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
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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
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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
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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
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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
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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
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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
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Cost Avoidance What is cost avoidance?
• When a provider determines a member has
a TPL resource, that resource must be
billed first
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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
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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
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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
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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
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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
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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)
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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
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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
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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
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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
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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))
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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
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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
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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
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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
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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
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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
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Web interChange – Eligibility Inquiry
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TPL Update Request
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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
Indianapolis, IN 46207-7262
− Telephone: (317) 488-5046 or
1-800-457-4510
− Fax: (317) 488-5217
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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
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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
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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
Indianapolis, IN 46207-7263
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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
Q&A