Medicare claims processing contractors shall use remittance advice remark code RARC M32 to indicate a conditional payment is being made.

Transcription

1 Clarification of Medicare Conditional Payment Policy and Billing Procedures for Liability, No- Fault and Workers Compensation Medicare Secondary Payer (MSP) Claims Change Request (CR) 7355, dated May 2, 2012, details FISS & CWF coding and implementation requirements effective January 1, 2013 in regards to Medicare Secondary Payer (MSP) processing. CR 7355 clarifies the process and procedures MACs must follow when processing liability (L), No Fault (NF) or Workers Compensation (WC) claims when the insurer does not make prompt payment. The instructions also include definitions of the promptly payment rules and how MACs must identify conditional payment requests on MSP claims received from providers. When specified conditions are met the MSP statute prohibits Medicare from making payment where payment has been made or can reasonably be expected to be made by group health plans (GHPs), a workers compensation law or plan, liability insurance (including self-insurance), or no-fault insurance. If payment has not been made or cannot be reasonably be expected to be made promptly by workers compensation, liability insurance (including self-insurance), or no-fault insurance, Medicare may make conditional payments. Medicare Administrative Contractors (MACs) and shared systems continue to follow instructions found in the IOM , Chapter 1, section 10, Chapter 2, section 60, Chapter 3, section 30.2, and Chapter 5, section 40.6 and to determine when to pay conditionally on incoming claims. Prompt Payment Prompt payment means payment from the no-fault insurer or workers compensation entity within 120 days after receipt of the claim, for specific items and services, by the no-fault insurer or workers compensation entity. The Part A shared systems systematically informs MACs whether a claim is within or outside of the 120 promptly period. No-fault Insurance and WC Promptly Definition o For no-fault insurance and WC, promptly means payment within 120 days after receipt of the claim (for specific items and services) by the no-fault insurance or WC carrier. In the absence of evidence to the contrary, the date of service for specific items and service must be treated as the claim date when determining the promptly period. Further with respect to inpatient services, in the absence of evidence to the contrary, the date of discharge must be treated as the date of service when determining the promptly period. Liability Insurance Promptly Definition o For liability insurance (including self-insurance), promptly means payment within 120 days after the earlier of the following: o The date a general liability claim is filed with an insurer or a lien is filed against a potential liability settlement; or o The date the service was furnished or, in the case of inpatient hospital services, the date of discharge. The IOM , Chapter 1, Section 20, provides the definition of promptly (with respect to liability, no-fault, and WC) which all Medicare contractors must follow. In no-fault insurance or workers compensation situations, with respect to Part A inpatient services, MACs treat the date of discharge as the date of service, for purposes of determining the promptly period. Page 1 of 10

2 Medicare beneficiaries are not required to file a claim with a liability insurer or required to cooperate with a provider in filing such a claim. However, they are required to cooperate in the filing of no-fault claims. If the beneficiary refuses to cooperate in filing of no-fault claims, Medicare does not pay. MACs and shared systems make conditional payments for claims for specific items and service where the following conditions are met: (1) There is information on the claim or information on CWF that indicates that no-fault insurance or workers compensation is involved for that specific item or service, (2) There is/was no open GHP record on the MSP auxiliary file as of the date of service, (3) There is information on the claim that indicates that the physician, provider or other supplier sent the claim to the no-fault insurer or workers compensation entity first, and (4) There is information on the claim that indicates that the no-fault insurer or workers compensation entity did not pay the claim during the promptly period. Medicare claims processing contractors shall use remittance advice remark code RARC M32 to indicate a conditional payment is being made. Medicare claims processing contractors and shared systems shall deny claims, reject claims for Part A, where the following conditions are met: (1) There is information on the claim or information on CWF that indicates that no-fault insurance or workers compensation is involved for that specific item or service, (2) There is/was an open GHP record on the MSP auxiliary file as of the date of service, (3) There is no information on the claim that indicates that the claim was sent to the GHP, (4) There is information on the claim that indicates that the physician, provider, or supplier sent the claim to the no-fault insurer or workers compensation entity, and (5) There is information on the claim that indicates that the no-fault insurer or workers compensation entity did not pay the claim during the promptly period. Medicare claims processing contractors and shared systems shall use claim adjustment reason code (CARC) CO 22 and remittance advice remark code (RARC) MA04 to indicate in their denials that claims meeting these criteria need to be submitted to the GHP for payment Medicare Summary Notice (MSN) Message 29.5 shall also be used on beneficiary MSNs. Medicare claims processing contractors and shared systems deny claims, reject claims for Part A, where the following conditions are met: (1) There is information on the claim that indicates that no-fault insurance or workers compensation is involved for that specific item or service, (2) There is/was an open GHP record on the MSP auxiliary file as of the date of service, (3) There is information on the claim that indicates that the GHP denied the claim because the GHP asserted that the no-fault insurer or workers compensation entity should pay first, Page 2 of 10

3 (4) There is information on the claim that indicates that the physician, provider, or supplier sent the claim to the no-fault insurer or workers compensation entity; and (5) There is information on the claim that indicates that the no-fault or worker s compensation entity did not pay the claim during the promptly period. MACs and shared systems process no-fault insurance and workers compensation claims conditionally after the promptly period has expired and pay primary if services are not related to the accident or incident and no other GHP record exists as stated in CR All systems & MACs must take into consideration the DX code on the incoming claim as applicable when processing liability, no-fault, workers compensation claims as identified in CR7605. If there is no GHP insurance, CWF sends the 6819 error code and the shared systems process as applicable: Deny the claim or reject for Part A, if the diagnosis is considered a match (exact or match within family of diagnosis codes), the claim shows no evidence it was sent to the Liability insurer (including self-insurer), no-fault or Workers Compensation insurer, and the service is within the 120 day promptly period, utilizing the appropriate audit/denial code based on MSP type. Bypass the applicable error code & pay claim conditionally if the diagnosis is considered a match (exact or match within family of diagnosis codes) & claim is outside the 120 day promptly period. Pay the claim as primary if the diagnosis is not considered a match (exact or match within family of diagnosis codes); regardless of the 120 day period. MACs/shared systems determine the promptly period for liability insurance (including self-insurance) situations. Prompt or promptly, with regard to liability insurance (including self-insurance), means payment within 120 days after the earlier of the following: (1) The date a general liability claim is filed with an insurer or a lien is filed against a potential liability settlement; (2) The date the service was furnished or, in the case of inpatient services, the date of discharge. The date of accretion, listed on the liability MSP auxiliary record on CWF, is considered to be the date the general liability claim was filed for the purposes of determining the promptly period. MACs pay conditionally on the liability claim, if the Part A serviced date, or for a Home Health, Skilled Nursing Facility or Inpatient stay date of discharge, or the date of accretion listed on the liability MSP auxiliary record on CWF if earlier, is less than 120 days and MACs receive information, stating the liability insurer will not make payment. MACs and shared systems make conditional payments for claims for specific items and services where the following conditions are met: (1) There is information on the claim or information on CWF that indicates that liability insurance (including self-insurance) is involved for that specific item or service, (2) There is/was no open GHP record on the MSP auxiliary file as of the date of service, (3) There is information on the claim that indicates that the physician, provider or other supplier sent the claim to the liability insurer (including the self-insurer) first, and (4) There is information on the claim that indicates that the liability insurer (including the self-insurer) did not make payment on the claim during the promptly period. Page 3 of 10

4 MACs use remittance advice remark code RARC M32 to indicate a conditional payment is being made and deny claims, reject claims for Part A, where the following conditions are met: (1) There is information on the claim or information on CWF that indicates that liability insurance (including self-insurance) is involved for that specific item or service, (2) There is/was an open GHP record on the MSP auxiliary file as of the date of service, (3) There is no information on the claim that indicates that the claim was sent to the GHP, (4) There is information on the claim that indicates that the physician, provider, or supplier sent the claim to the liability insurer (including the self-insurer), (5) There is information on the claim that indicates that the liability insurer (including the self-insurer) did not pay the claim during the promptly period. MACs use CARC CO 22 RARC MA04 to indicate in their denials that claims meeting these criteria need to be submitted to the GHP for payment. Medicare Summary Notice (MSN) Message 29.5 is also used on beneficiary MSNs. Prepare and Submit an MSP Conditional Claim Before you can bill Medicare, you are first required to bill the payer(s) you have identified as primary for the beneficiary s services. Step 1: Determine if You Can Submit a Conditional Claim If you bill the primary payer but you do not receive payment for a valid reason (for all primary payers except MSP VC 16 (PHS), you can submit a conditional claim to Medicare. For MSP VC 16, if payer does not make payment for a valid reason, you can submit Medicare primary claims (not conditional). If you bill the primary payer for an accident but you do not receive payment within 120 days (for primary payers of accidents including MSP VCs 14, 15, 41, or 47), you can submit a conditional claim to Medicare. Note on Liability Plans: After waiting 120 days from the date on which you billed the primary payer, you can choose to submit a conditional claim to Medicare or to maintain all claims/liens against the liability insurance/beneficiary s liability insurance settlement. If you choose to submit a conditional claim to Medicare in a case where liability is the primary payer, you must first withdraw all claims/liens against the liability insurance/beneficiary s liability insurance settlement. You may maintain liens with the liability insurance/beneficiary s liability insurance settlement only for services not covered by Medicare and for Medicare deductible and coinsurance amounts. See CMS IOM Publication , Medicare Secondary Payer Manual, Chapter 2, Section 40.2, letter B. Conditional claims are coded similarly to MSP claims since the primary payer is reported as the first payer and Medicare is reported as the secondary payer (unless Medicare is tertiary or greater). However, for conditional claims, you report: A primary payer s payment amount of zero An OC 24 and the date on which you learned that the primary payer was not going to pay for the claim (in all but one situation) Remarks Page 4 of 10

5 From a reimbursement standpoint, a claim paid conditionally is paid the same as if there was no insurance other than Medicare. Step 2: Prepare a Conditional Claim Once it has been determine that a conditional claim will be submitted, prepare the conditional claim using the following guidelines: A. Use a covered TOB; do not use a noncovered TOB, e.g., 110 or 130, etc. B. Complete the claim (UB-04CMS-1450 claim form, FISS DDE claim entry or 837I claim) in the usual manner. C. Report all claim coding usually required for the services including charges for all Medicarecovered services D. If submitting an inpatient conditional claim, report the covered and noncovered days/charges as usual E. Follow Medicare s technical, medical and billing requirements since these requirements apply to conditional claims just as they do to Medicare primary claims. F. Follow the Medicare frequency of billing guidelines. For example, if your provider type is required to submit claims to Medicare every 30 days or every 60 days, then this remains true even though Medicare is not the primary payer. G. In addition, report the following MSP billing codes from the Conditional Billing Code Table (below) on the claim, if applicable. H. Report on the claim any applicable adjustments made by the primary payer by including the group codes and CARC and associated amounts from the primary payer s RA. Group Codes are required when primary payer adjusts billed charges. They identify the general category of the payment adjustment. Options are: CO (Contractual Obligations) CR (Corrections and Reversals OA (Other Adjustments) PI (Payer Initiated Reductions) PR (Patient Responsibility) CARCs are required when the primary payer adjusts billed charges. They explain why the primary payer paid differently than it was billed. The primary payer s remittance advice (RA) shows the CARCs for each group code. For CARC definitions, refer to If using FISS DDE to enter an MSP claim: Enter the information from the primary payer s RA in the Claim Entry page 03 (MAP1719). To reach MAP1719, press F11 from MAP1713 (the original Claim Entry page 03). You can enter information for up to two primary payers (up to 20 entries for each payer). Page 5 of 10

6 Once you enter the information for primary payer #1, you can enter information for primary payer #2 on the second page of MAP1719 (press F6 from the first page). MAP1719 fields: o Paid date: Enter paid date from primary payer s RA o Paid amount: Enter paid amount from primary payer s RA. This amount must equal MSP VC amount reported on claim (which must be zero for conditional claims) and must equal charges less amounts with the group codes and CARCs. o GRP: Enter Group Code o CARC: Enter CARCs o AMT: Enter dollar amount associated with each pair Conditional Billing Code Table Code Condition Code Occurrence code & date UB-04/ CMS Associated Field on 837I Claim FL HI (BG) FL HI (BH) FISS DDE Claim Entry Page Page 01 (MAP1711) Page 01 (MAP1711) Instruction In addition to any other required CC, report, as applicable: CC 02 = Condition is employment-related (also requires OC 04 and MSP VC 15 or 41) CC 06 = ESRD beneficiary in first 30 months of eligibility/entitlement covered by an EGHP (also requires MSP VC 13) Note: Do not report a CC 77. In addition to any other required OC and date, report, as applicable: 01 & DOA or injury = primary payer is medical-payment coverage (also requires MSP VC = 14) 02 & DOA or injury = primary payer is no-fault (also requires MSP VC = 14) 03 & DOA or injury = primary payer is liability (also requires MSP VC = 47) OC 04 & DOA/injury = primary payer is WC (also requires CC 02 & MSP VC 15 or 41) OC 24 and date of primary payer s denial/rejection/eob statement that explains the reason why the primary payer is not making payment on the claim. Note: Do not report OC 24 and date on the conditional claim when the claim is for an accident AND the reason the conditional claim is being submitted is because the primary payer has not made payment within 120 days (promptly). OC 33 and first day of MSP ESRD coordination period for ESRD beneficiaries covered by an EGHP (also requires CC 06 and MSP VC = 13) Page 6 of 10

7 Value code and amount FL HI (BE) Page 01 (MAP1711) In addition to any other required VC and amount, report the MSP VC that represents MSP Provision (see options below) and the dollar amount paid by primary payer toward Medicare covered charges on claim. For a conditional claim, the primary payer s payment amount is zero (there s no specific requirement as to number of zeroes that must be reported next to the MSP VC). Payer code (Code ID) Primary FL 50A, insurer name (Payer Name) Insured s name N/A N/A Page 03 (MAP1713) FL 58 A, 2320.SBR A.NM 104 Page 03 (MAP1713) Page 05 (MAP1715) Note: If the primary payer s payment was zero because of failure to file a proper claim (unless failure was due to beneficiary s mental or physical incapacity), report the amount you would have received had you filed a proper claim with the primary payer, i.e. submit the claim as an MSP claim & not a conditional claim. MSP VC options: 12 = Working Aged beneficiary/spouse with an EGHP (beneficiary age 65 or over) Beneficiary must be enrolled in Part A for this Provision to apply 13 = ESRD beneficiary with EGHP in MSP/ESRD 30-month coordination period (also requires CC 06 and OC 33) 14 = No-fault including automobile/other types Examples: Personal injury protection (PIP) and medical-payment coverage (also requires OC 01 or 02) 15 = WC (also requires CC 02 and OC 04) 16 = PHS or other federal agency 41 = Federal Black Lung program (also requires CC 02 and OC 04) 43 = Disabled beneficiary under age 65 with LGHP Beneficiary must be enrolled in Part A for this Provision to apply 47 = Any liability insurance (also requires OC 03) Notes: Do not submit conditional claims for MSP VC 16 or VC 42. If these payers do not make primary payment for a valid reason, submit the claims as primary claims. Do not report VC 44 and the amount you expected to receive from the primary payer on conditional claims. For first three payers (payers marked A, B and C), report payer ID (code ID). Use payer code Z for Medicare. For conditional claims, always report a C for the payer code (Code ID) of the primary payer, regardless of the MSP Provision and MSP VC on the claim. Report name of primary insurer(s). Report full, actual, complete names; not vague names such as no-fault, GHP, etc. Note: If using FISS DDE, Medicare will populate for lines on which you reported the payer code (code ID) Z. Report insured s name for each payer. Page 7 of 10

8 Patient s relationship to insured Insured s unique ID Insurance Group Name Insurance Group Number Employer Name Reason why primary payer did not make payment & primary insurer s address FL 59 A, FL 60A, FL 61A, FL 62A, FL 65A, 2320.SBR A.NM SBR SBR0 3 Page 05 (MAP1715) Page 05 (MAP1715) Report beneficiary s relationship to insured for each payer. Options: 01 = spouse 18 = self 19 = child 20 = employee 21 = unknown 39 = organ donor 40 = cadaver 53 = life partner G8 = other relationship Report insured s ID for each payer (beneficiary s HICN for Medicare line) Page 05 (MAP1715) Report name of primary insurance group for each primary payer Page 05 (MAP1715) Report primary insurance group number for each primary payer N/A N/A For UB-04 (CMS-1450) only, report name of employer that provides health care coverage for individual FL NTE Page 06 (MAP1716) Reason Why Primary Payer did Not Make Payment May report a two-digit explanation code and, if applicable, a date in MM/DD/YY format to explain the reason why the primary payer did not make payment. There are ten options that may be used as a means to summarize the various reasons why the primary payer did not make payment promptly or for a valid reason. Options: BE = Benefits exhausted. Requires date benefits exhausted in MM/DD/YY format. This is the date on which benefits exhausted which may not be the same as the date on which you learned that benefits exhausted (reported with OC 24). Automobile no-fault states should not use BE for automobile accident claims - see code PE below. Acceptable with MSP VCs 12, 13, 14, 15, 41 or 43. Note: If the primary payer is medical-payment coverage (VC 14), benefits have exhausted, the claim s date of service is after the date on which benefits are exhausted, and the claim is also not the responsibility of another payer such as liability, submit the claim as a primary claim. First, contact the BCRC to request that they correct the MSP record with a termination date equal to date on which benefits exhausted. CD = Charges applied to co-payment, coinsurance, and/or deductible. Acceptable with MSP VCs 12, 13, 14, or 43. DA = 120 days have passed since the primary payer was billed. Requires date primary payer was billed in MM/DD/YY format. Do not also report OC 24 with date insurance denied. Acceptable with MSP VCs 14, 15, 41, or 47 but for VC 47, you must have withdrawn claim with liability. DP = Delay in payment from liability insurer (you have been Page 8 of 10

9 notified of the delay). Acceptable with MSP VC 47. FG = Beneficiary did not follow guidelines of their primary health plan. Used in only three situations (see below) and provider must indicate which is the reason for submission of the conditional claim. Acceptable with MSP VCs 12, 13, 15, or Out of network (Medicare can pay only one time) 2. Untimely filing with primary payer (Medicare can pay but claim must be filed timely with Medicare) or 3. No prior authorization (Medicare cannot pay). LD = Response is received from liability insurer stating they feel they are not responsible for the claim. Acceptable with MSP VC 47. NB = Not a covered benefit. Acceptable with MSP VCs 12, 13, 14, 15, 41, or 43. PC = Pre-existing condition. Acceptable with MSP VCs 12, 13, or 43. PE = No-fault (also known as PIP) benefits exhausted toward medical expenses. Requires date benefits exhausted in MM/DD/YY format. This is the date on which benefits are exhausted which may not be the same as the date on which you learned that benefits exhausted (reported with OC 24). Acceptable with MSP VC 14. You must have copy of PIP on file. Note: If the primary payer is no-fault, benefits have exhausted, the claim s date of service is after the date on which benefits are exhausted, and the claim is also not the responsibility of another payer such as liability; submit the claim as a primary claim. First, contact BCRC to request that they correct the MSP record with a termination date equal to date on which benefits exhausted PP = Beneficiary paid by liability insurer. Used only for conditional claims involving liability insurance payments to the beneficiary where you are not expecting any payment from the beneficiary. May not be used for medical payment insurance payments to the beneficiary (MSP VC 14). You are required to pursue those dollars. Acceptable with MSP VC 47. Primary Insurer Address For UB-04 (CMS-1450) and 837I claims, report primary insurer s full address in Remarks (on the line below the two-digit explanation code (and associated date, if any). The primary insurer was reported in FL 50A (see above). For FISS DDE Claim Entry, report primary insurer(s) full address in Page 06 Page 9 of 10

10 Step 4: Wait for the BCRC to Set Up the Open MSP Beneficiary Record Continue to check for the MSP record to be set up. If the BCRC does not set up the MSP record, you must follow up with them. If you submit a conditional claim when there is no matching MSP record, Medicare suspends your claim and contacts the BCRC to request that they set up the MSP record which can take up to 100 days. Step 5: Once the MSP Record is Set Up, Submit the Conditional Claim to Medicare Once a matching MSP record is set up, submit the conditional claim: Via the 837I claim (per CMS CR 6426) Via FISS DDE (per CR 8486 effective 1/1/16). Medicare Processing of Conditional Claims Claim accepted: If conditional claims are submitted in accordance with the above instructions and do not encounter any other editing, they proceed to the payment floor. Claim RTP: If conditional claims fail to meet Medicare s usual claim submission requirements (technical, medical, and frequency of billing) and/or fail to meet the requirements for conditional billing, they will not be accepted and you must correct the claims which you may do in the FISS DDE per CMS CR 8486 effective January 1, Related Content CMS Benefits Coordination & Recovery Center (BCRC) contacts web page CMS Change Request 6426: Instructions on Utilizing 837 Institutional CAS Segments for Medicare Secondary Payer (MSP) Part A Claims CMS Change Request 7355: Clarification of Medicare Conditional Payment Policy and Billing Procedures for Liability, No-Fault and Workers Compensation Medicare Secondary Payer (MSP) Claims CMS Change Request 8486: Instructions on Using the Claim Adjustment Segment (CAS) for Medicare Secondary Payer (MSP) Part A CMS-1450 Paper Claims, Direct Data Entry (DDE), and 837 Institutional Claims Transactions CMS IOM Publication , Medicare Claims Processing Manual, Chapter 25, Completing and Processing the Form CMS-1450 Data Set, Section 75 CMS IOM Publication , Medicare Secondary Payer Manual, o Chapter 1, Background and Overview, Sections 10, 10.5, 10.7, 20, 30 and 40 o Chapter 2, Sections 40, 40.2, 50, and 60 o Chapter 3, MSP Provider, Physician, and Other Supplier Billing Requirements, Sections 10.2, 20.1, , 30.3, and o Chapter 5, Contractor Prepayment Processing Requirements, Sections 40 and 50 Page 10 of 10