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Section 1011 Trailblazer Health Claims Processing PowerPoint Presentation
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Section 1011 Trailblazer Health Claims Processing

Section 1011 Trailblazer Health Claims Processing

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Section 1011 Trailblazer Health Claims Processing

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  1. Section 1011Trailblazer Health Claims Processing Presenter Kathy Whitmire

  2. Agenda • Overview • Georgia Funding – Enrolled Hospitals • Where to find the resources • • 8 Steps to receiving payments from Trailblazer • Questions

  3. Overview of Section 1011 Program • On December 8, 2003, the President signed into law the Medicare Prescription Drug, Improvement and Modernization Act of 2003 (MMA), Section 1011, Federal Reimbursement of Emergency Health Services Furnished to Undocumented Aliens. • Congress has mandated that the Secretary of HHS directly pay hospitals, physicians, and ambulance providers for their otherwise un-reimbursed costs of providing services required by section 1867 of the Social Security Act (EMTALA) and related hospital inpatient, outpatient, and ambulance services furnished to undocumented aliens • Section 1011 provides $250 million per year for Fiscal Years (FY) 2005-2008 for payments to eligible providers for emergency health services provided to undocumented aliens and other specified aliens.

  4. 2007 State Allocations

  5. 2007 Hospitals Enrolled in GA

  6. Provider Enrollment Process • • EDI Enrollment Packet - • The Section 1011 Final Policy requires all provider types to submit payment requests electronically. Facilities may submit payment requests via Direct Data Entry (DDE) or facility charges only through Electronic Media Claims (EMC) while any physician or ambulance payment requests must be submitted through DDE.

  7. Provider Enrollment Process • STEP 1 • Complete the Section 1011 Provider Application • Submit and mail a hard copy enrollment application, signed by the authorized representative, to TrailBlazer. • Note: Only Medicare participating hospitals are eligible to enroll and receive reimbursement from Section 1011. Physicians and ambulance companies do not need to participate in Medicare to be eligible. •

  8. Provider Enrollment Application – STEP 1 County required in Section 4 Medicare Fiscal Intermediary in Section 7

  9. Provider Enrollment Application Provide the authorized official’s signature in Section 16

  10. Provider Enrollment Application

  11. STEP 2EFT Authorization Agreement -Required

  12. STEP 3ERA Request Form

  13. STEP 4Attachment 1 -

  14. 4 Simple Steps and you are enrolled To expedite the enrollment process, please ensure all applications are complete and mailed to the address below: • TrailBlazer Health Enterprises, LLC Section 1011 P.O. Box 660529 Dallas, Texas 75266-0529

  15. Enrollment Form Process • Enrollment Form Process • Upon receipt of the completed hard copy application, TrailBlazer will begin the application verification process. The verification process will take approximately two weeks. Applicants will be mailed a written notification upon completion of the verification process. This written notification will include the Welcome Letter and the applicable Provider Identification Number (PIN) Letter for each approved provider. • Welcome LetterSection 1011 Ambulance PIN LetterSection 1011 Hospital Only PIN LetterSection 1011 Hospital Roster PIN LetterSection 1011 Physician PIN Letter • If during the verification process it is determined that required data elements are missing, the application will be returned to the provider along with a Missing Data Elements Letter.

  16. STEP 5 – EDI Enrollment Packet = From Welcome Letter

  17. STEP 5 – EDI Enrollment Packet

  18. STEP 6 – Provider Payment Determination Providers must gather the information requested on the Section 1011 Provider Payment Determination to determine if a patient is eligible for services under the Section 1011 program. This form is not required when the payment request is submitted;however, the completed form must be maintained on file and submitted as part of the necessary paperwork for any records request.

  19. STEP 6 – Provider Payment Determination

  20. STEP 6 – Provider Payment Determination

  21. STEP 6 – Provider Payment Determination

  22. Section 1011 Patient Signature Requirements All Section 1011 providers must secure and maintain a patient signature for all Section 1011 payment requests they submit. CMS has adopted the position, as outlined on pages 31-32 of the Final Policy Notice, that all Section 1011-enrolled providers are subject to the Electronic Data Interchange (EDI) agreement submitted with the Section 1011 enrollment application. In Section A(4)(c) of the EDI agreement, the provider has agreed, "That it will submit claims only on behalf of those ... beneficiaries who have given their written permission to do so, and to certify that required beneficiary signatures, or legally authorized signatures on behalf of beneficiaries, are on file.“ Patients are not required to sign the Section 1011 Provider Payment Determination form which is the reason no space for the patient’s signature provided on the form.The patient's signature, however, must be kept on file with the rest of the documentation that providers are required to keep as part of their Section 1011 verification information. This signature document does not need to be submitted with payment requests.Providers should continue to follow their normal intake process, which should include some type of patient consent for treatment form that has been signed and dated by the patient or the patient's representative providing consent. This form will meet the Section 1011 patient signature requirement.

  23. STEP 7 – FILE CLAIMSDDE Screens for Hospitals Providers will access an online payment request system, called Undocumented Aliens Reimbursement System (UARS). Using Direct Data Entry (DDE), they will enter information as illustrated in the fields below. Hospital providers will select transaction 20 from the Payment Request

  24. STEP 7 – DDE Screens for Hospitals The following three Payment Request entry screens are marked with circled numbers that correspond to the table following the screen shots.

  25. STEP 7 – DDE Screens for Hospitals The following three Payment Request entry screens are marked with circled numbers that correspond to the table following the screen shots.

  26. STEP 8 – GET PAID - Reimbursement Page 53 of the Section 1011 Final Policy states: All payment requests would be aggregated (by CMS during claims processing) at the state level. Each provider within a state would receive payment equal to the lesser of its costs, the Medicare reimbursement rate or, if provider payments exceed the state allotment, a proportional payment of the Medicare reimbursement rate. Review the Section 1011 Payment Calculation Example, which can also be found under Payment Request Resources on this page. Additional information on Section 1011 payment rules may be found on the Section 1011 Final Policy under Section XIII.

  27. STEP 8 – Payment Calculation Explanation 1. Medicare rules apply to all providers, e.g., hospitals, physicians, and ambulance services. 2. Calculate Medicare payment. 3. Calculate the cost of providing the emergency services as follows: From the Provider Specific File: Multiply the Covered Charges times the Cost To Charge (CTC) 4. Compare Number 2 to Number 3 above and select the lesser value. This is Section 1011 payment. 5. For outpatient services only: Multiply value found in Number 4 above times 1.1. To calculate inpatient services: Use the value arrived at in Number 4. 6. The value from Number 5 is the final Section 1011 payment.

  28. STEP 8 – Payment Calculation Example

  29. STEP 8 – Payment Request Summary

  30. STEP 8 – Payments • Payment will not be made on a first come, first served basis. • Electronic payments will be made directly to providers, not the involved states, for services provided to undocumented and certain other aliens on or after May 10, 2005. • Providers will receive Electronic Remittance Advices (ERA) that include the provider name, Provider Identification Number (PIN), calculated Medicare payment amount and amount actually approved for each payment request submitted. • Because Section 1011 is a payer of last resort and providers are required to seek payment from all other payment sources, TrailBlazer will not be required to coordinate benefits or cross over payment requests with any other medical insurance plan. • Review Section 1011 Payment Request Cycles for service dates, payment request due dates and payment dates.

  31. Patient Identifier Number Methodology

  32. Professional Fees Billing for Professional Fees All professional fees must be billed under the physician’s Section 1011 Provider Identification Number (PIN) as an outpatient payment request. Type of Bill (TOB) 131 is used for all outpatient payment requests. Professional fees are keyed using the 096X, 097X and 098X revenue codes. The Fiscal Intermediary Standard System - Undocumented Alien Reimbursement System (FISS-UARS) will not accept a payment request if the last six digits of the Section 1011 provider number are zeros and revenue code(s) 096X - 098X are present. If the payment request is entered with the hospital's provider number (TOB 131 or 111), the provider will receive edit 7PFEE, which states: REVENUE CODES 096X, 097X AND 098X ARE IDENTIFIED AS PROFESSIONAL FEES AND MUST BE BILLED UNDER THE PHYSICIAN'S NUMBER. PAYMENT REQUESTS WITH PROFESSIONAL FEES ARE NOT ALLOWED FOR HOSPITALS.

  33. What about protection of privacy? Some hospitals are cautious about participating in the program because of privacy issues for the undocumented patients. What practices are in place to ensure that patients can access needed healthcare without any repercussions? Section 1011 does not require a name or address to be submitted with the payment request and the provider may mark out personally-identifiable information (the name, address, etc) on any medical records requested for Medical and/or Compliance review purposes.

  34. Summary • Summarize – Questions • Email Kathy Whitmire – • Thanks