HP Provider Relations October 2010 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 or Crossover? Eligibility Verification CMS-1500 Billing for Replacement Plans Related Web interChange Features Reimbursement for Replacement Plans Helpful Tools Questions 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 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 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 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 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 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 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 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 CMS-1500 Billing Medicare Replacement PlansOctober 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 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 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 providers charges over the combined Medicare and Medicaid payments must be written off; it cannot be charged to the member Deny Most Common Denial CMS-1500 Billing Medicare Replacement PlansOctober 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 Find Help Resources Available CMS-1500 Billing Medicare Replacement PlansOctober Helpful Tools Avenues of resolution IHCP Web site at IHCP Provider Manual (Web, CD- ROM, or paper) Customer Assistance , or (317) in the Indianapolis local area Written Correspondence P.O. Box 7263 Indianapolis, IN Provider field consultant Q&A