HP Provider Relations October 2011 CMS-1500 – Medicare Crossover Claim Billing

CMS-1500 – Medicare Crossover Claim BillingOctober Agenda – Session Objectives – Crossover Claim – Defined – Crossover Claims via Web interChange – Crossover Claims via CMS Claim Form – Reimbursement Methodology – Automatic Crossover – Common Denials – Helpful Tools – Questions

CMS-1500 – Medicare Crossover Claim BillingOctober Objectives Following this session, providers will: – Know the definition of a crossover claim – Understand how to report crossover information on Web interChange – Understand how to report crossover information on the CMS claim form – Understand the difference between crossover and third-party liability (TPL) claims – Understand how crossover claims are reimbursed

Define Crossover Claim

CMS-1500 – Medicare Crossover Claim BillingOctober Crossover Claim – Defined The term “crossover claim” is defined as allowed line items billed to Traditional Medicare Part A and/or Part B and applies when a member has Medicare as the primary insurance: – The Medicare coverage is not from one of the Medicare Replacement (or Medicare HMO) plans AND – Medicare issued a payment of any amount, or the entire payment was applied to the deductible

CMS-1500 – Medicare Crossover Claim BillingOctober Crossover Claim – Defined A claim is not a crossover claim when: – The member’s primary insurance is not Traditional Medicare – Medicare denied the entire claim In this instance, the claim is a straight Medicaid claim and is subject to the one- year filing limit These claims are also subject to prior authorization requirements Note: Crossover claims are not subject to the one-year filing limit

Learn Crossover Claims – Web interChange

CMS-1500 – Medicare Crossover Claim BillingOctober Crossover Claims via Web interChange – Crossover information must be reported for both the header and detail levels – Header information is reported in the Benefit Information window Header information pertains to the entire claim – Detailed information is reported in the Detail Benefits Info window Detail information pertains to individual detail lines of the claim

CMS-1500 – Medicare Crossover Claim BillingOctober 20119

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CMS-1500 – Medicare Crossover Claim BillingOctober

CMS-1500 – Medicare Crossover Claim BillingOctober Coordination of Benefits

CMS-1500 – Medicare Crossover Claim BillingOctober Coordination of Benefits

CMS-1500 – Medicare Crossover Claim BillingOctober Coordination of Benefits

CMS-1500 – Medicare Crossover Claim BillingOctober Crossover Claims via Web interChange –To report header information, perform the following: Click Benefit Information on the Claim Submission screen Payer ID = Payer Name = Medicare Part B TPL/Medicare Paid Amount = The total amount paid by Medicare for the claim Subscriber Name Primary ID = Medicare number w/ alpha Relationship Code = 18 (self) Gender Date of birth Claim Filing Code = MB Crossover header information

CMS-1500 – Medicare Crossover Claim BillingOctober Crossover Claims via Web interChange –To report header information, perform the following: Click Save Benefits at the bottom of the screen Scroll to the top of the screen and Click Save and Close Crossover header information

Learn Crossover Claims Detail Information – Web interChange

CMS-1500 – Medicare Crossover Claim BillingOctober Crossover – Detail Screen

CMS-1500 – Medicare Crossover Claim BillingOctober Crossover – Detail Screen Detail line paid amount

CMS-1500 – Medicare Crossover Claim BillingOctober Crossover – Detail Screen

CMS-1500 – Medicare Crossover Claim BillingOctober Crossover – Detail Screen

CMS-1500 – Medicare Crossover Claim BillingOctober Crossover Claims via Web interChange –To report detail information, perform the following: Click Detail Benefits Info Payer ID = TPL/Medicare Paid Amount = Enter the amount paid by Medicare for the highlighted detail line only Click Save Payer Group Code = Enter CO Reason Code = Enter 1 for deductible, 2 for coinsurance, and 122 for psychiatric reduction – Do not report write-off or contractual adjustment/discount amounts Amount = Enter the amount of the deductible and/or coinsurance Crossover detail information

CMS-1500 – Medicare Crossover Claim BillingOctober Crossover Claims via Web interChange –To report detail information, perform the following: Click Save Group Code Scroll to the top of the screen and Click Save and Close –At the bottom of the Claim Submission screen, click on the next detail line, be sure it is highlighted in blue and repeat the steps to complete the Detail Benefits Info screen Complete this screen for each line of detail on the claim Note: Claims for rural health clinics (RHCs) and Federally Qualified Health Centers (FQHCs) that did not cross over electronically should be rebilled with code T1015 added to the claim Crossover detail information

Detail Crossovers – CMS-1500 Claim Form

CMS-1500 – Medicare Crossover Claim BillingOctober Crossovers –Field Locator 22 is used to report crossover information –Left side – Medicaid Resubmission Code = sum of the Medicare coinsurance, deductible, and psychiatric reduction –Right side – Original Ref. No. = Actual amount paid by Medicare –Do not report crossover information in field locator 29 –Crossover claims are mailed to: HP Medical Crossover Claims P O Box 7267 Indianapolis, IN CMS-1500 claim form

CMS-1500 – Medicare Crossover Claim BillingOctober CMS-1500 Claim Form

CMS-1500 – Medicare Crossover Claim BillingOctober CMS-1500 Claim Form – Fields 22 and MEDICAID RESUBMISSION CODE ORIGINAL REF. NO. 29. AMOUNT PAID $

Explain Reimbursement Methodology

CMS-1500 – Medicare Crossover Claim BillingOctober Reimbursement Methodology – IHCP makes payment on crossover claims only when the total Medicaid rate for the entire claim exceeds the amount paid by Medicare for the entire claim – IHCP reimbursement includes the lesser of the: Medicare coinsurance and deductible OR Difference between the IHCP rate and the Medicare paid amount for the entire claim

CMS-1500 – Medicare Crossover Claim BillingOctober Claims Partially Paid by Medicare When Medicare allows only some of the services on the claim: –Only the Medicare-allowed services apply to crossover logic Allowed services should be billed to Medicaid separately from the Medicare-denied services Providers should not send the Medicare Remittance Notice (MRN) to Medicaid when billing allowed services –Only the Medicare-allowed services are exempt from the one-year filing limit –Services denied by Medicare are subject to the one-year filing limit These services should be billed separately to Medicaid with a copy of the MRN These services are also subject to all PA requirements

Describe Automatic Crossover

CMS-1500 – Medicare Crossover Claim BillingOctober Automatic Crossover –Following are some of the reasons why claims fail to cross over from Medicare automatically Failure to establish a one-to-one match of the National Provider Identifier (NPI) and the Legacy Provider Identifier (LPI) The Medicare intermediary is not National Government Services (NGS) or is not an intermediary that has a partnership agreement with HP Member has a secondary insurer other than Medicaid Ambulatory surgical center (ASC) claims billed to Medicare on a CMS-1500 claim form with the SG modifier Data errors on the crossover file −Examples include incorrect Social Security number (SSN) or spelling of member name Why claims do not cross over automatically

Deny Common Denials

CMS-1500 – Medicare Crossover Claim BillingOctober Edit 2502 Recipient covered by Medicare Part B – Cause Medical claims for Medicare Part B coverage for a member have Part B on the eligibility screen but there is no Medicare MRN with the claim showing Medicare denial – Resolution Submit the Medicare payment on the right side of field 22 and sum of the coinsurance, deductible, or blood deductible on the left side –Resolution Submit the coordination of benefits information

Enroll Providers: An Overview of Provider EnrollmentAugust Edit 558 Coinsurance and deductible amount missing – Cause Coinsurance and deductible amount is missing indicating this is not a crossover claim – Resolution Add coinsurance and/or deductible amount and/or Medicare paid amount to the CMS CMS-1500  Add coinsurance and/or deductible amount on the left side of field 22  Add the Medicare Payment amount on the right side in field 22

Enroll Providers: An Overview of Provider EnrollmentAugust Edit 2505 Recipient covered by private insurance – Cause This member has private insurance, which must be billed prior to Medicaid – Resolution Add the other insurance payment to the claim CMS-1500  Add other insurance excluding Medicare payments to field 29 If the primary insurance denies, the explanation of benefits (EOB) must be sent with the claim, either on paper with a paper claim, or as an attachment if claim is sent on Web interChange

Find Help Resources Available

CMS-1500 – Medicare Crossover Claim BillingOctober Helpful Tools Avenues of resolution –IHCP website 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