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  • 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

  • Third Party Liability October 2013 3

    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 October 2013 5

    Third Party Liability What is TPL?

    A commercial group plan through the members 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 October 2013 6

    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

    Childrens Special Health Care Services

    (CSHCS)

    These programs are secondary to Medicaid

    because they are fully funded by the State

  • Third Party Liability October 2013 7

    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

  • Third Party Liability October 2013 8

    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

  • Third Party Liability October 2013 9

    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

  • Third Party Liability October 2013 10

    Cost Avoidance What is cost avoidance?

    When a provider determines a member has

    a TPL resource, that resource must be

    billed first

  • Third Party Liability October 2013 11

    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

  • Third Party Liability October 2013 12

    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

  • Third Party Liability October 2013 13

    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 homeowners 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

  • Third Party Liability October 2013 14

    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

    members 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

  • Third Party Liability October 2013 15

    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

  • Third Party Liability October 2013 16

    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)

  • Third Party Liability October 2013 17

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

    QMB-Only

    The members benefits are limited to payment of the members 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 members benefits include payment of the members Medicare Part A and Part

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

  • Claims Processing Requirements

  • Third Party Liability October 2013 19

    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

  • Third Party Liability October 2013 20

    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

  • Third Party Liability October 2013 21

    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

  • Third Party Liability October 2013 22

    TPL Claims Processing G

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