hp provider relations october 2011 third party liability

HP Provider RelationsOctober 2011

Third Party Liability

Third Party Liability October 20112

Agenda

– Objectives

– Third Party Liability (TPL)

– TPL Program Responsibilities

– TPL Resources

– Cost Avoidance

– Claims Processing Guidelines

– TPL Update Procedures

– Disallowance Projects

– Common Denials

– Questions and Answers


Objectives

– Define TPL

– Explain the TPL program

– Provide information on the sources of TPL information

– Give an overview of TPL claim processing requirements

– Illustrate how TPL information is updated

DefineThird Party Liability


Third Party Liability – TPL

– TPL may be:• A commercial group plan through the member’s employer

• An individually purchased plan

• Medicare

• Insurance available as a result of an accident or injury

– Private insurance coverage does not preclude an individual from having Indiana Health Coverage Programs (IHCP) benefits

• The IHCP supplements other available coverage

• The IHCP is responsible for paying only the State plan authorized medical expenses that other insurance does not cover

What is TPL?

Can a member have another insurance in addition to Medicaid?


Third Party Liability – TPL

Federal regulation (42 CFR 433.139) establishes the IHCP (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

Is TPL the primary payer?


TPL Program

– Identify IHCP members who have TPL resources available

– Ensure that those resources pay before the IHCP

– Support compliance with federal and state TPL regulations

What are the responsibilities of the TPL program?


TPL Resources

– Caseworkers/Division of Family Resources (DFR)• Members provide TPL information, which is updated in Indiana Client Eligibility

System (ICES) and transferred to IHCP

– Providers• Providers can report TPL information in writing, by telephone call, via Web

interChange, or by information submitted on claim forms

– Data Matches • Data matches are performed with all major insurance companies and reported to

the IHCP

– 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 provider.indianamedicaid.com

How are TPL resources identified?

http://provider.indianamedicaid.com/


Cost Avoidance

– When a provider determines a member has a TPL resource, that resource must be billed first

– If the provider bills the IHCP without proper documentation that the TPL was billed first, the claim will deny

What is cost avoidance?


Cost Avoidance

Some services are exempt:

– 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

– Procedure codes listed on Medicare Bypass Table• Some diagnosis and procedure codes are exempt from cost avoidance; these

codes are listed in IHCP Provider Manual, Chapter 5, Section 2

Are all services subject to cost avoidance?


Cost Avoidance

– The IHCP requires that a member follow the rules of the primary insurance carrier

– The IHCP does not reimburse for services rendered out of another plan’s network• Exception: Court-ordered services, such

as alcohol or drug rehabilitation

– If the primary carrier pays for out-of-network services, the IHCP may be billed

Are out-of-network provider services covered?


Cost Avoidance

– Liability insurance generally reimburses Medicaid for claim payments only under certain circumstances• Example: Auto or homeowner’s policies where liability is established

– Due to the circumstantial nature of this coverage, the IHCP does not cost-avoid claims based on liability coverage

– 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

Is liability insurance subject to cost avoidance?


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 not normally involved in or aware of this recovery process

– 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 or 1-800-457-4510

Is liability insurance subject to cost avoidance?


Cost Avoidance

– HP partners with HMS to collect credit balances due to the IHCP

– HMS mails letters and credit balance worksheets to select providers quarterly

– Refunds are due 60 days from the date of the letter

– Adjustments are processed weekly for providers that want credit balances subtracted from future payments

– Although letters are sent to selected providers, the credit balance worksheets can be used by any provider to return overpayments

– Contact HMS Provider Relations at 1-877-264-4854 with questions

– Credit Balance Worksheets and instructions are available at provider.indianamedicaid.com

How are TPL credit balances resolved?



Cost Avoidance

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)

What is the Medicare Buy-In program?


Cost Avoidance

– 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

What is the Medicare Buy-In program?


Cost Avoidance

– 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 should be notified in advance if services will not be covered; if they still want to have the service provided, they should 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

What is the difference between QMB only and QMB also?

LearnClaims Processing Requirements


TPL Claims Processing Guidelines

– 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

How is TPL coverage identified?



– If a service requires prior authorization by the IHCP, that requirement must be satisfied, even if a third party has paid or will pay a portion of the charge

– Therefore, a provider may have to obtain prior authorization from the third party and from the IHCP

– Exception:• Medicare Part A or Part B covered charges

Are TPL claims exempt from prior authorization?



– 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• Medicare Replacement Plans always require an EOB

– If the primary insurance denies payment, or applies the payment in full to the deductible, a copy of the denial EOB must be attached to the claim• If the claim is submitted electronically via Web interChange, the EOB may be

submitted by using the "Attachment" feature

What information is needed for a TPL claim?



– The IHCP payment will be the total Medicaid "allowable" amount, minus what was paid by the primary insurance

– 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 (refer to 405 IAC 1-1-3 (I))

How are TPL claims paid?



– 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 should write "BLANKET DENIAL" on the original denial EOB and at the top of the claim form

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

What is a blanket denial?



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

– 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 TPL billed

– 90-Day No Response claims may be submitted on Web interChange using the "Notes" feature• Provide the same information above, as on paper attachments

What is the 90-day provision?



– 90-Day No Response claims may be submitted on Web interChange using the "Notes" feature• Enter “90 Days No Response” in the note

• Include the name of the TPL that was billed

• List the dates the claim was billed to the TPL

What is the 90-day provision? (Cont.)



When the insurance carrier reimburses the member:• 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 and 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 member to the State contractor if member fraud is suspected

• Telephone: Member 1-800-446-1993 Provider 1-800-382-1039

What if the member receives the TPL check?



– The provider should submit a replacement claim via Web interChange or use the paper adjustment form

or

– The provider can use the credit balance reporting process administered by HMS

What if a third party or the member makes payment after IHCP has paid the claim?



– 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

– 2510 – Recipient covered by Medicare D

What are some of the edits applied to TPL claims?

DescribeTPL Update Procedures


TPL Update Procedures

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

Note: Sending a TPL denial with a claim does NOT update TPL information in the eligibility system

Can a provider update a member’s TPL information?


Web interChange – Eligibility Inquiry


TPL Update Request



– Include the member’s RID and any other pertinent data• Remittance Advice (RA), explanation of

benefits (EOB), carrier letters

– Send updated TPL information to:HP TPL UnitThird Party Liability UpdateP.O. Box 7262Indianapolis, IN 46207-7262

Telephone:(317) 488-5046 or 1-800-457-4510Fax: (317) 488-5217

TPL can be updated by faxing or calling the TPL Unit

Can a provider update a member’s TPL information?



– The member has not updated the information with the Division of Family Resources

– A redetermination is completed and the old information is put back in the Eligibility Verification System

– The member may have the TPL coverage for services provided by other provider specialty types

– The verification of information is pending from the TPL carrier

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

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



Through the Division of Family Resources (DFR):

– The caseworker or State eligibility worker enters TPL information into ICES (Indiana Client Eligibility Services) when members enroll in Medicaid• The ICES transfer of information 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

How do members update their TPL information?



– A Medicaid Third Party Liability Questionnaire is available at the "Forms" link atprovider.indianamedicaid.com

– The completed questionnaire can be emailed to [email protected]

Is there a TPL update form that can be sent in?


mailto:[email protected]

DetailTPL Disallowance Projects


TPL Disallowance Projects

– IHCP identifies Medicaid paid claims that should have been

billed to Medicare as primary

– IHCP will send listings of paid Medicaid claims to providers with

instructions asking them to bill Medicare for the claims paid by

Medicaid and respond within 60 days

– Providers are to report back to IHCP within 60 days by

submitting a Credit Balance Worksheet and to notify Medicaid

as to which claims have been paid by Medicare and which have

been denied

How does the Medicare disallowance project work?


TPL Disallowance Projects

– IHCP identifies Medicaid paid claims that should have been

billed to commercial carriers

– IHCP will send listings of paid Medicaid claims to providers with

instructions asking them to bill the commercial carriers for the

claims paid by Medicaid and respond within 60 days

– Providers are to report back to IHCP within 60 days and notify

Medicaid as to which claims have been paid by the commercial

carrier and which have been denied

How does the Commercial Insurance disallowance project work?


TPL - Common Denials

2504 – Recipient is covered by private insurance which must be billed prior to Medicaid

Claim was filed without information from primary payer

Resubmit claim with TPL information. Verify the claim was filed to the TPL carrier listed on the eligibility verification

2508 – Your service has been denied. The code billed to Medicaid is not the code billed to the primary carrier/insurer

Information on the EOB from the primary carrier does not match information submitted to Medicaid

File claim with the appropriate code

What are the top TPL denial codes?

Find HelpResources Available


Helpful Tools

– IHCP Web site at indianamedicaid.com

– IHCP Provider Manual (Web, CD, or paper)• Chapter 5 – Third Party Liability

– Customer Assistance• Local (317) 655-3240

• All others 1-800-577-1278

– Written Correspondence• HP Provider Written Correspondence

P. O. Box 7263Indianapolis, IN 46207-7263

– Provider field consultant

– TPL Unit• (317) 488-5046 or 1-800-457-4510

Avenues of resolution

http://www.indianamedicaid.com/

hp provider relations october 2011 third party liability

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