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

HP Provider Relations

October 2011

CMS-1500 Billing

Medicare

Replacement Plans

CMS-1500 Billing Medicare Replacement Plans October 20112

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


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

LearnMedicare Replacement Plans


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


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


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


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


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


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

BillCMS-1500 Claims


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



– Paper claims should be submitted to the regular IHCP claims address, not to the crossover address • HP CMS-1500 Claims

P.O. Box 7269Indianapolis, 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

• Field 22 is the field used for coinsurance, deductibles, and payments on a Medicare Crossover claim



– 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



– 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 30Example:200.00 – 50.00 = 150.00

MEDICARE REPLACEMENT PLAN



– The following slides illustrate how to access the Web interChange screens to enter benefit information for Medicare Replacement Plans and Attachment and description information


Claims Processing Menu


Professional Claim


Coordination of Benefits


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”


Attachment Information


Claims Attachment Cover Sheet


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

DenyMost Common Denials


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



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




• On paper claims






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




• On paper claims






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


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?


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 HelpResources Available


Helpful ToolsAvenues of resolution

– IHCP Web site at indianamedicaid.com

– IHCP Provider Manual (Web, CD, 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

http://www.indianamedicaid.com/

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

Documents

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