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UB-04 Billing Medicare Replacement Plans

UB-04 Billing Medicare Replacement Plans. HP Provider Relations October 2011. Agenda. Session Objectives Medicare Replacement Plans Definition of a Medicare Replacement Plan The concept of the replacement plan

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UB-04 Billing Medicare Replacement Plans

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  1. UB-04 Billing Medicare Replacement Plans HP Provider Relations October 2011

  2. Agenda Session Objectives Medicare Replacement Plans • Definition of a Medicare Replacement Plan • The concept of the replacement plan • Definition of the difference between a Medicare crossover and a replacement plan Billing Requirements (electronic/paper) • Supporting documentation Most Common Denials Helpful Tools Questions

  3. Session Objectives Define what a Medicare Replacement Plan is and how it processes Clarify the difference between a Medicare crossover and a Medicare Replacement Plan Billing requirements for UB-04 electronic and paper claims submission What supporting documentation is required How to identify and notate the supporting documentation when necessary

  4. Learn Medicare Replacement Plans

  5. What Is a Medicare Replacement Plan? Created by the Balanced Budget Act of 1997 Medicare beneficiaries given the option to receive Medicare benefits through private health insurance plans Replacement of original Part A and Part B plan Sometimes referred to as Medicare+Choice, Medicare Advantage Plan, or Medicare HMO

  6. How Replacement Plans Work Plans are approved by Medicare but administered by private carriers Some plans require referrals to see specialists Premiums, copays, and deductibles often lower Covers Part A and Part B services Often have networks requiring member to use certain doctors and hospitals Offer extra benefits, such as prescription drug coverage

  7. Medicare Replacement Plans Health Maintenance Organizations (HMOs) Preferred Provider Organizations (PPOs) Private Fee-for-Service Plans (PFFS) Medicare Medical Savings Account (MSA) Medicare Special Needs Plans

  8. Reimbursement Reimbursement is the Medicaid allowed amount minus the payment from the Medicare Replacement Plan Reimbursement is based on the aggregate (totals), not line-by-line calculations The excess of the provider’s charges over the combined Medicare and Medicaid payments must be written off, the balance cannot be charged to the member

  9. Eligibility Verification For a member with a Medicare Replacement Plan, the Web interChange Eligibility Inquiry screen will indicate that the member has Medicare Part A and Medicare Part B No information will appear about the Medicare Replacement Plan in the Third Party Carrier section

  10. Common Misconceptions about Replacement Plans – Crossover or TPL? Replacement plans are regarded as Third Party Liability (TPL) claims, not as Medicare crossovers This is a critical distinction, as billing requirements and reimbursement are different for TPL vs. crossover claims A Medicare crossover is defined as a claim billed to traditional Medicare Part A or Part B for a covered service • Noncovered claims should be billed separately to Medicaid as a TPL • Attach copies of the Medicare Remittance Notice if services are Medicare noncovered

  11. Common Misconceptions about Medicare Replacement Plans Standard Medicaid prior authorization rules apply • Medicare Replacement Plan claims are subject to prior authorization (PA) guidelines • Reminder: A Medicare Replacement is processed as a TPL secondary claim and not as a Medicare crossover; therefore, all PA criteria must be satisfied Standard Medicaid timely filing limits apply • Medicare Replacement Plans are subject to the 365-day filing limit • If claims past the 365-day filing are submitted, past filing documentation must be included with the claim

  12. Bill Electronic Claims

  13. Electronic Billing – Medicare Replacement Plans Medicare Replacement Plans will not automatically cross over from the Medicare carrier to Medicaid Medicare Replacement Plans can be submitted via Web interChange • Coordination of Benefits information must be entered at the “header” level, but not at the “detail” level • Must use the “Attachment” feature and mail the Medicare Remittance Notice (EOB) as an attachment, along with an Attachment Cover Sheet • The words “Medicare Replacement Plan” must be written on the top of the attachment • The words “Replacement Plan” should be entered in the Notes section of the attachment window

  14. UB-04 Billing – Medicare Replacement Plans The following slides illustrate how to access the Web interChange screens to enter benefit information at the header Medicare Replacement Plans, and to enter Attachment and Note information

  15. Web interChange – Claims Processing Menu

  16. Institutional Claim

  17. Coordination of Benefits

  18. Coordination of Benefits

  19. Attachment Information

  20. Claims Attachment Cover Sheet

  21. Bill Paper Claims

  22. UB-04 Billing – Medicare Replacement Plans Paper claims should be submitted to the regular IHCP claims address • P.O. Box 7271Indianapolis, IN 46207-7271 Enter the words “Replacement Plan” in the Payer Name field 50B Do not enter any reference to Medicare in Payer Name field, as this causes the claim to be treated as a crossover claim Enter the payment received from the Medicare Replacement Plan in the Prior Payments field 54B

  23. UB-04 Paper Claim Submission Requirements

  24. UB-04 Billing – Medicare Replacement Plans Submit a copy of the Medicare Replacement plan EOB The words “Medicare Replacement Plan” must be written at the top of the claim form and on the attachment Standard Medicaid prior authorization rules apply to these claims Standard Medicaid timely filing limits apply to these claims

  25. Deny Common Denials

  26. Most Common Denial Codes Edit 2502 – Recipient Covered by Medicare Part B or D (with attachment) Cause • The member is covered by Medicare Part B and has a Medicare Replacement Plan, but the attachment does not adequately document the replacement plan Resolution • Electronic • Verify “Replacement Plan” is entered in the Notes section of the attachment window • Verify the name of the replacement/HMO is entered in the Benefit Information window • Paper • Verify the Medicare Replacement Plan payment is indicated in field 54B • Verify “Medicare Replacement Plan” is written at the top of the claim and the attached replacement plan EOB

  27. Most Common Denial Codes Edit 2501 – Recipient Covered by Medicare Part A (with attachment) Cause • The member is covered by Medicare Part A and has a Medicare Replacement Plan, but the attachment does not adequately document the replacement plan Resolution • Electronic • Verify “Replacement Plan” is entered in the Notes section of the attachment window • Verify the name of the replacement/HMO is entered in the Benefit Information window • Paper • Verify the Medicare Replacement Plan payment is indicated in field 54B • Verify “Medicare Replacement Plan” is written at the top of the claim and the attached the replacement plan EOB

  28. Most Common DenialCodes • Cause • Coinsurance and deductible amount is missing indicating this is not a crossover claim. The claim processed as a cross over due to a Medicare indicator on the claim • Resolution • Remove any formatting of a Medicare payment from claim. • Remove coinsurance and/or deductible amounts in field 39 a-d • Write “Replacement Plan” in field 50 B • Do not write “Medicare” in field 50 A or B Edit 0558 Coinsurance and deductible amount missing

  29. Most Common Denial Codes • Cause • A claim being submitted that has the same recipient number, rendering provider number, dates of service and procedure code of a claim that is in a current paid status • Resolution • Review Remittance Advices and/or Web Interchange to see if there is a claim in a paid status Edit 5001 – Exact Duplicate

  30. Most Common Denials Cause • When the days between the last date of service and the ICN date are greater than the filing limit Resolution • The provider should attach evidence of prior claim submission or inquiries • Retroactive Eligibility • Previous Submission History • Late Third Party Liability Notification • Retroactive Prior Authorization Edit 0512 Claim Past Filing Limit

  31. Find Help Resources Available

  32. Helpful Tools Avenues of resolution IHCP Web site at indianamedicaid.com Provider Enrollment • 1-877-707-5750 Customer Assistance • 1-800-577-1278, or • (317) 655-3240 in the Indianapolis local area Written Correspondence • P.O. Box 7263Indianapolis, IN 46207-7263 Provider Relations field consultant

  33. Q&A

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