Indiana Health Coverage Programs

DXC Technology

Fee-for-Service

UB-04 Tips and Reminders

Annual Provider Seminar ‒ October 2018

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Agenda• IHCP website resources for UB-04 billers

• Common questions for UB-04 billing

• Written correspondence

• Reminder

• Helpful tools

• Questions

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IHCP website resources

for UB-04 billers

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General information

Subscribe to email notices

indianamedicaid.com

is your #1 venue for

education and

information!

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Home page showing user functions

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Provider Reference Materials

Medical Policy

Manual

IHCP Companion

Guides

IHCP Provider

Reference Modules

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Examples of

commonly accessed modules

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Table of contents –

Outpatient Facility Services module

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Information about revenue codes and

linkages on the website

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Service- and provider-specific codes ‒

Inpatient Hospital Services Codes

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Outpatient Fee Schedule

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Outpatient Fee Schedule

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Common questions

for UB-04 billing

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What is the best way

to view claims billed?

• Search by Member ID and date of service

(DOS)

* When searching in this

manner, all claims paid,

denied, or suspended are

viewable.

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Search claims by Claim ID or

Member ID and date range

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Search Results

Searching by Member ID and DOS shows you all claims

within your requested parameters.

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When do I check

“Include Other Insurance”?

• When the primary insurance made a

payment

• When the primary insurance applied entire

claim to deductible

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When is the primary EOB required for

Other Insurance (TPL)?

• When the TPL has DENIED the service as noncovered

– Exception – If the TPL primary EOB contains an acceptable denial

Adjustment Reason Code (ARC), the secondary windows can be

completed with the ARC code, and no EOB is required.

• When TPL has applied the amount to the copay, coinsurance, or deductible

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When is the primary EOB for Other

Insurance information (TPL) NOT needed?

• The primary insurance COVERS the service and has PAID on the claim.

– Actual dollars were received.

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When is the primary Medicare or Medicare

Replacement Plan EOB required?

When Medicare or the Medicare Replacement Plan DENIES the service.

When the replacement plan EOB is required, write

MEDICARE REPLACEMENT PLAN on the EOB.

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When is the primary EOB for Medicare or

Medicare replacement plans NOT needed?

When the Medicare or Medicare Replacement Plan COVERS the service:

– Actual dollars were received.

– Entire or partial amount was applied to deductible, coinsurance, or

copay.

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How to complete the IHCP Third-Party Liability

(TPL)/Medicare Special Attachment Form

Refer to indianamedicaid.com > IHCP Third Party Liability

(TPL)/Medicare Special Attachment Form Instructions.

Required fields – RED

Required if applicable –

Dark BLUE

Required for Medicare

crossovers – Green

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How do I add attachments to my claim

in the Portal?

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How do I ask DXC to update TPL

on the member file?

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How to submit

Other Insurance (TPL) updates

Responses to previous inquiries are listed here.

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How to submit

Other Insurance (TPL) updates

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How to submit

Other Insurance (TPL) updates

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How to submit

Other Insurance (TPL) updates

Add any available attachments to support the request.

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Why am I getting paid for only one of my

treatment line items?

• The IHCP allows one treatment room per

member per day per provider.

• Treatment rooms are reimbursed at a flat

rate

*EXCEPTION: Ambulatory surgical center (ASC)

surgical services are paid at ASC rate on file.

• Stand-alone services are allowed the same

day as a treatment room (x-rays, labs, etc.).

• Add-on services are denied when billed in

conjunction with a treatment room

(pharmacy, supplies).

See the Outpatient Facility Services provider reference module

online for complete details!

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What form should I use for ambulatory

surgical center claims?

• ASC claims must be submitted to the IHCP primary claims on the UB-04.

• ASCs can submit claims to Medicare on the CMS-1500.

• If the claim crosses directly from Medicare to DXC, it will adjudicate.

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Do I need to split my detail lines on an ASC

surgery claim?

• Per the Surgical Services provider reference module, combine all charges

and associated services on one detail line under the surgical revenue code.

• The IHCP does not allow add-on or stand-alone services with any surgical

revenue codes.

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What happens if a member’s coverage

changes during an inpatient stay?

• The payer listed on eligibility at the time of admission will be responsible for

the inpatient (DRG) reimbursement.

– DRG-paid claims cannot be split billed.

• What happens if the member becomes ineligible in the middle of an

inpatient stay?

– The stay is covered based on the member eligibility dates.

– Bill only the dates the member is eligible.

– Add the occurrence code 42 and

discharge date.

– DRG is paid based on the length of the

stay.

• Is an inpatient stay payable if the

member becomes eligible in the

middle of an inpatient stay?

– The member must be eligible on the

admission date.

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Why did the claim deny?

• The member was admitted via the emergency

room. Why did the claim deny?

– The claim requirement for prior

authorization (PA) is based on the

admission type code.

– Admission via the ER does not constitute

coding the claim as an emergency

admission; medical documentation

substantiating the use of the “1” for

emergency admission must be present in

the patient chart.

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What do I need to do to get a PA request

approved?

• Review information in the Prior Authorization provider reference module

online.

• Verify member eligibility to determine the payer source.

• Track PA submission online to ensure that any additional information

requests are reviewed and submitted within time frames stated on the

suspended PA.

• Attach all pertinent documentation to prove medical necessity.

• For additional questions on the PA process, contact Cooperative Managed

Care Services (CMCS).

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I put the PA number on the claim, but it

still denied. Why?

CoreMMIS does not refer to any PA numbers entered on the claim. The system

references the member file to ensure that the PA is in place for the services

billed.

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How do I transfer PA?

• If a member changes from a managed care program to Traditional Medicaid or vice

versa, all existing PAs are honored for one of the following, depending on which

comes first:

– The first 30 calendar days, starting on the member’s effective date in the new plan

– The remainder of the PA dates of service

– When approved units of service are exhausted

* Does not apply to inpatient unless it is a per diem stay

• When it is discovered that the member’s

eligibility has changed, providers should notify

the new payer of any outstanding PAs and

supply documentation to substantiate the PAs.

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How do I bill implantable DME?

• Some DME items are included in the institutional claim.

• Some DME items are separately billable on the CMS-

1500 claim.

• Detailed information is available in the Surgical Services

provider reference module.

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Why doesn’t DXC process my claim under

the submitted DRG?

• The DRG is determined by the grouper.

• When determining expected payment, verify that you are using the IHCP’s

grouper version.

• The IHCP currently uses APR-DRG version 30.

• Effective January 1, 2019, the IHCP will change to APR-DRG, version 35.

• The change will affect any claims with discharge dates on or after January

1, 2019.

– Inpatient psychiatric per diem grouping will be based on the date of service instead of the

discharge date.

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How do I bill a Medicare exhaust claim?

• Do not include Medicare crossover information

in the header of claim (A1, A2).

• Enter “EXHAUST/NO PART A” in field 50A,

not 50B.

• Enter the Medicare Part B payment in field

54A.

• Enter the member’s Medicaid information in fields 50C through 55C.

• Enter the total charges for column 47, minus the Medicare Part B payment

in field 54A, as estimated amount due in field 55C.

• Do not attach the Medicare Part B EOB.

• Put proof of Medicare exhaust from Medicare behind the claim.

– Clearly write “EXHAUST/NO PART A” on the attachment.

* If the Medicare Part B claim that crosses over to Medicaid is paid by

Medicaid, it must be voided.

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Claim completion

Medicare Member name

Medicaid Member name

Medicare Member name

Medicaid Member ID

Medicare Part B payment

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Written Correspondence

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When to use written correspondence

Providers should submit written correspondence via the Portal or on paper for

the following

• Provider disagrees with claim payment or denial.

• Provider is requesting a copy of an RA from before

February 13, 2017.

• Provider disagrees with claim denial due to benefit limit

having been reached.

• Provider is requesting administrative review of an

NCCI claim denial.

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When to use written correspondence

Include all pertinent documentation supporting reconsideration with the

correspondence, including the claim form and proof of timely filing, if required:

• The unusual circumstances in which the provider believes the claim was

coded correctly and would like a reconsideration of the NCCI editing

• The reason for disagreement

• The denial reason and the reason the payment is being disputed

File the formal administrative review request within 60 calendar days of

notification of claim payment or denial from DXC Technology. The date of

notification is considered the date on the RA.

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When NOT to use

written correspondence

Providers should not use written correspondence to:

• Check claim status

– Claim status can be determined by checking RA statements or inquiring through the Provider

Healthcare Portal or Interactive Voice Response system (IVR).

• Submit or resubmit claims, unless specifically directed to do so

The provider should exhaust routine

measures to obtain payment before filing

an administrative review request.

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Reminder

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Claim filing limit

The IHCP will mandate a 180-day filing limit for fee-for-service (FFS) claims,

effective January 1, 2019. Refer to BT201829, published on June 19, 2018,

for additional details.

• The 180-day filing limit will be effective based on date of service:– Any services rendered on or after January 1, 2019, will be subject to the 180-day filing

limit.

– Dates of service before January 1, 2019, will be subject to the 365-day filing limit.

Watch for additional communications!

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Helpful tools

Helpful tools

Provider Relations

Consultants

Helpful tools

IHCP website at indianamedicaid.com:

• IHCP Provider Reference Modules

• Medical Policy Manual

• Contact Us – Provider Relations Field Consultants

Customer Assistance available:

• Monday – Friday, 8 a.m. – 6 p.m. Eastern Time

• 1-800-457-4584

Secure Correspondence:

• Via the Provider Healthcare Portal

• Written Correspondence:DXC Technology Provider Written Correspondence

P.O. Box 7263

Indianapolis, In 46207-7263

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QuestionsFollowing this session, please review your schedule for the next session

you are registered to attend.