Kansas Medical Assistance Program. Vertical Perspective. Other Insurance/Medicare Training Packet - Professional

Transcription

1 Kansas Medical Assistance Program Vertical Perspective Other Insurance/Medicare Training Packet - Professional

2 Other Insurance/Medicare Training Packet - Professional The training materials provided in this packet help in submitting a claim with other insurance or Medicare as a primary payer. The Kansas Medical Assistance Program (KMAP) will begin processing other insurance payments and adjustments at the detail level of the claim as opposed to lumping the individual payments and adjustments together. Currently, payments and adjustments from other insurance payers such as patient liability, copayments, and contractual obligations are processed at the header level. This information will now be reported at the detail level for more accurate posting. Currently, pricing is not impacted and will follow the old pricing logic until the second phase of this project is implemented. All claims submitted after January 1, 2011, regardless of date of service require the use of the HIPAA-compliant codes. In order to process this information at this level, screen changes have been made to accommodate the HIPAA claim adjustment reason codes (CARCs) and remittance advice remarks codes (RARCs) data provided by the primary payer. This information is typically found on your explanation of benefits (EOB) or RA from the primary payer and is defined as a payment or denial reason. All payers are required to be HIPAA compliant and return codes defining why a payment was denied or how a payment was made. The TPL/Medicare and Detail sections have been modified. The Crossover section contains data from the Medicare explanation of medical benefits (EOMB) and is gathered from the TPL/Medicare or Detail section. No data entry is allowed. The TPL/Medicare, Payer Information, and Detail Information is described in greater detail below. July

3 TPL Section Information The TPL section contains a TPL Paid Amount field. This information is gathered from the TPL/Medicare or Detail section. Data entry is not allowed. When entering the From DOS, the system displays a pop-up window with all the TPL active policies on the from date of service and appropriate for the claim type being billed. Medicare A and B policies are not included in the listing of optional carriers in the Select a Carrier field. Ignore this field if Medicare payment information should be added. Use the TPL/Medicare section to add the Medicare information. Note: Please refer to the Professional Billing Packet for instructions on completing the other sections of the web claim form. TPL/Medicare Information TPL and Medicare policies are entered in the TPL/Medicare section. To expand the TPL/Medicare section of the online claim form, click on the two arrows pointing downward on the far right side of the blue bar containing the word TPL/Medicare or click the little dots next to the title TPL/Medicare in the blue box. This will expand the TPL/Medicare section and allow you to enter data in the fields. If you enter a From DOS into the TPL section above, this section expands automatically. If there is not a TPL or Medicare payment, this does not apply. This box will only expand if a TPL From DOS is entered. To enter additional lines, click Add. To remove a line previously entered, click on the line and click Remove. This is considered the header level. Enter one policy at a time. Up to 10 policies can be added to each claim. The Policyholder s Last Name, First Name, Middle Initial, and Suffix are on the first line. The Policy Number, Plan Name, and Payer ID are on the second line. If a Payer ID is not entered, the system defaults to Payer 1, Payer 2 and continues sequentially based on the number of payers entered. When the claim is submitted, a pop-up window appears to alert you the default payer ID has been selected. The Date Adjudicated and Paid Amount are entered on the third line. The Paid Amount should be the total paid amount reported by the selected payer. The Policyholder Relationship to Patient and Insurance Type are drop-down lists on the fourth line. Select the appropriate choice. July

4 The Release of Information is a dropdown list on the fifth line. Select the appropriate choice. Remittance Advise Remarks Codes (RARC) should be added if the claim adjustment reason code (CARCs) states in the description it is needed or if one is returned from the primary payer. A RARC is used to convey information about remittance processing or to provide a supplemental explanation for an adjustment already described by a CARC. Each RARC identifies a specific message. Additionally, there are some informational RARCs, starting with the word Alert, which are used to provide general adjudication information (for example, appeal rights). These RARCs can be used without any associated CARC and/or when there is not an adjustment. RARCs must be entered at the header level. Use the Add and Remove buttons to add or remove the codes as needed. Enter the RARC code in the Code field using the RARCs lookup if needed. This information is located on the TPL or Medicare RA or EOB. RARCs can only be entered at the header level. CARC information should only be submitted in the Claim Adjustment Reason Code (CARC) section if it applies to the entire claim. This is considered the header level. There are only two situations where payment information should be added here: if there is only one line item or if the primary insurance only pays at the header level and there is no detail information available. If CARC information is added here, you cannot add it a second time in the detail section under Payer Information. The claim will not balance and process. Use the instructions for adding these codes in the Payer Information section below when these two situations do not apply. July

5 Payer Information Payment details from a primary payer are entered in this section. This is considered the detail level. If payer information is not listed in the TPL/Medicare section, this section will not accept data. It only applies to a claim with a primary payer. Once the TPL/Medicare information is entered, the payer name autopopulates in the Payer drop- down field. These fields cannot be used until the TPL/Medicare section is completed. Enter the Amount and Date Adjudicated information for each line. The Amount should be the total amount paid by the selected payer for the line item. Use the Add and Remove buttons to add or remove payer information as needed. The Claim Adjustment Reason Code (CARC) section autopopulates with information under the Group, Reason Code, and Description headings for deductible, coinsurance and copayment. The preselected codes will disappear if information is not entered because they are not appropriate for the claim. Group - in this field indicate the appropriate group code; CO indicates contractual obligation, CR for correction and reversal, OA for other adjustment, PI for payer initiated reductions, and PR for patient responsibility. If the group code is not provided by the primary payer, use your best judgment to identify which group code matches the CARC used. Code - in this field you will indicate the CARC code provided by the primary insurance. If the primary payer returned a non-hipaa compliant CARC, the system produces a pop-up window and explains the default code 192 is being entered. Enter a corresponding amount for each line. The Amount should be the line detail amount reported by the selected payer. Note: If multiple line details are entered in the detail section, corresponding payer information needs to be included. Each sum of the line detail payments must balance to the header paid amount. The system verifies the line item amounts entered equal the billed amount. Example: If you bill $100.00, you have to indicate the amount the other insurance paid, CARC information for patient responsibility, contractual obligation amounts, and any other adjustment to equal the billed amount of $ July

6 Adjusting Claims Claims adjusted after January 1, 2011, when Medicare or a TPL was billed primary, must have the payer information entered at the line detail level regardless of the date of service. If the TPL information was entered in the previous internal control number (ICN), the information displays in the TPL/Medicare section. Medicare policy information needs to be added. Enter the RARC information at the header level and the CARC information at the detail level. The TPL and Crossover sections are grayed out and changes are not permitted, except for the TPL From DOS field. If a date is added, the system displays a pop-up window with all active TPL policies on the from date of service and appropriate for the claim type being billed. July

7 Additional Information Copy Claim Function The Copy Claim function mirrors the original claim submitted. If the beneficiary has had a primary insurance added, the CARC and RARC default information will not be displayed. The information must be added in the header and detail sections as explained previously. Denied Primary Payer Information Regardless of denial or payment from the primary payer, the TPL/Medicare and Payer sections need to be completed. CARC information is required at the detail line level. Multiple Payer Balancing If a payment is made by two or more payers before billing KMAP, the secondary payer information must still balance to the billed amount. If Payer 1 pays $ toward a $ billed amount, Payer 2 will need to include an adjustment for the primary payer s payment with an OA code to make up the difference between the payment amount and the billed amount balance. Primary Insurance Payment Exceeds Paid Amount If the other insurance or Medicare pays more than the billed amount, the CARC information needs to be entered as a negative amount to balance the billed amount and the total paid amount including adjustments by the other insurance or Medicare. This will most likely occur with claims billed by rural health clinics, federally qualified health centers, and Indian Health Services; however, this applies anytime the primary insurance pays more than the billed amount. Paper Billing If a beneficiary has other applicable insurance and providers are submitting paper claims, providers will need to attach a copy of the explanation of benefits (EOB) and/or RA from the other insurance company for all affected services. If the primary insurance EOB or RA does not contain a HIPAA compliant CARC code, KMAP will automatically apply the generic CARC code of 192. An adjustment group code must always be used in conjunction with a CARC to show the liability for amounts not covered or identify a correction or reversal of a prior decision. Acceptable group codes include: contractual obligation (CO), patient responsibility (PR), correction and reversal (CR), other adjustment (OA), or payer initiated reductions (PI). The provider is responsible for providing the applicable adjustment group code associated with the applicable CARC and adjustment amount. It must be identified if the group code, CARC, and adjustment amount applies to the entire claim or to a specific detail line item. If the other insurance does not specify this information, then this must be written on the EOB or RA. If the EOB from the other insurance does not include all proportioning of the monies, the claim will be returned to the provider (RTP). The EOB must clearly indicate the paid amount, patient responsibility, and contractual write-off. If the EOB does not specifically indicate these things, you must write on the face of the EOB (for example, Paid Amount = $100.00, Patient Responsibility = $25.00, Contractual Obligation = $75.00). If a provider is not allowed to enroll in a health insurance company s network, the provider should use CARC 170 as a generic denial of out-of-network services. Note: Not all denials from an insurance company are acceptable denials for the Kansas Medicaid program to pay the claim. These denials will appear on the RA with EOB codes 9802 and Note: For providers who are enrolled as both pharmacy and durable medical equipment (DME) providers, this will only impact the DME claims filed to Medicaid as secondary. Trouble Shooting If your claim is not balancing; Verify the CARC information has not been entered at both the detail and header level. The CARC information should only be entered once per payer. Verify you entered the full Paid Amount in the header TPL/Medicare section. July

8 Pop-Up Explanations Error Code/Message The Payer ID must be unique for each Payer. A Payer ID is required when entering TPL information. Due to the absence of a Payer ID entered, a unique default Payer ID has been applied systematically. Service level paid amount for Payer X should be equal to service level billed amount minus detail level adjustment amounts at detail number X. The claim level other payer paid amount should be equal to the claim level billed amount minus claim level and detail level adjustment amounts for Payer X. Detail x is missing payer information. TPL Paid Amount is required when entering TPL information. A Claim Adjustment Group Code must always be used in conjunction with a Claim Adjustment Reason Code (CARC) to show liability for amounts not covered or to identify a correction or reversal of a prior decision. TPL Date Adjudicated is required when entering TPL information. Payer ID must be unique for each TPL/MEDICARE Reason code can not be blank. Click on 'Remove' if you do not want to enter a reason code Insurance Type is required when entering TPL information TPL Paid Amount is required when entering TPL information. Paid Amount must be a number equal or greater than zero. The selected payer is invalid. Please select a valid payer. The Payer ID must be unique for each Payer. TPL Plan Name is required when entering TPL information. Correction Method Enter a unique payer ID or leave blank for the system to populate. The Payer ID field will be updated with a unique ID. No action is required. Correct the amounts. The service level paid amount should be equal to the billed amount minus the adjustment amounts on the detail for the payer. Correct the amounts. The claim level paid amount should be equal to the claim level billed amount minus claim and detail level adjustment amounts per payer. Enter the required payer fields. Enter a TPL paid amount in the TPL/Medicare section at the claim level. Enter the CARC group and code at the header and detail level. Enter a valid adjudication date in the TPL/Medicare section. Enter a unique payer ID for each TPL. Enter a reason code or delete (remove) the line item data. Select the claim filing indicator available for the claim type billed. Enter a TPL paid amount. Enter an amount equal to or greater than zero. Select a valid payer from the payer drop-down list. Payer ID should be unique to each TPL payer ID entered. Enter the TPL carrier's name. July

9 TPL Policy # is required when entering TPL information. TPL Last Name is required when entering TPL information. Policyholder Relationship to Patient is required when entering TPL information Enter the policy number for the insurance policy. Enter a last name. Select the relationship of the policyholder to the beneficiary. Returned Edits Edits returned after submission specifically related to HIPAA-compliant submissions are capable of denying the claim or posting as pay and list. Edit 2031 INACTIVE REMITTANCE ADVICE REMARK CODE Occurs when a RARC submitted on the claim header is found on the national standard code listing of HIPAA-compliant RARC s but is considered no longer active for use. EOB code 9805 will be returned - DENIED - THE REMITTANCE ADVICE REMARK CODE (RARC) IS NO LONGER ACTIVE. SEE THE WASHINGTON PUBLISHING COMPANY WEB SITE FOR A LISTING OF INDUSTRY STANDARD COMPLIANT CODES. EDI.COM/PRODUCTS/CODELISTS/ALERTSERVICE Edit 2032 INACTIVE CLAIM ADJUSTMENT REASON CODE Occurs when a CARC submitted on the claim header is found on the national standard code listing of HIPAA-compliant CARCs but is considered no longer active for use. -Or- If a CARC submitted on the claim detail is found on the national standard code listing of HIPAAcompliant CARCs but is considered no longer active. EOB code 9804 will be returned - DENIED. THE CLAIM ADJUSTMENT REASON CODE (CARC) IS NO LONGER ACTIVE. SEE THEWASHINGTON PUBLISHING COMPANY WEB SITE FOR A LISTING OF INDUSTRY STANDARD COMPLIANT CODES. EDI.COM/PRODUCTS/CODELISTS/ALERTSERVICE Edit 2035 NON HIPAA COMPLIANT CLAIM ADJUSTMENT REASON CODES Occurs when a CARC submitted on the claim header is not found on the national standard code listing of HIPAA-compliant CARCs. Or- Occurs when a CARC submitted on the claim detail is not found on the national standard code listing of HIPAA-compliant CARCs. EOB code 9999 will be returned - CLAIM PROCESSED IN ACCORDANCE WITH KANSAS MEDICAL ASSISTANCE PROGRAM POLICIES. SEE THEWASHINGTON PUBLISHING COMPANY WEB SITE FOR A LISTING OF INDUSTRY STANDARD COMPLIANT CODES. EDI.COM/PRODUCTS/CODELISTS/ALERTSERVICE Edit Kansas Department of Health and Environment, Division of Health Care Finance (KDHE-DHCF) IDENTIFIED NON-PAYABLE CARC Occurs when a CARC submitted on the claim detail is a KDHE- DHCF -defined denial CARC. Edit 2037 GENERIC HIPAA COMPLIANT CARC CODE 192 Is used when a primary payer returned a non-hipaa compliant CARC. July

10 Edit 2038 NON HIPAA COMPLIANT REMITTANCE ADVICE REMARK CODE Occurs when a RARC submitted on the claim header is not found on the national standard code listing of HIPAA-compliant RARCs. EOB code 9999 will be returned - CLAIM PROCESSED IN ACCORDANCE WITH KANSAS MEDICAL ASSISTANCE PROGRAM POLICIES. SEE THEWASHINGTON PUBLISHING COMPANY WEB SITE FOR A LISTING OF INDUSTRY STANDARD COMPLIANT CODES. EDI.COM/PRODUCTS/CODELISTS/ALERTSERVICE Edit 2039 KDHE-DHCF IDENTIFIED NON PAYABLE RARC When a RARC submitted on the claim header is a KDHE-DHCF-defined nonpayable RARC. July