october 2009 third party liability presented by eds provider field consultants

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October 2009 Third Party Liability Presented by EDS Provider Field Consultants

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Page 1: October 2009 Third Party Liability Presented by EDS Provider Field Consultants

October 2009

Third Party Liability

Presented byEDS Provider Field Consultants

Page 2: October 2009 Third Party Liability Presented by EDS Provider Field Consultants

2 / October 2009Third Party Liability

Agenda

•Session Objectives

•TPL Responsibilities

• Identifying TPL Resources

•Updating TPL Information

•TPL Policies

•Casualty Cases

•Submitting TPL Claims and Attachments

•Managed Care and TPL

•TPL Payments After IHCP Payments

•Health Management Systems

•Cost Avoidance and TPL Resource Information

•Disallowance Project

•Medicare Buy-In

•Common Denials

•Helpful Tools

•Questions

Page 3: October 2009 Third Party Liability Presented by EDS Provider Field Consultants

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Session Objectives

Following this session, providers will better understand the following:

• IHCP is the payer of last resort

•Coordination of benefits with other payors

•Recovery of funds due the IHCP

•The role of HMS

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Identifying TPL Resources

What is TPL?

•TPL stands for third-party liability. It is a term used to refer to insurance other than the IHCP, including:

– A commercial group health or medical plan

– An individually purchased health or medical plan

– Casualty insurance, such as a homeowners or automobile liability policy, or compensation resulting from an accident or injury

• This type of insurance is used only for casualty recovery, not cost avoidance

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TPL Responsibilities

• Identify Medicaid member third-party insurance coverage; verify and update insurance information

•Maintain TPL insurance information by accepting adds, updates, or deletes from various external entities

•Maintain Medicare and other TPL insurance information by accepting adds, updates, or deletes from various external entities

•File and pursue Medicaid liens in casualty cases

•Provide Medicaid member birth expenditure information to county prosecutor’s office

•Pay private health insurance premiums for Medicaid members when it is deemed cost-effective to do so

•Meet federal and State TPL reporting requirements

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Identifying TPL Resources

•Verify TPL member eligibility using one of the following verification options:

– Automated Voice Response

– Omni swipe card• BT200711 includes download instructions for the

Omni machine for expanded NPI information

– Web interChange

•What is the best option for TPL information?

– Web interChange offers expanded TPL detail including:

• Primary insurance name, address, and telephone number

• Policy holder information

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Identifying TPL Resources

• QMB (Qualified Medicare Beneficiary)

– Medicare Premiums are paid by the state. This is referred to as Buy-in coverage. Discussed later in the presentation

• If member eligibility reads QMB-Only, Medicaid is only liable for the Medicare coinsurance and deductible only

• There is no Medicaid reimbursement when Medicare does not allow a service– Dental– Hearing Aids– Vision Refraction

• Verify eligibility for Medicare at the following numbers:– Part A – 1-866-580-5987 – Part B – 1-866-250-5665

Impact of QMB-Only Members

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Updating TPL Information – Via Paper

What is needed to update the member’s insurance information?

•A copy of the member’s medical insurance card

•A copy of the explanation of benefits (EOB) stating coverage is terminated

•A letter on company letterhead from the insurance carrier or the employer stating what date the member’s coverage terminated

•A copy of the Medicaid Third Party Liability Questionnaire form

– Download this form from the Forms link at www.indianamedicaid.com

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Updating TPL Information – Electronically

•Submit an electronic request to the EDS TPL Unit to update a member’s insurance information

•The TPL Unit receives the request, researches, confirms the information, and updates the eligibility screen with corrected information

– Updates are usually made within 20 days

•Confirm that eligibility has been updated by reviewing the Eligibility Inquiry feature

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10 / October 2009Third Party Liability

Updating TPL Information

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TPL Policies that Pay the Member

What if a member has a health insurance policy that pays the member only?

• Attempt to retrieve the funds from the payor via an assignment of benefits form

– Providers should always ask members to sign an assignment of benefits form to submit to the other insurance with the claim

– Providers create their own assignment forms• If carrier refuses to honor the assignment of benefits form,

request that member forward TPL payment to the provider

– If the member refuses to forward the TPL payment to the provider, submit the claim to EDS following the 90-Day Provision procedure (discussed later in this presentation)

• Indemnity policies are not loaded as a TPL resource. When providers or others notify EDS, the TPL unit will terminate the indemnity policy in IndianaAIM

Note: Reference Chapter 5, Section 3 of the IHCP Provider Manual for more information

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Reporting Casualty Cases to TPL

•Providers should notify the Casualty Unit within the TPL Unit if they receive a request for a member’s medical records due to an accident or illness resulting from the negligent act of another person

•Contact the Casualty Unit – By e-mail at [email protected]– By telephone local (317) 488-5046 or

toll-free at 1-800-457-4510– By U.S. mail at:

EDS TPL Casualty Unit P.O. Box 7262 Indianapolis, IN 46207-7262

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•Providers may not collect insurer copayments from the member

•Providers must bill Medicaid for the usual and customary charges and report the TPL payment

– The usual and customary charge includes the copay amount

– Do not include write-off amounts on the claim

Note: State-mandated copayments are not the same as TPL copayments, and may be collected from the member

Billing the IHCP for Insurer CopaymentsSubmitting Claims with TPL

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Submitting Claims with TPL

What is a blanket denial?

• When a healthcare service is not a covered benefit for the insured, the IHCP accepts an EOB from the other insurer showing that the service is not covered

What must the blanket denial EOB include?• Name of primary insurance carrier• Information sufficient to identify the member• Description of healthcare service• Statement of noncoverage of the service

When does a blanket denial expire?

• Blanket denial EOBs are valid until the end of the calendar year

Blanket Denial

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What if the third-party insurance does not respond?

•When a third-party payer fails to respond within 90 days of the provider’s billing date, the claim may be submitted to the IHCP for payment consideration

How to submit claims under the 90-Day Provision:

• Indicate 90-Day Provision

• Include attachments to support previous attempts to file with the primary carrier

– Web interChange users may insert a claim note to invoke the 90-Day Provision. Provider should write 90-day rule no response, insurance carrier, and dates sent to carrier

IHCP Provider Manual, Chapter 5, contains billing instructions

90-Day ProvisionSubmitting Claims with TPL

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Submitting Claims with TPL

When submitting TPL claims: • Include member identification (name and RID number) on the

claim attachment • Clearly state the reason for noncoverage on the TPL attachment• Ensure that the primary insurance company name on the

attachment matches the information in the member’s file• Hand write “Medicare Replacement Policy” on the claim form

and EOB for Medicare HMO claims• Hand write the procedure code(s) on the EOB if not already

indicated• Submit TPL claims to the appropriate claim P.O. Box

– P.O. Box 7269 for CMS-1500 claims– P.O. Box 7271 for UB-04 claims

Note: No attachments are required when TPL has made a payment

Helpful Hints

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Submitting Claims with TPL

Did the member receive service outside a commercial network?

•The member must follow the rules of his or her commercial plan first

• If a provider is not in a member’s primary plan network, the provider should check with the primary plan before rendering service

•The IHCP does not reimburse for services rendered out-of-network of another plan unless the policy reimburses for out-of-network services

– If the plan makes payment, it is business as usual

Member Receives Services outside the Commercial Network

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Submitting Claims without TPL

• If the IHCP has a TPL resource for a member on file and a claim is submitted for payment with zero dollars in the TPL field and no EOB is sent, the claim will deny for TPL

•The TPL edits are:– 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

TPL Edits

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Submitting Claims without TPL

Claims that bypass TPL edits:

•Claims from a state psychiatric hospital

•Claims with principal diagnosis code of:– Prenatal care

– Pregnancy

– Preventive pediatric

– Early and Periodic Screening, Diagnosis, and Treatment (EPSDT)

•Services for dually eligible Medicare and Medicaid members, when the service is always noncovered by Medicare (program excluded)– Services sometimes covered by Medicare will not bypass TPL

TPL Edits

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Submitting Claims without TPL

•Updating the TPL bypass tables:

– EDS reviews the Medicare bypass tables annually

– EDS uses the Medicare Covered and Non-Covered Manual to be sure the Medicare bypass tables are up-to-date with codes that are never covered by Medicare

– EDS updates the commercial bypass tables based on information received from outside sources such as other carriers and providers

TPL Bypass Tables

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Managed Care and TPL

• Insurance questions concerning members who are enrolled in the risk-based managed care (RBMC) delivery system should be directed to the appropriate managed care organization (MCO)

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TPL Payments After IHCP Payments

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

– 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 Health Management Systems (HMS)

• Additional information was published in IHCP provider newsletter NL200604

• For additional questions, call 1-877-264-4854

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Health Management Systems

•HMS is contracted by EDS to perform retro-recovery (or “pay and chase”) of Medicaid claims from commercial insurance carriers and bills the carriers monthly

•HMS performs data matches with commercial carriers to determine member TPL eligibility and provides IndianaAIM with this insurance resource information

•Beginning in May 2009, EDS and HMS have increased the frequency of TPL updates to the IndianaAIM system from bimonthly to biweekly updates, in an effort to provide the most up to date TPL information

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Health Management Systems

•HMS conducts disallowance projects where it looks for claims that should have been paid by Medicare or the Federal Employee Program (FEP) and notifies the provider to submit the claim to Medicare or FEP

– Once the claim is paid by Medicare or FEP, the Medicaid claim is adjusted to show this payment and the funds recouped by Medicaid

•HMS conducts provider self-audits for providers to report credit balances

•Beginning in 2008, HMS conducts commercial insurance disallowance projects focused on hospital providers where it looks for claims covered by commercial carriers and notifies the provider to bill the carrier

Page 25: October 2009 Third Party Liability Presented by EDS Provider Field Consultants

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Cost Avoidance and TPL Resource Information Updates

•When a member’s TPL insurance information is listed in IndianaAIM, the member’s claim will be cost avoided (or denied) unless it was first submitted to the TPL carrier

•EDS receives insurance information updates from the Indiana Client Eligibility System (ICES), HMS, claims data, members, providers, insurance carriers, and caseworkers

•EDS verifies third-party insurance information and adds updates to IndianaAIM within 20 business days of receipt

•Update requirements are as follows:– Copy of the member’s medical insurance card– Copy of the EOB stating coverage is terminated

– Letter on company letterhead from the insurance carrier or the employer stating what date the member’s coverage terminated

– Copy of the Medicaid Third Party Liability Questionnaire form• This form can be downloaded from the IHCP Web site

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TPL: Disallowance Project

• Effective May 23, 2007, Medicare carriers can only be billed by the provider of services

– Because Medicaid can no longer bill TPL claims directly to Medicare carriers, the billing of TPL claims through the provider of service is the only viable method of recovery

– Consequently, in addition to the Medicare Part A and FEP disallowance projects, HMS will also conduct a Medicare Part B disallowance project on a quarterly basis

• How the disallowance projects work:

– HMS identifies Medicaid paid claims that should have been billed to Medicare/FEP as primary

– HMS will send listings of paid Medicaid claims to providers with instructions asking them to bill Medicare/FEP for the claims paid by Medicaid and respond within 60 days

– Providers are to report back to HMS within 60 days by submitting a Credit Balance Worksheet and notify Medicaid as to which claims have been paid by Medicare/FEP and which have been denied

Medicare

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• How the Commercial Insurance disallowance projects work:

– Focused on hospital providers

– HMS identifies Medicaid paid claims that should have been billed to commercial carriers

– HMS 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 HMS within 60 days and notify Medicaid as to which claims have been paid by the commercial carrier and which have been denied

Commercial InsuranceTPL: Disallowance Project

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•Credit Balance Worksheet

– EDS will process adjustments to the claims

– Instructions can be located at www.indianamedicaid.com Web site under Forms, TPL

•Direct Refunds

– Mail refunds to HMS at:

Fifth Third BankIndiana Medicaid/EDSP.O. Box 2303 Dept. 132DIndianapolis, IN 46206-2303

Credit Balance CorrectionsTPL: Disallowance Project

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Medicare Buy-In Overview

• Allows states to pay Part B Medicare premiums for dually eligible members (members eligible for both Medicaid and Medicare)

• Automated data exchanges between EDS and the Centers for Medicare & Medicaid Services (CMS) are conducted monthly to identify, update, resolve differences, and monitor new and ongoing Medicare buy-in cases

• The state is responsible for initiating Medicare buy-in for eligible members and EDS 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 beneficiaries (QMB)• Qualified disabled working individual (QDWI)• Specified low-income Medicare beneficiaries (SLMB)• Money grant members Social Security Income (SSI)• Qualified individual (QI-1)

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Top Denials

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Edit 0558

•Cause

– Coinsurance and deductible amount is missing on the claim showing payment from Medicare

•Resolution– Bill Medicare First for payment– CMS-1500

• Field 22Left = The sum of Medicare Coinsurance, Deductible, and Psych ReductionRight – Medicare paid amount

- UB-04• Field 39a-41d • Value code A1 – Medicare deductible amount• Value code A2 – Medicare coinsurance amount• Value code 06 – Medicare blood deductible amount• Field 54A – Medicare paid amount

Coinsurance and Deductible Amount Missing

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•Cause

– Occurs when Medicare denies a detail line and are included with the paid detail lines

•Resolution

– Refile new claim with Medicare Remittance Notice (MRN) electronically

– Do not include paid detail lines on the new claim

– These claims are processed as TPL claims

Medicare Denied DetailEdit 0593

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•Cause

– Claim was billed to Medicare Replacement or HMO policy but was never indicated on claim as a replacement or HMO policy

•Resolution

– Bill To Medicare Replacement or HMO Plan as primary

– If payment was made from other plan, indicate payment on claim and write “Medicare Replacement” or “Medicare HMO”

– If no payment from other plan write “Medicare Replacement” or “Medicare HMO” on claim and submit EOB from other plan with claim to non-crossover address

QMB-Recipient – Bill Medicare First

Edit 2007

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•Cause

– If a physician or outpatient claim is submitted for a Medicare Part B covered service and recipient is covered by Medicare Part B

– The claim will deny if no attachment indicating Part B has been billed

•Resolution

– Bill Medicare Part B first

– Bill Medicaid with claim with Medicare Remittance Notice (MRN) or electronically using the attachment (ACN) process

Recipient Covered by Medicare Part B (No Attachment)Edit 2502

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•Cause

– This member has private insurance, which must be billed prior to Medicaid

•Resolution

– Add the other insurance payment to the claim electronically

– CMS-1500• Add other insurance excluding Medicare

payments to field 29

– UB-04• Add other insurance excluding Medicare

payments in field 54B

Recipient Covered by Private InsuranceEdit 2505

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• 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 7263

Indianapolis, IN 46207-7263

•Provider Relations field consultant

Avenues of ResolutionHelpful Tools

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Questions

Page 38: October 2009 Third Party Liability Presented by EDS Provider Field Consultants

October 2009

Office of Medicaid Policy and Planning (OMPP)

402 W. Washington St, Room W374

Indianapolis, IN 46204

EDS, an HP Company

950 N. Meridian St., Suite 1150

Indianapolis, IN 46204

EDS and the EDS logo are registered trademarks of Hewlett-Packard Development Company, LP. HP is an equal opportunity employer and values the diversity of its people. ©2009 Hewlett-Packard Development Company, LP.