Download - Third Party Liability - inprovider.indianamedicaid.com/media/29035/third party liability... · 3 Third Party Liability October 2013 Objectives At the end of this session, providers

Third Party Liability HP Provider Relations/October 2013

Third Party Liability October 2013 2

Agenda

• Objectives

• Third Party Liability (TPL)

• TPL Program Responsibilities

• TPL Resources

• Cost Avoidance

• Claims Processing Guidelines

• TPL Update Procedures

• Common Denials

• Questions

• Resources


Objectives At the end of this session, providers will

understand:

• What is Third Party Liability (TPL)

• The TPL program

• How to update TPL

• In what manner claims are processed

with a TPL

• How the TPL information is updated

Define Third Party Liability


Third Party Liability • What is TPL?

− A commercial group plan through the member’s employer

− An individually purchased plan

− Insurance available as a result of an accident or injury

• Can a member have insurance in addition to Medicaid?

− Private insurance coverage does not preclude an individual from having Indiana

Health Coverage Programs (IHCP) benefits except Healthy Indiana Plan (HIP)

− The IHCP supplements other available coverage

− The IHCP is responsible for paying only the Indiana Health Coverage plan authorized

medical expenses

• It is NOT a Medicare plan nor a Medicare Replacement Plann


Third Party Liability Is TPL the primary payer?

• Federal regulation (42 CFR 433.139)

establishes Medicaid as the payer of last

resort

• Exceptions:

− Victim Assistance

− First Choice

− Children’s Special Health Care Services

(CSHCS)

− These programs are secondary to Medicaid

because they are fully funded by the State


TPL Program What are the responsibilities of the TPL Unit?

• Identify IHCP members who have TPL resources

available

• Ensure that those resources pay before the IHCP

• Support compliance with federal and state TPL

regulations


TPL Resources How are TPL resources identified?

• Caseworkers/Division of Family Resources (DFR)

− Members provide TPL information, which is updated in Indiana Client Eligibility System

(ICES) and transferred to the IHCP

• Providers

− Providers report TPL information in writing, by telephone call, via Web interChange, or on

claim forms

• Data matches

− Data matches are performed with all major insurance companies and reported to the

IHCP


TPL Resources How are TPL resources identified?

• Hoosier Healthwise Managed Care Entity (MCEs)

− MCEs report information about members enrolled in their networks

• Medicaid Third Party Liability Questionnaire

− Providers and members may complete the questionnaire and e-mail, fax, or mail to the

HP TPL Unit

− The questionnaire is available on the Forms page of indianamedicaid.com

http://provider.indianamedicaid.com/media/27745/matrix.pdf


Cost Avoidance What is cost avoidance?

• When a provider determines a member has

a TPL resource, that resource must be

billed first


Cost Avoidance Some services are exempt from cost avoidance

• Pregnancy care

• Prenatal care

• Preventative pediatric care, including Early and

Periodic Screening, Diagnosis, and Treatment

(EPSDT/HealthWatch)

• Medicaid Rehabilitation Option (MRO)

• Home and community-based waiver services

• State psychiatric hospitals


Cost Avoidance Are Primary insurance out-of-network provider services covered?

• The IHCP requires that a member follow the rules

of the primary insurance carrier

• The IHCP does not reimburse for services rendered

out of network by the primary insurance

− Exception: Court-ordered services, such as alcohol or

drug rehabilitation

• If the primary insurance carrier pays for out-of-

network services, the IHCP may be billed


Cost Avoidance Is other types of liability insurance subject to cost avoidance?

• Liability insurance generally reimburses Medicaid for claim payments only under

certain circumstances

− Example: Auto or homeowner’s policies where liability is established

• If a provider is aware that a member has been in an accident, the provider may

bill the IHCP or pursue payment from the liable party (the provider is

encouraged to bill the third party first)

• If the IHCP is billed, the provider must indicate that the claim is for accident-

related services

• When the IHCP pays accident-related claims, postpayment research is

conducted to identify cases with potentially liable third parties


Cost Avoidance Is liability insurance subject to cost avoidance?

• When third parties are identified, the IHCP presents all paid claims associated

with the accident to the third party for reimbursement

• Providers are encouraged to report all identified TPL cases to the HP TPL

Casualty Unit

− Notify the TPL Casualty Unit if a request for medical records is received by an IHCP

member’s attorney regarding a personal injury claim

• Contact information:

− HP TPL Casualty Unit

P.O. Box 7262

Indianapolis, IN 46207-7262

− Telephone: (317) 488-5046 in the Indianapolis local area

or 1-800-457-4510


Cost Avoidance What is the Medicare Buy-In program?

• Allows states to pay Part B Medicare premiums

for dually eligible members (members eligible for

both Medicaid and Medicare)

• Automated data exchanges between HP and the

Centers for Medicare & Medicaid Services

(CMS) are conducted daily to identify, update,

resolve differences, and monitor new and

ongoing Medicare buy-in cases


Cost Avoidance What is the Medicare Buy-In program?

• The State is responsible for initiating Medicare buy-in for eligible members,

and HP coordinates Medicare buy-in resolution with CMS

• Medicare is generally the primary payer

− Payment of Medicare premiums, coinsurance, and deductibles cost less than

Medicaid benefits

− States receive Federal Financial Participation (FFP) for premiums paid for

members eligible as:

Qualified Medicare Beneficiary (QMB)

Qualified Disabled Working Individual (QDWI)

Specified Low-income Medicare Beneficiary (SLMB)

Money grant members Social Security Income (SSI)

Qualified Individual (QI-1)


Cost Avoidance What is the difference between QMB-Only and QMB-Also?

• QMB-Only

− The member’s benefits are limited to payment of the member’s Medicare Part A

and Part B premiums, as well as deductibles and coinsurance for Medicare

covered services only

− Claims for services not covered by Medicare are denied

− Members must be notified in advance if services will not be covered; if they still

want to have the service provided, they must sign a waiver acknowledging they

understand they will be billed

• QMB-Also

− The member’s benefits include payment of the member’s Medicare Part A and Part

B premiums, deductibles and coinsurance, and also traditional Medicaid benefits

Claims Processing Requirements


TPL Claims Processing Guidelines How is TPL coverage identified?

• Prior to rendering service, the provider must verify

Medicaid eligibility using the Eligibility Verification System

(EVS) options:

− Web interChange

− Omni

− AVR (Automated Voice Response system)

• The EVS should also be used to verify TPL information to

determine if another insurance is liable for the claim

• The EVS contains the most current TPL information,

including health insurance carrier, benefit coverage, and

policy numbers on file with the IHCP


TPL Claims Processing Guidelines Are TPL claims exempt from prior authorization?

• Prior authorization (PA) must be obtained

for any Medicaid service requiring a PA

• A provider may have to obtain PA from the

third party and from the IHCP

• Exception:

− Medicare Part A or Part B covered charges


TPL Claims Processing Guidelines What information is needed for a TPL claim?

• When submitting claims, the amount paid by the third party must be

entered in the appropriate field on the claim form or electronic

transaction, even if the TPL payment is zero

• If a third party made a payment, the explanation of benefits (EOB) is not

required

• If the primary insurance denies payment, or applies the payment in full

to the deductible, a copy of the denial EOB must be accompanied with

the claim


TPL Claims Processing Guidelines How are TPL claims paid?

• The IHCP payment will be the lessor of the

provider's usual and customary fee or the

Medicaid allowable

• If the primary insurance payment is equal to or

greater than the total Medicaid "allowable"

amount, the IHCP payment will be zero

• The member cannot be billed for any remaining

balance, or copayments/deductibles (see 405

IAC 1-1-3 (I))


TPL Claims Processing Guidelines What is a blanket denial?

• When a service that is repeatedly furnished to a member and repeatedly

billed to the IHCP, but is not covered by a third-party insurer, a photocopy

of the original denial EOB can be used for the remainder of the calendar

year

• The provider is not required to bill the TPL each time

• The provider must write "BLANKET DENIAL" on the original denial EOB

and on the top of the claim form

• The denial reason must relate to the specific services on the claim


TPL Claims Processing Guidelines What is the 90-day provision?

• When a third-party payer fails to respond within 90 days of a provider’s billing

date, the provider can submit the claim to the IHCP

• Attach one of the following to the claim:

− Copies of unpaid bills or statements sent to the insurance company

− Written notification from the provider indicating the billing dates and explaining the third-

party failed to respond within 90 days


TPL Claims Processing Guidelines What is the 90-day provision?

• Boldly indicate the following on the attachments:

− Date of the filing attempts

− The words NO RESPONSE AFTER 90 DAYS

− Member identification number (RID)

− Provider’s National Provider Identifier (NPI)

− Name of third party billed

• 90-Day No Response claims may be submitted on Web interChange using the

"Notes" feature

− Provide the same information listed above


TPL Claims Processing Guidelines What if the member receives the TPL check?

• Request the member to forward the payment to the provider, or if necessary:

− Notify the insurance carrier the payment was made to the member in error

− Request the payment be reissued to the provider

− If unsuccessful, document the attempts made and submit the claim to the IHCP under

the 90-day provision

• In future visits with the member, request the member sign an "assignment of

benefits" authorization form

• Submit the assignment of benefits with the next claim to the insurance carrier

• Providers may report the members to the fraud line if fraud is suspected

− Provider and Member Concern Line (317) 234-7598 or 1-800-457-4515


TPL Claims Processing Guidelines What are some of the edits applied to TPL claims?

• 2500 – Recipient covered by Medicare A – no attachment

• 2501 – Recipient covered by Medicare A – with attachment

• 2502 – Recipient covered by Medicare B – no attachment

• 2503 – Recipient covered by Medicare B – with attachment

• 2504 – Recipient covered by private insurance – no attachment

• 2505 – Recipient covered by private Insurance – with attachment

TPL Update Procedures


TPL Update Procedures Can a provider update a member’s TPL information?

• Providers can update TPL information via Web interChange

• From Eligibility Inquiry screen, Third Party Carrier Information section, click

TPL Update Request

• Enter all information about TPL, including comments

• HP TPL Unit will verify and update information within 20 business days


Web interChange – Eligibility Inquiry


TPL Update Request


TPL Update Procedures Can a provider update a member’s TPL information?

• TPL can be updated by faxing or calling the TPL

Unit

• Include the member’s RID and any other

pertinent data

• Send updated TPL information to:

− HP TPL Unit Third Party Liability Update

P.O. Box 7262


− Telephone: (317) 488-5046 or

1-800-457-4510

− Fax: (317) 488-5217


TPL Update Procedures Frequently Asked Questions

• Once TPL has been updated, what causes the old information to appear back in

the eligibility?

− The member has not updated the information with the DFR

− A redetermination is completed and the old information is put back in the Eligibility

Verification System

• A TPL update has been sent in; why hasn’t the information changed?

− The member may have the TPL coverage for services provided by other provider

specialty types

− The verification of information with the TPL carrier is pending


TPL Update Procedures How do members update their TPL information?

• Through the DFR:

− The caseworker or State eligibility worker enters TPL information into ICES when

members enroll in Medicaid

− The transfer of information from ICES to HP occurs within three business days

− This information is transmitted nightly to IndianaAIM and Web interChange

• Providers receiving TPL information that is different from what is in Web

interChange should immediately report the information to the TPL Unit

Find Help


Helpful Tools Avenues of resolution

• IHCP website at indianamedicaid.com

• IHCP Provider Manual Chapter 5 – Third Party

Liability

• Customer Assistance

− 1-800-577-1278 or

(317) 655-3240 in the Indianapolis local area

• HP Written Correspondence

P.O. Box 7263


http://www.indianamedicaid.com/


Helpful Tools Avenues of resolution

• Locate area consultant map on:

− indianamedicaid.com (provider home page>

Contact Us> Provider Relations Field

Consultants)

or

− Web interChange > Help > Contact Us

• TPL Unit

− (317) 488-5046 or

1-800-457-4510

Download - Third Party Liability - inprovider.indianamedicaid.com/media/29035/third party liability... · 3 Third Party Liability October 2013 Objectives At the end of this session, providers

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