hp provider relations october 2011 cms-1500 billing medicare replacement plans
TRANSCRIPT
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HP Provider Relations
October 2011
CMS-1500 Billing
Medicare
Replacement Plans
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CMS-1500 Billing Medicare Replacement Plans October 20112
Agenda– Session Objectives
– What is a Medicare Replacement Plan?
– How Medicare Replacement Plans Work
– Who May be included in Medicare Replacement Plans
– Medicare Replacements – TPL (Third Party Liability) or Crossover?
– Eligibility Verification
– CMS-1500 Billing for Replacement Plans
– Related Web interChange Features
– Reimbursement for Replacement Plans
– Top Denials
– Helpful Tools
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CMS-1500 Billing Medicare Replacement Plans October 20113
Session Objectives
Following this session, providers will be able to:
– Provide a clear definition of Medicare Replacement Plans and how they work
– Explain the critical differences between Medicare Crossovers and Medicare Replacement Plans
– Clearly define the CMS-1500 electronic and paper billing requirements for Medicare Replacement Plans
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LearnMedicare Replacement Plans
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CMS-1500 Billing Medicare Replacement Plans October 20115
What Is a Medicare Replacement Plan?
– Created by the Balanced Budget Act of 1997
– Medicare beneficiaries given the option to receive Medicare benefits through private health insurance plans
– Replacement of original Part A and Part B plan
– Sometimes referred to as Medicare+Choice, Medicare Advantage Plan, or Medicare HMO
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How Replacement Plans Work
– Plans are approved by Medicare but administered by private companies
– Some plans require referrals to see specialists
– Premiums, copays, and deductibles are often lower
– Cover all Part A and Part B services
– Often have networks requiring member to use certain doctors and hospitals
– Offer extra benefits, such as prescription drug coverage
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Medicare Replacement Plans
– Health Maintenance Organizations (HMOs)
– Preferred Provider Organizations (PPOs)
– Private Fee-for-Service Plans (PFFS)
– Medicare Medical Savings Account (MSA)
– Medicare Special Needs Plans
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CMS-1500 Billing Medicare Replacement Plans October 20118
Common Medicare Replacement Plans– ADVANTAGE Preferred
– Arnett HMO
– Humana Gold Plus Standard
– Humana Gold Plus Enhanced
– Humana Insurance Co.
– Humana Choice PPO
– Humana Gold Choice PFFS
– M-Plan Senior Smart Choice
– M-Plan Senior Smart Choice High Option
– Wellborn Plans Basic
– Wellborn Plans Plus Plan
– Wellborn Health Plans
– United Mine workers
– Railroadmen’s
– Unicare Life & Health Insurance
– ADVANTAGE Health Solutions, Inc.
– Unicare Security Choice
– Anthem Senior Advantage
– United Healthcare Insurance
– Anthem Medicare Preferred
– Anthem Blue Cross and Blue Shield
– Security Choice Plus
– United Health Care
– Sterling Option 1
– Today’s Option
– Secure Horizons Direct
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CMS-1500 Billing Medicare Replacement Plans October 20119
Medicare Replacement Plans – TPL or Crossover?
– Replacement plans must be submitted with the EOB (Explanation of Benefits), even if a payment is received– EOBs are not required when a payment is made on a regular TPL or a
Medicare crossover
– These claims are not Medicare crossovers
– This is a critical distinction, as billing requirements and reimbursement are different for TPL vs. crossover claims
– A Medicare crossover is defined as allowed line items billed to Traditional Medicare Part A and/or Part B
– Medicare Replacement Plans and all other private insurances are considered TPL
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Eligibility Verification
– For a member with a Medicare Replacement Plan, the Web interChange Eligibility Inquiry screen will indicate that the member has Medicare Part A and Medicare Part B
– No information will appear about the Medicare Replacement Plan in the Third Party Carrier section
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BillCMS-1500 Claims
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CMS-1500 Billing – Medicare Replacement Plans
– Medicare Replacement Plans will not automatically cross over from the Medicare carrier to Medicaid
– Medicare Replacement Plans can be submitted via Web interChange• Coordination of Benefits information must be entered at the “header” level,
but not required at the “detail” level• A Medicare crossover entered on Web interChange requires information to be
entered at the “header level” and “detail” level
• Must use the “Attachment” feature, and mail the Medicare Replacement Plan Remittance Notice (EOB) as an attachment, along with an Attachment Cover Sheet
• The words “Medicare Replacement Plan” must be written on the attachment
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CMS-1500 Billing Medicare Replacement Plans October 201113
CMS-1500 Billing – Medicare Replacement Plans
– Paper claims should be submitted to the regular IHCP claims address, not to the crossover address • HP CMS-1500 Claims
P.O. Box 7269Indianapolis, IN 46207-7269
– Enter the payment received from the Medicare Replacement Plan in field 29• If payment is zero, enter 0.00 in field 29
• Field 28 minus field 29 must equal field 30
• Field 22 should be totally blank; do not put 0.00
• Field 22 is the field used for coinsurance, deductibles, and payments on a Medicare Crossover claim
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CMS-1500 Billing – Medicare Replacement Plans
– Attach a copy of the replacement plan EOB
– The words “Medicare Replacement Plan ” must be written at the top of the claim form and at the top of the EOB
– Standard Medicaid prior authorization rules apply to these claims
– Standard Medicaid timely filing limits apply to these claims
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CMS-1500 Billing – Medicare Replacement Plans
– Write “Medicare Replacement Plan” at top of claim (and attached EOB)
– Field 22 must be blank, as this field indicates a Medicare Crossover
– Payment from Medicare Replacement Plan must be indicated in field 29, including 0.00 if no payment received
– Field 28 minus Field 29 must equal Field 30Example:200.00 – 50.00 = 150.00
MEDICARE REPLACEMENT PLAN
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CMS-1500 Billing – Medicare Replacement Plans
– The following slides illustrate how to access the Web interChange screens to enter benefit information for Medicare Replacement Plans and Attachment and description information
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CMS-1500 Billing Medicare Replacement Plans October 201117
Claims Processing Menu
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Professional Claim
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Coordination of Benefits
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Coordination of Benefits
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Coordination of Benefits Information
– Information that must be entered:• Payer ID – Name of Medicare Replacement Plan with no spaces
• Payer Name – Name of Medicare Replacement Plan with no spaces
• TPL/Medicare Amount Paid – Amount Medicare Replacement Plan paid
• Last Name
• First Name
• Primary ID – As printed on EOB, or social security number
• Relationship Code – Usually 18 for “Self”
• Gender
• DOB
−Click on “Save Benefits” and then “Save and Close”
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Attachment Information
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Claims Attachment Cover Sheet
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Reimbursement for Replacement Plan
– Medicare Replacement Plan reimbursement is equal to the Medicaid “allowable” minus the payment from the Medicare Replacement Plan carrier
– Reimbursement is based on the aggregate (totals), not line-by-line calculations
– The excess of the provider’s charges over the combined Medicare and Medicaid payments must be written off; it cannot be charged to the member
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DenyMost Common Denials
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Most Common Denial Codes
Edit 2503 – Recipient Covered by Medicare Part B or D (with attachment)
– Cause – The member is covered by Medicare Part B and has a Medicare Replacement Plan, but the attachment does not adequately document the replacement plan
– Resolution• On electronic claims
– Make sure the attachment process was followed
– Indicate payment and all other information in the benefits information section
• On paper claims
– Indicate Medicare Replacement Plan payment is in field 29
– Write “Medicare Replacement Plan” at the top of the claim and the attached Medicare Replacement Plan EOB
– Make sure field 22 is entirely blank
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Most Common Denial Codes
Edit 2504 – Recipient Covered by Medicare Part B or D (with no attachment)
– Cause – The member is covered by Medicare Part B and has a Medicare Replacement Plan, but there is no attachment
– Resolution• On electronic claims
– Make sure the attachment process was followed
– Indicate payment and all other information in the benefits information section
• On paper claims
– Indicate Medicare Replacement Plan payment is in field 29
– Write “Medicare Replacement Plan” at the top of the claim and the attached Medicare Replacement Plan EOB
– Make sure field 22 is entirely blank
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Most Common Denial Codes
Edit 0558 – Coinsurance and deductible amount missing indicating this is not a crossover claim
– Cause – A claim for a member with Medicare must have coinsurance or deductible recorded, unless the claim is filed properly as a Medicare Replacement Plan
– Resolution• On electronic claims
– Make sure the attachment process was followed
– Indicate payment and all other information in the benefits information section
• On paper claims
– Indicate Medicare Replacement Plan payment is in field 29
– Write “Medicare Replacement Plan” at the top of the claim and the attached Medicare Replacement Plan EOB
– Make sure field 22 is entirely blank
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CMS-1500 Billing Medicare Replacement Plans October 201129
Most Common Denial Codes
Edit 0512 – Your claim was filed past the filing limit without acceptable documentation
– Cause – The claim was filed more than one year from the date of service
– Resolution• Resubmit the claim with proof of timely filing and request filing limit be waived
• If the claim is filed on Web Interchange, use the attachment feature to submit proof of timely filing
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CMS-1500 Billing Medicare Replacement Plans October 201130
Let’s Play True of False!
– Medicare Replacement Plans are considered TPLs, and not Medicare crossovers?
– The payment from the Medicare Replacement Plan must be indicated in the right side of field 22 on a paper claim?
– You can only file Medicare Replacement Plans on paper?
– Field 30 on a Medicare Replacement Plan should be the “patient responsibility amount” from the EOB?
– “Medicare Replacement Plan” must be clearly written at the top of the claim form and on the EOB?
– The reimbursement on a Medicare Replacement Plan is the aggregate Medicaid “allowable” amount, minus what was paid by the Medicare Replacement Plan?
– When submitting a Medicare Replacement claim on Web interChange, you must enter Coordination of Benefits information, and use the Attachment feature to submit the EOB?
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Let’s Play True of False!
– Medicare Replacement Plans are considered TPLs, and not Medicare Crossovers? True
– The payment from the Medicare Replacement Plan must be indicated in the right side of field 22 on a paper claim? False
– You can only file Medicare Replacement Plans on paper? False
– Field 30 on a Medicare Replacement Plan should be the “patient responsibility amount” from the EOB? False
– “Medicare Replacement Plan” must be clearly written at the top of the claim form, and on the EOB? True
– The reimbursement on a Medicare Replacement Plan is the aggregate Medicaid “allowable” amount, minus what was paid by the Medicare Replacement Plan? True
– When submitting a Medicare Replacement claim on Web interChange, you must enter Coordination of Benefits information, and use the Attachment feature to submit the EOB? True
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Find HelpResources Available
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CMS-1500 Billing Medicare Replacement Plans October 201133
Helpful ToolsAvenues of resolution
– IHCP Web site at indianamedicaid.com
– IHCP Provider Manual (Web, CD, or paper)
– 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 field consultant
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Q&A