1. HP Provider Relations October 2010 CMS-1500 Billing Medicare Replacement Plans

2. CMS-1500 Billing Medicare Replacement PlansOctober 20102 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 or Crossover? – Eligibility Verification – CMS-1500 Billing for Replacement Plans – Related Web interChange Features – Reimbursement for Replacement Plans – Helpful Tools – Questions

3. CMS-1500 Billing Medicare Replacement PlansOctober 20103 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 replacement plans

4. Learn Medicare Replacement Plans

5. CMS-1500 Billing Medicare Replacement PlansOctober 20105 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

6. CMS-1500 Billing Medicare Replacement PlansOctober 20106 How Replacement Plans Work –Plans are approved by Medicare but run by private companies –Some plans require referrals to see specialists –Premiums, copays, and deductibles 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

7. CMS-1500 Billing Medicare Replacement PlansOctober 20107 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

8. CMS-1500 Billing Medicare Replacement PlansOctober 20108 Medicare Replacement Plans – TPL or Crossover? – Replacement plans must be submitted with the Remittance Advice – 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

9. CMS-1500 Billing Medicare Replacement PlansOctober 20109 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

10. Bill CMS-1500 Claims

11. CMS-1500 Billing Medicare Replacement PlansOctober 201011 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 Must use the “Attachment” feature, and mail the Medicare Remittance Notice (EOB) as an attachment, along with an Attachment Cover Sheet The words “Medicare Replacement Policy” must be written on the attachment

12. CMS-1500 Billing Medicare Replacement PlansOctober 201012 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 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

13. CMS-1500 Billing Medicare Replacement PlansOctober 201013 CMS-1500 Billing – Medicare Replacement Plans – Attach a copy of the Replacement plan EOB – The words “Medicare Replacement ” must be written at the top of the claim form and at the top of the attachments – Standard Medicaid prior authorization rules apply to these claims – Standard Medicaid timely filing limits apply to these claims

14. CMS-1500 Billing Medicare Replacement PlansOctober 201014 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

15. CMS-1500 Billing Medicare Replacement PlansOctober 201015 Claims Processing Menu

16. CMS-1500 Billing Medicare Replacement PlansOctober 201016 Professional Claim

17. CMS-1500 Billing Medicare Replacement PlansOctober 201017 Coordination of Benefits

18. CMS-1500 Billing Medicare Replacement PlansOctober 201018 Coordination of Benefits

19. CMS-1500 Billing Medicare Replacement PlansOctober 201019 Attachment Information

20. CMS-1500 Billing Medicare Replacement PlansOctober 201020 Claims Attachment Cover Sheet

21. CMS-1500 Billing Medicare Replacement PlansOctober 201021 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

22. Deny Most Common Denial

23. CMS-1500 Billing Medicare Replacement PlansOctober 201023 Most Common Denial Code 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 Policy” at the top of the claim and the attached Medicare remittance notice – Make sure field 22 is entirely blank

24. Find Help Resources Available

25. CMS-1500 Billing Medicare Replacement PlansOctober 201025 Helpful Tools Avenues of resolution –IHCP Web site at www.indianamedicaid.com www.indianamedicaid.com –IHCP Provider Manual (Web, CD- ROM, 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

26. Q&A