HP Provider Relations October 2010 Third Party Liability

Third Party LiabilityOctober Agenda –Objectives –Third Party Liability (TPL) Overview –TPL Program Responsibilities –Identifying TPL Resources –Cost Avoidance –Claims Processing Requirements –TPL Update Procedures –Disallowance Projects –Questions & Answers

Third Party LiabilityOctober Objectives –Define TPL –Explain the responsibilities of the TPL program –Provide information on the sources of TPL information –Give an overview of TPL claim processing requirements –Illustrate how TPL information is updated –Answer any questions that may arise during the presentation

Introduce Third Party Liability

Third Party LiabilityOctober Introduction to Third Party Liability – TPL –Private insurance coverage does not preclude an individual from having Indiana Health Coverage Programs (IHCP) benefits –The IHCP supplements other available coverage –The IHCP is responsible for paying only the State plan authorized medical expenses that other insurance does not cover –TPL may be: A commercial group plan through the member’s employer An individually purchased plan Medicare Insurance available as a result of an accident or injury

Third Party LiabilityOctober IHCP – Payer of Last Resort –Federal regulation (42 CFR ) establishes the IHCP as the payer of last resort –Exceptions: Victim Assistance First Choice Children’s Special Health Care Services (CSHCS) −These programs are secondary to Medicaid because they are fully funded by the State

Third Party LiabilityOctober TPL Program Responsibilities –The IHCP TPL Program supports compliance with federal and state TPL regulations and has two primary purposes: Identify IHCP members who have TPL resources available Ensure that those resources pay before the IHCP

Third Party LiabilityOctober Identifying TPL Resources –The TPL Program has five primary sources of information to identify members who have other health insurance: Caseworkers/Division of Family Resources (DFR) −Member TPL information is updated in Indiana Client Eligibility System (ICES) and transferred to IHCP Providers −Providers can report TPL information in writing, by telephone call, via Web interChange, or by information submitted on claim forms Data Matches −Data matches are performed with all major insurance companies and reported to the IHCP Hoosier Healthwise Managed Care Entity (MCEs) −MCEs report information about members enrolled in their networks Medicaid Third Party Liability Questionnaire −Providers and members may complete the questionnaire and , fax, or mail to the HP TPL Unit

Third Party LiabilityOctober Cost Avoidance –When a provider determines a member has a TPL resource, that resource must be billed first –If the provider bills the IHCP without proper documentation that the TPL was billed first, the claim will deny –This process is known as cost avoidance

Third Party LiabilityOctober Services Exempt from TPL Cost Avoidance –Pregnancy care –Prenatal care –Preventative pediatric care, including Early and Periodic Screening, Diagnosis, and Treatment (EPSDT/HealthWatch) –Medicaid Rehabilitation Option (MRO) –Home and Community-Based Waiver services –State psychiatric hospitals –Procedure codes listed on Medicare Bypass Table Some of the diagnosis and procedure codes that are exempt from cost avoidance are listed in the IHCP Provider Manual, Chapter 5, Section 2

Third Party LiabilityOctober Services Rendered by Out-of-Network Providers –The IHCP requires that a member follow the rules of the primary insurance carrier –The IHCP does not reimburse for services rendered out of another plan’s network Exception: Court-ordered services, such as alcohol or drug rehabilitation –If the primary carrier pays for out- of-network services, the IHCP may be billed

Third Party LiabilityOctober Liability Insurance –Liability insurance generally reimburses Medicaid for claim payments only under certain circumstances Example: Auto or homeowner’s policies where liability is established –Due to the circumstantial nature of this coverage, the IHCP does not cost avoid claims based on liability coverage –If a provider is aware that a member has been in an accident, the provider may bill the IHCP or pursue payment from the liable party (the provider is encouraged to bill the third party first) –If the IHCP is billed, the provider must indicate that the claim is for accident-related services –When the IHCP pays accident-related claims, postpayment research is conducted to identify cases with potentially liable third parties

Third Party LiabilityOctober Liability Insurance –When third parties are identified, the IHCP presents all paid claims associated with the accident to the third party for reimbursement –Providers are not normally involved in or aware of this recovery process –Providers are encouraged to report all identified TPL cases to the HP TPL Casualty Unit Notify the TPL Casualty Unit if a request for medical records is received by an IHCP member’s attorney regarding a personal injury claim –Contact information: HP TPL Casualty Unit P.O. Box 7262 Indianapolis, IN Telephone (317) or

Third Party LiabilityOctober TPL Credit Balance Letters and Worksheets –HP partners with HMS to collect credit balances due to the IHCP –HMS mails letters and credit balance worksheets to select providers quarterly –Refunds are due 60 days from the date of the letter –Adjustments are processed weekly for providers that want credit balances subtracted from future payments –Although letters are sent to selected providers, the credit balance worksheets can be used by any provider to return overpayments –Contact HMS Provider Relations at with questions –Credit Balance Worksheets and instructions are available at

Third Party LiabilityOctober Medicare Buy-in Overview –Allows states to pay Part B Medicare premiums for dually eligible members (members eligible for both Medicaid and Medicare) –Automated data exchanges between HP and the Centers for Medicare & Medicaid Services (CMS) are conducted daily to identify, update, resolve differences, and monitor new and ongoing Medicare buy-in cases

Third Party LiabilityOctober Medicare Buy-in Overview – The state is responsible for initiating Medicare buy-in for eligible members and HP coordinates Medicare buy-in resolution with CMS – Medicare is generally the primary payer Payment of Medicare premiums, coinsurance, and deductibles cost less than Medicaid benefits States receive Federal Financial Participation (FFP) for premiums paid for members eligible as:  Qualified Medicare beneficiary (QMB)  Qualified disabled working individual (QDWI)  Specified low-income Medicare beneficiary (SLMB)  Money grant members Social Security Income (SSI)  Qualified individual (QI-1)

Third Party LiabilityOctober Medicare Buy-in – Qualified Medicare Beneficiary – QMB-Only The member’s benefits are limited to payment of the member’s Medicare Part A and Part B premiums, as well as deductibles and coinsurance for Medicare covered services Claims for services not covered by Medicare are denied as Medicaid non- covered services The member should be notified in advance if services will not be covered, and if they still want to have the service provided they should sign a waiver acknowledging they understand they will be billed – QMB-Also The member’s benefits include payment of the member’s Medicare Part A and Part B premiums, deductibles and coinsurance, as well as traditional Medicaid benefits

Learn Claims processing requirements

Third Party LiabilityOctober TPL Claims Processing Requirements –Prior to rendering service, the provider must verify Medicaid eligibility using the Eligibility Verification System (EVS) options: Web interChange Omni AVR (Automated Voice Response system) –The EVS should also be used to verify TPL information to determine if another insurance is liable for the claim –The EVS contains the most current TPL information, including health insurance carrier, benefit coverage, and policy numbers on file with the IHCP TPL identification

Third Party LiabilityOctober TPL Claims Processing Requirements –If a service requires prior authorization by the IHCP, that requirement must be satisfied, even if a third party has paid or will pay a portion of the charge –Therefore, a provider may have to obtain prior authorization from the third party and from the IHCP –Exception: Medicare Part A or Part B covered charges Prior authorization

Third Party LiabilityOctober TPL Claims Processing Requirements –When submitting claims, the amount paid by the third party must be entered in the appropriate field on the claim form or electronic transaction, even if the TPL payment is zero –If a third party made a payment, the explanation of benefit (EOB) is not required –If the primary insurance denies payment, or applies the payment in full to the deductible, a copy of the denial EOB must be attached to the claim If the claim is submitted electronically via Web interChange, the EOB may be submitted by using the "Attachment" feature Billing procedures

Third Party LiabilityOctober TPL Claims Processing Requirements –The IHCP payment will be the total Medicaid "allowable" amount, minus what was paid by the primary insurance –If the primary insurance payment is equal to or greater than the total Medicaid "allowable" amount, the IHCP payment will be zero The member cannot be billed for any remaining balance, or copayments/ deductibles (refer to 405 IAC (I)) Billing procedures

Third Party LiabilityOctober TPL Claims Processing Requirements –When a service that is repeatedly furnished to a member and repeatedly billed to the IHCP is not covered by a third-party insurer, a photocopy of the original denial EOB can be used for the remainder of the calendar year –This eliminates unnecessary billing to the third-party insurer –The provider should write "BLANKET DENIAL" on the original denial EOB and at the top of the claim form –The denial reason must relate to the specific services and time frame of the new claim Blanket denials

Third Party LiabilityOctober TPL Claims Processing Requirements –Claims denying for TPL reasons will have one of the following edits: – 2500 – Recipient covered by Medicare A – no attachment – 2501 – Recipient covered by Medicare A – with attachment – 2502 – Recipient covered by Medicare B – no attachment – 2503 – Recipient covered by Medicare B – with attachment – 2504 – Recipient covered by private insurance – no attachment – 2505 – Recipient covered by private Insurance – with attachment – 2510 – Recipient covered by Medicare D Remittance Advice information

Third Party LiabilityOctober TPL Claims Processing Requirements –When a third-party payer fails to respond within 90 days of a provider’s billing date, the provider can submit the claim to the IHCP –Attach one of the following to the claim: Copies of unpaid bills or statements sent to the insurance company Written notification from the provider indicating the billing dates and explaining the third- party failed to respond within 90 days –Boldly indicate the following on the attachments: Date of the filing attempts The words NO RESPONSE AFTER 90 DAYS Member identification number (RID #) Provider’s NPI number Name of TPL billed –90-Day No Response claims may be submitted on Web interChange using the "Notes" feature Provide the same information above, as on paper attachments Third-party payer fails to respond (90-day provision)

Third Party LiabilityOctober TPL Claims Processing Requirements –When the insurance carrier reimburses the member: Request the member to forward the payment to the provider, or if necessary:  Notify the insurance carrier the payment was made to the member in error and request the payment be reissued to the provider  If unsuccessful, document the attempts made and submit the claim to the IHCP under the 90-day provision –In future visits with the member, request the member sign an "assignment of benefits" authorization form –Submit the assignment of benefits with the next claim to the insurance carrier –Providers may report the member to the State contractor if member fraud is suspected Telephone: Member Provider Insurance carrier reimburses IHCP member

Third Party LiabilityOctober TPL Claims Processing Requirements –What if a third party or the member makes payment after IHCP has paid the claim? The provider should submit a replacement claim via Web interChange or use the paper adjustment form or The provider can use the credit balance reporting process administered by HMS TPL payments received after IHCP payments

Describe TPL update procedures

Third Party LiabilityOctober TPL Update Procedures –Providers can update TPL information via Web interChange –From Eligibility Inquiry screen, Third Party Carrier Information section, click TPL Update Request –Enter all information about TPL, including "Comments" –HP TPL Unit will verify and update information within 20 business days TPL update request on Web interChange

Third Party LiabilityOctober Web interChange – Eligibility Inquiry

Third Party LiabilityOctober TPL Update Request

Third Party LiabilityOctober TPL Update Procedures –The caseworker or State eligibility worker enters TPL information into ICES when members enroll in Medicaid –This information is transmitted nightly to IndianaAIM and Web interChange –Providers that receive TPL information that is different from what is in Web interChange should immediately report the information to the TPL Unit Division of Family Resources (DFR)

Third Party LiabilityOctober TPL Update Procedures –When forwarding updated TPL information to the TPL Unit, include the member’s RID # and any other pertinent data Remittance Advice (RA), Explanation of Benefits (EOB), carrier letters –Send updated TPL information to: HP TPL Unit Third Party Liability Update P.O. Box 7262 Indianapolis, IN Telephone : (317) or Fax: (317) General update procedures

Third Party LiabilityOctober TPL Update Procedures –The questionnaire is available at the "Forms" link at –The completed questionnaire can be e- mailed to Medicaid Third Party Liability Questionnaire

Detail TPL disallowance projects

Third Party LiabilityOctober TPL Disallowance Projects How the disallowance projects work: –IHCP identifies Medicaid paid claims that should have been billed to Medicare as primary –IHCP will send listings of paid Medicaid claims to providers with instructions asking them to bill Medicare for the claims paid by Medicaid and respond within 60 days –Providers are to report back to IHCP within 60 days by submitting a Credit Balance Worksheet and to notify Medicaid as to which claims have been paid by Medicare and which have been denied Medicare

Third Party LiabilityOctober TPL Disallowance Projects How the Commercial Insurance disallowance projects work: –Focus is on hospital providers –IHCP identifies Medicaid paid claims that should have been billed to commercial carriers –IHCP will send listings of paid Medicaid claims to providers with instructions asking them to bill the commercial carriers for the claims paid by Medicaid and respond within 60 days –Providers are to report back to IHCP within 60 days and notify Medicaid as to which claims have been paid by the commercial carrier and which have been denied Commercial insurance

Find Help Resources Available

Third Party LiabilityOctober Helpful Tools Avenues of resolution –IHCP Web site at –IHCP Provider Manual (Web, CD-ROM, or paper) Chapter 5 – Third Party Liability –Customer Assistance Local (317) All others –Written Correspondence HP Provider Written Correspondence P. O. Box 7263 Indianapolis, IN –Provider field consultant –TPL Department - (317) ; (800)

Q&A