Spend-down. HP Provider Relations/October 2013

Transcription

1 Spend-down HP Provider Relations/October 2013

2 Agenda Objectives Spend-down Rule Eligibility Billing the Member Quiz Claims Processing Helpful Tools Questions & Answers 2

3 Objectives To explain how the spend-down process works To explain when it is appropriate to bill Medicaid members for spenddown To outline claims processing procedures related to spend-down 3

4 Spend-down Rule 405 IAC Providing services to members enrolled under the Medicaid spend-down provision Subsection (d) states: A provider may not refuse service to a Medicaid member pending verification that the monthly spend-down obligation has been satisfied A provider may not refuse service to a Medicaid member solely on the basis of the member s spend-down status 4

5 Spend-down Spend-down is applicable to members assigned to the following aid categories: Traditional Medicaid fee-for service (FFS) Medicaid for Employees with Disabilities (M.E.D. Works) Home and Community-Based Services (HCBS) Waiver Members with spend-down are not assigned to Care Select or the risk-based managed care (RBMC) programs 5

6 Spend-down determination Spend-down amounts are determined by the Division of Family Resources (DRF) Certain types of income are counted in determining Medicaid eligibility Income greater than a certain threshold is considered "excess income and is referred to as the "spend-down obligation The Medicaid member is responsible to pay their spend-down amount each month A summary notice is sent on the third day of the following month, to the member detailing the amount of the spend-down obligation to each provider Note: The member should contact the DFR if they believe the spend-down amount is not accurate 6

7 Eligibility

8 Eligibility Using the Eligibility Verification System (EVS), providers can determine: If the member has a spend-down, and if yes The amount of spend-down remaining to be met for a particular month Providers may use this information to prepare the member for the potential of having to pay out-of-pocket expenses The amount indicated may not be the actual spend-down amount credited to your claim; therefore, providers may not collect the spend-down amount at the time of service Pharmacy providers that bill claims on a point-of-sale (POS) system receive immediate claim adjudication and may collect the amount of spend-down credit at the time of service 8

9 Spend-down 9

10 Billing a Member

11 Billing a Member Once the claim has adjudicated, providers are responsible to bill the member for the spend-down amount credited on the claim The member is not obligated to pay the provider until the member receives the Medicaid Spend-down Summary Notice listing the amount applied to spend-down Notices are sent on the second business day following the end of the month The notices give a detailed itemization of how the spend-down was applied for that month, including provider name, amounts, and dates of service Providers may direct members to contact the DFR to update an old address in.gov/fssa/dfr

12 Billing a Member Providers can quickly determine when spend-down has impacted claims on the weekly Remittance Advice (RA): Review the ARC code listing at the end of the RA to verify if ARC 178 appears ARC 178 indicates there is a spend-down amount billable to at least one member on that week s RA A provider may bill a member for the dollar amount identified beside ARC 178 on the RA statement This amount appears in the "Patient Responsibility" column on the RA 12

13 Billing a Member What if the member doesn t pay their spend-down? Providers may discharge a member from their care if a member does not adhere to established payment arrangements of outstanding copayments or spend-down Providers cannot be more restrictive with spend-down members than with other patients 13

14 Quiz Q A How can providers determine when a member has a spend-down? Providers can verify that a member has a spend-down using Web interchange, Automated Voice Response (AVR), Omni, or the Health Insurance Portability and Accountability Act (HIPAA) 277/278 transaction Q A Why can t providers collect the spend-down at the time of service? The amount credited to spend-down is not known until the claim adjudicates Q A How is the provider informed that spend-down has been credited on claims? Providers should review the RA for the presence of ARC 178 and the amount listed as patient responsibility to determine how much has been credited to spend-down

15 Claims Processing

16 Claims Processing The first claims processed by the Indiana Health Coverage Programs (IHCP) will credit the spend-down The basis for crediting spend-down is the order in which claims are processed, not the chronological date of service within that month The system uses the billed amount to determine how much to credit spend-down Therefore, providers should bill their usual and customary charge Third-party liability (TPL) amounts are subtracted from the billed amount prior to crediting spend-down 16

17 Claim is Processed by IndianaAIM Denied services Services that are not covered by the Medicaid program do not credit spend-down Exception: A service that is denied because the member exceeds a benefit limitation, which cannot be overridden with prior authorization (PA), may credit spend-down Denied services may be split among spend-down months 17

18 Claims Processing Benefit limit exhausted Date Billed: September 25, 2013 $ Spend-down Remaining for September $ Spend-down Remaining for October Billed Amount Claim Status Audit Credit to Spenddown $ Denied 6122 Chiropractic Therapeutic Physical Medicine Treatments Limited to 50 $ September $ October 18

19 Claims Processing Voids and replacements When a claim is paid and credits the member s spend-down, a providerinitiated void or replacement can cause an increase or decrease in the spend-down amount owed to a provider Voids and replacements adjust the spend-down credit immediately In the event a refund is due to the member as a result of an adjusted or voided claim, the member is notified in the Medicaid Spend-down Summary Notice The member must have paid the provider to be eligible for a refund 19

20 Claims Processing The Division of Family Resources may also credit spend-down for certain nonclaim expenses, including: Medical expenses incurred by a recipient s spouse or other person whose income is considered in determining eligibility Medical services provided by non-medicaid providers Services rendered prior to eligibility 20

21 Claims Processing Hierarchy of spend-down credits Nonclaim items entered by the DFR State-mandated transportation and pharmacy copayments Note: Each month, HP performs a month-end balancing process to ensure all spend-down credits follow the prioritization of this hierarchy Denied details, when permitted Paid details 21

22 Claims Processing Month-end balancing The month-end balancing process ensures that all nonclaim transactions credit spend-down before claim-related transactions HP may initiate claim adjustments as a result of month-end balancing Claims adjusted by the month-end balancing process have an internal control number (ICN) that begins with 64 The adjusted claims may result in additional reimbursement to the provider 22

23 Error Codes 0387 and 0388 Providers may have encountered claim denials due to explanation of benefits (EOB) codes 0387 or 0388 This service is not payable. The recipient has not satisfied spend-down for the month. Providers should notify their field consultant when claims deny for these error codes Note: Claims adjudicate to a paid status when spend-down is credited on a claim. Spend-down-related claims should not adjudicate to a denied status. 23

24 Claims Processing Example 1 Spend-down activity for September $500 Order of Claims that Credit the Spend-down Date of Service Provider Type Amount Incurred 1 9/2/13 Pharmacy $50.00 (Includes Copay) Method of Claim Submission Point of Sale (POS) 2 9/5/13 Physician $ Web interchange Claim Processing Date Claim Status 9/2/13 Paid $0.00 $ /5/13 Paid $0.00 $ Spend-down Balance for September 3 9/8/13 Pharmacy $50.00 (Includes Copay) Point Of Sale (POS) 4 9/7/13 Nonclaim $50.00 ICES (County Office) 5 9/8/13 Outpatient Hospital $ I (Electronic) 9/8/13 Paid $0.00 $ /15/13 $ Credit spend-down $ $0.00 (Allowed amount is less) Paid $ /2/13 Dental $ Paper 9/20/13 Paid IHCP Allowed

25 Claims Processing Example 2 Spend-down activity for October $300 Order of Claims that Credit the Spend-down Date of Service Provider Type Amount Incurred 1 10/2/13 Pharmacy $20.00 (Includes Copay) Method of Claim Submission Point of Sale (10:00 a.m.) 2 10/2/13 Physician $50.00 Web interchange (2:00 p.m.) 3 10/8/13 Dental $ Web interchange 4 10/25/13 Physician Void of Claim #2 for $50.00 Web interchange Claim Processing Date Claim Status 10/2/13 Paid $0.00 $ /2/13 Paid $0.00 $ /8/13 Paid $0.00 $ /25/13 Void Entire Claim Spend-down Balance for September $ /28/13 Dentist $ Paper 10/15/13 Paid $0.00 $ /29/13 Transport $ Paper 10/20/13 $80.00 Credit Spend-down $0.00 (Allowed amount is less)

26 Claims Processing Example 3 Spend-down activity for June $400 Order of Claims that Credit the Spend-down Date of Service Provider Type Amount Incurred 1 6/2/13 Pharmacy $50.00 (Includes Copay) Method of Claim Submission Point of Sale (POS) 2 6/5/13 Physician $ Web interchange 3 6/8/13 Pharmacy $50.00 (Includes Copay) 4 6/8/13 Outpatient Hospital Point Of Sale (POS) $ I (Electronic) Claim Processing Date Claim Status 6/2/13 Paid $0.00 $ /5/13 TPL paid $25.00 Paid $0.00 Spend-down Balance for September $ /8/13 Paid $0.00 $ /15/13 Paid $0.00 $ /2/13 Transport $ Paper 6/20/13 $25.00 Credit $2.00 copay rolls forward) $0.00 (Allowed amount is less)

27 Spend-down Quiz (True or False) Q Q Q Q Q A provider may refuse to provide service to a member if they verify eligibility and determine the member has a spend-down? FALSE A provider may refuse to provide a service to a member who has a legitimate pastdue balance for a spend-down, but refuses to pay it? TRUE A provider may bill the member for spend-down as soon as they receive a Remittance Advice that includes ARC 178? TRUE Spend-down is credited based on the provider s usual and customary charge (UCC)? TRUE (when the provider bills the UCC) Spend-down is credited to claims in date-of-service order? FALSE

28 Spend-down Quiz Rank the priority of spend-down transactions: 1.? A State-mandated copays 2.? B Paid details 3.? C DFR nonclaim transactions 4.? D Denied details C, A, D, B 28

29 Find Help

30 Helpful Tools IHCP Provider Manual, Chapter 2, Section 4 (web, CD, or paper), available at indianamedicaid.com Customer Assistance Local (317) All others Provider Relations consultant Locate area consultant map on: indianamedicaid.com (provider home page > Contact Us > Provider Relations Field Consultants) or Web interchange > Help > Contact Us Written Correspondence HP Provider Written Correspondence P.O. Box 7263 Indianapolis, IN

31 Q&A