october 2009 presented by the eds provider field consultants automation of spend-down

October 2009

Presented by the EDS Provider Field Consultants

Automation ofSpend-down

AUTOMATION OF SPEND-DOWN2 / OCTOBER 2009

Agenda

• Introductions• Session Objectives • Spend-down Rule• Overview of Spend-down Population• Member Eligibility• Billing a Member• Eligibility Verification System• Claims Processing• Medicaid Spend-down Summary

Notice• Remittance Advice Statement or 835• Helpful Tools• Questions and Answers


Session Objectives

At the end of this session, providers will be able to:

• Understand how the spend-down is credited

• Identify when a member has a spend-down

• Understand how claims are affected before and after the spend-down is met

• Identify when spend-down is credited on a claim

• Identify the dollar amount credited to spend-down on a claim


Spend-down Rule

•405 IAC 1-1-3.1 – Provide Services to members enrolled in Medicaid spend-down provision

•405 IAC 2-3-10 – Spend-down eligibility


Overview of Spend-down Population


Number of Members on SLMB

Number of Members on Spend-down Only

Number of Members on Medicare, but not

QMB

IHCP

8,419 +

20,097 +

142 +

Number of Members on QMB Also

and Spend-down

15,203 +

35,442Data as of July 2009

Overview of Spend-down Population


Member Eligibility


Member Eligibility

•Member is eligible on the first of the month and may have a spouse on Medicaid

•Providers may not refuse service to a member pending verification of the status of spend-down for the month


Billing a Member


Billing a Member

•A provider may bill a member for the dollar amount identified beside ARC 178 on the Remittance Advice (RA) statement

•The member is not obligated to pay the provider until the member receives the Medicaid Spend-down Summary Notice listing the amount applied to spend-down

– Notices are sent on the second business day following the end of the month


Billing a Member

•Members cannot be billed for more than their spend-down amount

•Providers must bill their usual and customary charge to the Indiana Health Coverage Programs (IHCP)


Billing a Member

•Providers may discharge a member from their care if a member does not adhere to established payment arrangements of outstanding copayments or spend-down

•Providers cannot be more restrictive with spend-down members than with other patients


Eligibility Verification System


Eligibility Verification System

•All historical spend-down information is available on the Eligibility Verification System (EVS)

•Effective January 1, 2006, the EVS displays a spend-down indicator of “Yes” (member has spend-down) or “No” (member is not on spend-down)

•The met date only shows for dates of service prior to January 1, 2006

•The EVS does not display the member’s monthly spend-down amount


Web interChange


Claims Processing


Claims Processing

• If a spend-down met date is on file

• If no spend-down met date is on file

Dates of Service Prior to January 1, 2006:

• Form 8A is required if Date of Service = Met Date

• System uses the automation process

Dates of Service On or After January 1, 2006:

• Spend-down met date no longer applies

• Form 8A is no longer required

• Claims credit spend-down based on the order claims are processed

• Claims process directly through the system


Claims Processing

•The first claim processed by the IHCP applies to spend-down, regardless of the date of service within the month

•The system uses the billed amount to credit spend-down

•Third Party Liability (TPL) amounts are deducted from billed amount prior to crediting spend-down

•State-mandated copayments for pharmacy and transportation claims credit spend-down first


Claims Processing

•The combined total of the Medicare coinsurance, psychiatric reduction, deductible, and blood deductible amounts credit spend-down

•Claims for Medical Review Team (MRT) and Pre-admission Screening and Resident Review (PASRR) do not credit spend-down because they are not Medicaid claims and do not apply to spend-down processing


Claims Processing

The Division of Family Resources may credit spend-down for the following:

•Medical expenses incurred by a spouse of a member

•Services provided by non-Medicaid providers

•CHOICE

•Services rendered prior to eligibility


Claims Processing

Hierarchy of spend-down credits:• Nonclaim items entered by the

caseworker

– Including spousal medical expenses and expenses for children under age 18

• State-mandated transportation and pharmacy copayments

• Denied details, when permitted • Paid details


Claims Processing

•Medicaid is responsible for the Medicare coinsurance and deductible amounts

– These amounts do not credit spend-down

•Noncrossover claims credit spend-down based on spend-down policy

– Medicare noncovered services are not crossover claims

Qualified Medicare Beneficiaries – QMB Also with Spend-down


Claims Processing

•Services that are not covered by the Medicaid program do not credit spend-down

•A service that is denied because the member exceeds a benefit limitation, which cannot be overridden with prior authorization (PA), may credit spend-down

•Denied services may be split between spend-down months

Denied Services


Claims Processing

Date Billed: September 25, 2009

$100.00 Spend-down Remaining for September

$200.00 Spend-down Remaining for October

Billed Amount

Claim Status Audit Credit to Spend-down

$200.00 Denied 6122 –

Chiropractic Therapeutic Physical Medicine Treatments Limited to 50

$100.00 – September

$100.00 – October

Benefit Limit Exhausted – Example 1


Claims Processing

Date Billed: September 25, 2009

$700.00 Spend-down Remaining for October

Billed Amount

Claim Status

Audit Credit to Spend-down

Paid to Provider

$800.00 Denied 6238 –

Dental Services Limited to $600.00

$700.00 September

$0.00

$100.00 rolls forward to October

Benefit Limit Exhausted – Example 2


Claims Processing

•System edits are in place to ensure paid claims do not credit spend-down more than once

•System edits are in place to ensure denied claims that credit spend-down do not credit more than once

Preventing Duplicate Credits to Spend-down


Claims Processing

•Header Level – Prorate per day

– Inpatient

– Long Term Care

– Crossovers

•Detail Level – Credit applied based on the ‘From’ date of service

– CMS-1500

– Outpatient (UB-04)

– Home Health (UB-04)– Dental (ADA 2006)

Claims that Span More Than One Month


Claims Processing

Example:

Billed amount = $100,000

Number of Days billed = 25

$100,000 / 25 = $4,000 - per day credits spend-down

Prorating Inpatient Days That Span Months


Claims Processing

•For detail-level claims, whenever possible, providers should bill services for different months on separate detail lines

•By billing in this manner, the maximum amount possible credits the member’s spend-down per month

Span Dates - Detail


Claims Processing

Example 1 -

$100.00 credited toward July only

Paid Detail 1:

From Date of Service To Date of Service Billed Amount

7/31/09 8/2/09 $100.00

Span Dates


Claims Processing

Example 2 -

$25.00 toward July

$75.00 toward August

•Paid Detail 1:


7/31/09 7/31/09 $25.00

•Paid Detail 2:


8/1/09 8/02/09 $75.00

Span Dates


Claims Processing

•When a claim is paid and credits the member’s spend-down, a provider-initiated void or replacement can cause an increase or decrease in spend-down amount owed to a provider for the claim

• In the event a refund is due to the member as a result of a voided claim, the member is notified in the “Medicaid Spend-down Summary Notice”

– The member must have paid the provider to be eligible for a refund

•Voids and replacements adjust the spend-down credit immediately

Voids and Replacements


Claims Processing

• If the caseworker makes changes to the spend-down amount during the current month or previous month, the total spend-down amount only decreases, never increases

•Each month, EDS performs a month-end balancing process that ensures all credits applied by the county are used first

Month-End Balancing


Claims Processing

•This process ensures that any Indiana Client Eligibility System (ICES) nonclaim and claim items and State-mandated copayments are applied correctly

•Claims affected by the month-end balancing have an internal control number (ICN) with region code 64

•The amount used to credit spend-down on a claim only decreases by this process

Month-End Balancing


Example 1: Spend-down Activity for September - $500.00Order of

Claims that Credit the

Spend-down

Date of Service

Provider Type Amount Incurred

Method of Claim

Submission

Claim Processing

Date

Claim Status Spend-down

Balance for September

1 9/2/09 Pharmacy $50.00 (Includes Copay)

Point of Sale (POS)

9/2/09 Paid $0.00 $450.00

2 9/5/09 Physician $100.00 Web interChange

9/5/09 Paid $0.00 $350.00


Point Of Sale (POS)

9/8/09 Paid $0.00 $300.00

4 9/7/09 Non-Claim $50.00 ICES (County Office)

$250.00

5 9/8/09 Outpatient Hospital

$300.00 837I (Electronic)

9/15/09 $250.00 Credit spend-down

Paid $0.00

$0.00 (Allowed amount is less)

6 9/2/09 Dental $100.00 Paper 9/20/09 Paid IHCP Allowed

Claims Processing


Order of Claims

that Credit the Spend-

down

Date of Service

Provider Type

Amount Incurred

Method of Claim

Submission

Claim Processing

Date

Claim Status

Spend-down

Balance for October


Point of Sale(10:00 a.m.)

10/2/09 Paid $0.00

$280.00

2 10/2/09 Physician $50.00 Web interChange (2:00 p.m.)

10/2/09 Paid $0.00

$230.00

3 10/8/09 Dental $100.00 Web interChange

10/8/09 Paid $0.00

$130.00

4 10/25/09 Physician Void of Claim #2 for $50.00

Web interChange

10/25/09 Void Entire Claim

$180.00

5 10/28/09 Dentist $100.00 Paper 10/15/09 Paid $0.00

$80.00

6 10/29/09 Transport $150.00 Paper 10/20/09 $80.00 Credit Spend-down

$0.00 (Allowed amount is less)

Example 2: Spend-down Activity for October - $300.00

Claims Processing


Order of Claims that

Credit the Spend-down

Date of Service

Provider Type

Amount Incurred

Method of Claim

Submission

ClaimProcessing

Date

Claim Status Spend-down

Balance for

June

1 6/2/09 Pharmacy $50.00(Includes Copay)

Point of Sale (POS)

6/2/09 Paid $0.00 $350.00

2 6/5/09 Physician $100.00 Web interChange

6/5/09 TPL paid $25.00Paid $0.00

$275.00

3 6/8/09 Pharmacy $50.00(Includes Copay)

Point Of Sale (POS)

6/8/09 Paid $0.00 $225.00

4 6/8/09 Outpatient Hospital

$200.00 837I (Electronic)

6/15/09 Paid $0.00 $25.00

5 6/2/09 Transport $100.00 Paper 6/20/09 $25.00 Credit $2.00 co-pay rolls forward)

$0.00(Allowed amount is less)

Example 3: Spend-down Activity for June - $400.00 Claims Processing


Medicaid Spend-down Summary Notice


Medicaid Spend-down Summary Notice

•Notices are sent to the member on the second business day following the end of the month

•The notice includes a calendar month’s worth of spend-down activity


Remittance Advice Statement or 835

The Remittance Advice statement and 835 clearly identify amounts credited to spend-down, including any member co-payments that are used to credit spend-down

Providers refer to ARC 178 on the Remittance Advice and 835 for the amount credited to spend-down on the claim


Remittance Advice Statement or 835

Specific adjustment reason codes (ARCs) identify the exact amount used for each header level of detail level service.

ARC 178 – Payment Adjusted Because…Spend-down $117.75

ARC 132 – Prearranged Demonstration… $-60.75

ARC A2 – Contractual Adjustment $60.75

ARC 3 – Co-Payment Amount $3.00

Adjustment Reason Codes


Helpful Tools

• IHCP Web site at www.indianamedicaid.com

• IHCP Provider Manual (Web, CD-ROM, or paper)

•HCBS Waiver Provider Manual (Web)

•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

Avenues of Resolution


Questions

October 2009

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Office of Medicaid Policy and Planning (OMPP)

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Indianapolis, IN 46204

october 2009 presented by the eds provider field consultants automation of spend-down

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