enterprise edition homecare msp billing supplement · 1 on the main menu click master files. 2...

Enterprise Edition │ Homecare MSP Billing Supplement

Enterprise Edition

Homecare MSP Billing Supplement

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Revised 6.12.2013

Enterprise Edition Homecare MSP Billing Supplement, October 2012 Edition

Copyright © 2012 by HEALTHCAREfirst Inc., All rights reserved. Copyright claim is exclusive of U.S. government tables.

Information in this document is subject to change without notice. Program enhancements made after the time of printing may not be found in this document. Names, data, and examples used in this document are fictitious and do not represent actual people or companies. No part of this document may be reproduced or copied in any form or by any means without express written permission of HEALTHCAREfirst.

Trademarks

HEALTHCAREfirst, firstHOMECARE are registered trademarks of HEALTHCAREfirst, Inc. Other product names mentioned in this document may be trademarks or registered trademarks of their respective companies and are hereby acknowledged.

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Introduction

Medicare Secondary Payer (MSP) is the term used to describe a situation in which another insurer may make payment for services rendered primary to Medicare. It is the provider’s responsibility to identify the beneficiary’s primary payer by conducting a screening process at admission, and viewing online MSP files in CWF. The provider must bill the primary payer first and Medicare second when services rendered would be covered by another payer to Medicare. Providers should follow the MSP screening process described in Centers for Medicare & Medicaid Services (CMS) Internet-Only Manual (IOM) Publication 100-05, Medicare Secondary Payer Manual, Chapter 3, Section 20.

Regardless of whether or not the provider expects payment from Medicare, the provider is required to submit the claim to Medicare.

When submitting claims involving an MSP situation, specific data is required to be reported on the claim.

This guide is designed to assist the user with the creation of MSP claims when Medicare is the secondary payer for a patient. Once the primary payer for a Medicare beneficiary is identified, billed, and has been paid, the provider should use this guide to assist them in the secondary claim creation.

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Billing Medicare as a Secondary Payer

The home health rap claim (TOB 3x2) is still required (for 5+ visits) and should be submitted in the usual manner when submitting MSP. Only the home health final claim (TOB 3x9) will contain MSP necessary information.

Creating the MSP Final Claim

1 On the main menu click Master Files. 2 Click Payors/Plans. 3 Select the primary payer and ensure that the Receiver ID is set to Paper UB04 and that the box

next to Send Electronic 837 Bill is checked. 4 Click Save. 5 The rap claim should be sent as it normally would be for a primary claim. (Refer to the Billing

Module or OLM’s for further details on creating a rap claim.)

If PaperUB is not an available selection for you in the Receiver ID drop down, contact HEALTHCAREfirst support at (888) 563-7016 and notify them that you need your database setup to process MSP claims.

6 Navigate to Accounts | Billing | Create Batch. 7 Select Office from the Office drop-down menu. 8 Select Medicare from the Payor drop-down menu. 9 Select Secondary from the Sequence drop-down menu.

10 Check the box next to Process Final. 11 When the batch is ready click Save Batch. (Refer to the Billing Module and OLM’s for further

details regarding creating a batch.)

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12 Click the Work With Batches Tab. 13 Correct any necessary claim data issues. 14 When completed click Commit Clean Claims.

15 Click the Post Batches tab. 16 Select the batch. 17 Click Submit Bill.

Add Primary Payer Details in Download Claims

1 Click the Download Claims tab and select the proper office to enter the screen. 2 Correct any errors on the claim. 3 Once the claim is Clean (green), add and modify the claim with the MSP data by selecting

Subscribers from the drop-down menu.

4 The Subscribers Payer grid will appear. Check the box on the Medicare line. 5 Click Edit.

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6 The Subscriber Information screen will appear. Change the Payor Responsibility Sequence Number Code drop-down menu to Secondary.

7 Ensure no data is present in the Insured Group or Policy # & Group or Plan name fields, remove any data in both fields so that they appear blank.

8 Scroll down to bottom of screen. Under the Payer Specific Patient Info area set the ID Code qualifier drop-down menu to ZZ – Mutually Defined.

9 Enter the Patient’s HIC# in the Payer Patient Primary ID box. 10 Click Save.

11 Click Subscribers to go back to the Subscribers screen. The Type should now appear in the Type column as S.

12 Click Add.

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13 The Subscriber Information screen will appear for the primary payer entry. 14 Set the Individual Relationship Code to 18--Self. 15 Select the primary Payer from the Payer drop down. 16 Ensure no data is present in the Insured Group or Policy # & Group or Plan name fields,

remove any data in both fields so that they appear blank. 17 Select Yes from the Assignment of Benefits Indicator drop-down menu. 18 Select Y-Provider has a Signed Statement Permitting Release from the Release of Information

Code drop-down menu. 19 Click Same as Patient button.

20 The system will automatically revert back to the Subscribers payer grid screen Click the box on the primary payer line.

21 Click Edit.

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22 The Subscriber Information screen will appear. Scroll down and you will note that the demographic patient information has been completed.

23 Select MI – Member Identifier from the ID Code qualifier drop-down menu. 24 Enter the patient’s primary policy insurance number in the Primary Payer ID box. 25 Select ZZ-Mutually Defined from the ID Code qualifier drop-down menu. 26 Enter the patient’s primary policy insurance number again identical to above in the Payer Patient

Primary ID box. 27 Click Save.

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28 Click Edit next to the patient’s name under the Institutional claim tree. 29 Ensure that the claim is still clean (green).

Processing Final Claim into COB

1 Click the green dollar sign icon. 2 Select the primary payer’s Receiver ID value of PAPERUB/PAPER04 from the drop down menu.

3 The final claim will appear in the processing grid. 4 Click Process Claims in Grid. 5 Once you have received the Paper Claims Processed message, click COB. 6 Select Find and Add COB from the drop down.

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Adding MSP Specific Data to Claim

1 Select the search criteria, i.e. Patient Control Number, Patient Last Name, Policy No.,

Medical Record Number, by clicking the appropriate radio button(s). 1 Enter the search text in the box, else if searching by all claims select from the drop-down menu. 2 Click View. 3 Click the box next to the patient’s name on the record processed today. 4 Click Add COB Info.

5 The COB Institutional screen will appear. 6 On the Amount tab, complete only the Claim Paid Date and Prior Payment amount from the

original remittance (EOB) received from the primary payer. If no payment was received or payment was denied enter 0.00.

7 Click Save.

8 Skip the MOA tab. 9 Click the Edit Primary tab.

10 Specific MSP record data is located on this tab including value codes, remarks, condition codes that need to be added to the claim. Follow your intermediaries MSP guide in determining what necessary information is needed. Select the appropriate option from the Edit Original drop-down menu.

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Adding a Value Code

The Value Code data is the indicator for the type of Open MSP Provision showing online in the Medicare Beneficiaries Common Working File.

To add a value code:

a Select Value Codes from the Edit Original drop down menu. b Click Add. c Double click inside the new line in the grid. d A list of all available value codes will appear. Select the appropriate code that describes the

patient’s open MSP file online in the CWF. e On the same line as the newly added value code, click in the blank Amount box. f Enter the Amount paid by the primary payer, enter 0.00 if payment was denied or not

received. g Click Save.

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Adding Remarks

Remarks are needed to indicate to Medicare that this claim is for MSP processing and other specific details indicated by your intermediary.

To add remarks:

1 To add remarks to the claim select Notes/Remarks from the drop down menu. 2 Enter notes in Billing Note/Additional Info. 3 Click Save.

Adding Claim Adjustments

The claim adjustments area is used by Medicare to calculate the amount of reimbursement, it is crucial this information is reported correctly to ensure proper reimbursement by Medicare. The claim adjustments represent the difference between the total charges billed to the primary insurance and what the primary insurance reimbursed to the provider for those charges. The codes used here explain why the primary did not reimburse the entire amount billed to them. You will want to refer to the EOB received from the primary insurance for a listing of these adjustments and use the appropriate Claim Adjustment Reason Code published by the Washington Publishing Company that best matches that EOB adjustment reason. A listing of current CARC codes can be found at

http://www.wpc-edi.com/reference/codelists/healthcare/claim-adjustment-reason-codes/

http://www.wpc-edi.com/reference/codelists/healthcare/claim-adjustment-reason-codes/

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To add a claim adjustment:

1 Click Claim Adj.

2 The Claim Adjustment Info screen will appear. 3 Click Add.

4 Select the appropriate Group Code from the drop-down menu. Commonly used Group

codes are CO & PR. 5 Enter the appropriate Reason Cd. (Refer to the EOB for reason not paid to determine the

correct code needed.) This is a NUMERIC value only 6 Enter the Amount not paid by the primary payer. (Refer to the attached Reason Code list for

definition of each available code.) 7 If there is more than one reason indicated on the EOB for the same Group (CO), the quantity

field will need to be completed with the value of 1. The quantity field should not be filled in if there is only one reason code nor on the last reason code if entering multiple.

8 Click Save. 9 Click Go Back

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Processing the MSP Claim

1 Click the COB Edits tab. 2 Verify the claim is still Clean. 3 If the claim is Clean click Process COB else fix any errors being reported on the screen.

4 The Process Institutional COBs screen will appear with the clean claim in the grid. 5 Select the Medicare receiver in the Select Receiver drop-down menu.

6 Click the box on the line with the patient’s claim information. 7 Click Process Claims in Grid.

8 Scroll the bottom scroll bar to the right. 9 Click on the Data link to save the file to your local computer for delivery to Medicare.

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10 The Open/Save dialogue box will appear. 11 Save file as usual to your computer and submit the downloaded file to Medicare.

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Sending a Replacement Bill

If Medicare was billed as primary and should have been billed as MSP a replacement bill must be sent. When this occurs, Medicare creates the patient’s episode, which prevents the agency from sending an original MSP claim. In order to make the correction the agency must send a replacement bill.

To send a replacement bill:

1 On the main menu click Accounts | Account Summary. 2 Search for the applicable patient. 3 On the Account Summary tab click on the Medicare claim. 4 Click the Adjustments tab. 5 Click Replace Bill.

This will remove the original charges and place this claim in a ready to bill status. Follow the MSP steps shown above. When you reach the Adding Claim Adjustments section you will have to add a Contract and Authorization Code in order to enter the ICN number of the original claim, as well as a D condition code if applicable.

If the primary payer is also episodic, contact HEALTHCAREfirst Support at 888-563-7016 for assistance with creating the MSP final claim.

enterprise edition homecare msp billing supplement · 1 on the main menu click master files. 2...

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