HP Provider Relations October 2011 CMS-1500 Billing Medicare Replacement Plans

CMS-1500 Billing Medicare Replacement PlansOctober 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

CMS-1500 Billing Medicare Replacement PlansOctober 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

Learn Medicare Replacement Plans

CMS-1500 Billing Medicare Replacement PlansOctober 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

CMS-1500 Billing Medicare Replacement PlansOctober 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

CMS-1500 Billing Medicare Replacement PlansOctober 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

CMS-1500 Billing Medicare Replacement PlansOctober 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

CMS-1500 Billing Medicare Replacement PlansOctober 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

CMS-1500 Billing Medicare Replacement PlansOctober 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

Bill CMS-1500 Claims

CMS-1500 Billing Medicare Replacement PlansOctober 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

CMS-1500 Billing Medicare Replacement PlansOctober 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 7269 Indianapolis, IN – 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

CMS-1500 Billing Medicare Replacement PlansOctober 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

CMS-1500 Billing Medicare Replacement PlansOctober 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 30 Example: – = MEDICARE REPLACEMENT PLAN

CMS-1500 Billing Medicare Replacement PlansOctober 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

CMS-1500 Billing Medicare Replacement PlansOctober Claims Processing Menu

CMS-1500 Billing Medicare Replacement PlansOctober Professional Claim

CMS-1500 Billing Medicare Replacement PlansOctober Coordination of Benefits

CMS-1500 Billing Medicare Replacement PlansOctober Coordination of Benefits

CMS-1500 Billing Medicare Replacement PlansOctober 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”

CMS-1500 Billing Medicare Replacement PlansOctober Attachment Information

CMS-1500 Billing Medicare Replacement PlansOctober Claims Attachment Cover Sheet

CMS-1500 Billing Medicare Replacement PlansOctober 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

Deny Most Common Denials

CMS-1500 Billing Medicare Replacement PlansOctober 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

CMS-1500 Billing Medicare Replacement PlansOctober 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

CMS-1500 Billing Medicare Replacement PlansOctober 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

CMS-1500 Billing Medicare Replacement PlansOctober 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

CMS-1500 Billing Medicare Replacement PlansOctober 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?

CMS-1500 Billing Medicare Replacement PlansOctober 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

Find Help Resources Available

CMS-1500 Billing Medicare Replacement PlansOctober Helpful Tools Avenues of resolution –IHCP Web site at indianamedicaid.com indianamedicaid.com –IHCP Provider Manual (Web, CD, or paper) –Customer Assistance , or (317) in the Indianapolis local area –Written Correspondence P.O. Box 7263 Indianapolis, IN –Provider field consultant

Q&A