments may only be made to paid claims. Denied claims cannot be adjusted. Corrections to a claim that has been denied should be submitted as a new claim. If you have a denied adjustment be sure to check your Remittance Advice. Payment may be recouped and a new claim will need to be submitted. Always use the correct reference number on an adjusted claim. If information on the adjusted claim does not match, the claim will be denied. Enter the numeric value of 7 in Block 22 of the claim form if you are submitting an adjustment and the numeric value of 8 if you are submitting a void.

26 Billed Charges Always list the usual and customary charge (UCC) on the claim form. The UCC is the amount charged by the provider for the service. This amount should not contain any deductions. The amount listed on the claim form in Block 24 F and Block 28 will affect the payment amount from Medicaid. If you list an amount that is less than the fee schedule, you will be paid only the amount listed on the claim. If you leave these blocks blank, the claim will be denied.

27 Timely Filing Claims should be submitted every time an eligible service is provided for a Medicaid recipient. Please submit a claim as soon as possible following the date of service South Dakota Medicaid requires all claims to be received within 6 months following the month of the date of service Example: For a date of service of March 17, 2016, claim forms must be submitted by September 30, Claim forms must be submitted to South Dakota Medicaid within 3 months of a Medicaid denial Example: If a claim is denied on March 18, 2016, a new claim must be received by South Dakota Medicaid by June 18, 2016.

28 Timely Filing After Third Party Liability When a recipient has private health insurance or Medicare, claims must be submitted to those sources for payment before Medicaid Claim forms must be submitted to Medicaid within 6 months of notice of payment or denial from private health insurance or Medicare Example: Date of service is March 17, Provider submits to insurance, insurance makes a payment on June 21, Claim must be received by Medicaid no later than December 30, 2016.

29 NDC Claims Processing

30 NDC Claims Processing HCFA Medicare Crossover and Medicaid Claims If required data elements are missing or incorrect each line will deny until corrected Outpatient Medicare Crossover Claims If required data elements are missing or incorrect each claim will deny until corrected Outpatient Medicaid Claims Each line that required data elements are missing or incorrect will pay at $0 and the rest of the claim will pay as appropriate

31 Anesthesia Claims

32 Anesthesia Claims SD Medicaid will pay medically necessary services Referral is not required The only date required is the date of service Medicare crossovers follow Medicare guidelines SD Medicaid does not recognize physical status modifiers No special documentation needed for children Operating Room Modifiers Unplanned returns related to first surgery 78 Unrelated returns during post-operative period - 79

33 Online Portal

34 Online Portal Timeline Estimates Provider Testing: Starting 09/26/2016 Remittance Advice Implementation: 10/31/2016 More Information is Available: Portal Questions:

35 Q & A

36 More Information South Dakota Medicaid Website South Dakota Medicaid Listserv Frequently Asked Questions Provider Manuals OCR Portal

37 Contact Medicaid Eligibility or Claims Questions: Provider Enrollment: Portal Questions: Chelsea King: