HP Provider Relations October 2011 UB-04 Medicare Crossover Claims.

HP Provider Relations

October 2011

UB-04 Medicare

Crossover Claims

UB-04 – Medicare Crossover Claims October 20112

Agenda

– Objectives

– What is a Medicare Crossover Claim

– Billing Electronically

– Billing Paper Claims

– Supporting Documentation

– ANSI version 5010

– Helpful Tools

– Questions


Session Objectives

At the end of this session, providers will understand:

–What constitutes a Medicare crossover claim

–What supporting documentation is required

–How to identify and notate the supporting documentation

–What actions to take in preparation of ANSI version 5010

LearnMedicare Crossover Claims


Medicare Crossover Claim Defined

– The term, “crossover claim” applies when a member has Medicare as the primary insurance, and:• The Medicare coverage is from traditional Medicare, not one of the Medicare

Replacement (or Medicare HMO) plans

• Medicare issued a payment of any amount, or the entire payment was applied to the deductible

– A claim is not a crossover claim when:• The member’s primary insurance is not traditional Medicare

• Medicare denied the entire claim

• It is a Medicare benefit exhaust claim


Why Claims Do Not Automatically Cross Over

Following are some of the reasons why claims fail to cross over from Medicare automatically:

–NPI one-to-one match cannot be accomplished

–The Medicare intermediary is not National Government Services (NGS) or is not an intermediary that has a partnership agreement with HP

–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


Claim Filing Limit

– The standard filing limit for Medicaid claims is one year from the date of service

– Crossover claims are not subject to the one-year filing limit

• Crossover claims may be submitted and processed irrespective of the age of the claim


Claims Partially Paid by Medicare

When Medicare allows only some of the services on a nonsurgical outpatient claim:

– Only the Medicare-allowed services apply to crossover logic

• These 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 for services Medicare has paid

– 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

BillElectronic Crossover Claims


Web interChange – Claims Processing Menu


Institutional Claim


Coordination of Benefits


Where Do I Find Documented Claim Filing Instructions?

BillPaper Crossover Claims


How to Bill a Crossover Claim– Identify Medicare Remittance Notice (MRN) information in field

39 as follows:• Value Code A1 – Medicare deductible amount

• Value Code A2 – Medicare coinsurance amount

• Value Code 06 – Medicare blood deductible amount

• Value Code 80 – IHCP covered days


Crossover Claim


– Refer to Chapter 8 Section 2

Where Do I Find Documented Claim Filing Instructions for Paper Claims?

PrepareANSI version 5010


HIPAA 5010

– The mandatory compliance date for ANSI version 5010 and the National Council for Prescription Drug Programs (NCPDP) version D.0 for all covered entities is January 1, 2012

– If submitting claims to the IHCP, you need to prepare for these upgrades to prevent delay in payment

– HP has been accepting test files from approved Trading Partners during 2011


HIPAA 5010

– Transactions affected by this upgrade:

• Institutional claims (837I)

• Dental claims (837D)

• Medical claims (837P)

• Pharmacy claims (NCPDP)

• Eligibility verifications (270/271)

• Claim status inquiry (276/277)

• Electronic remittance advices (835)

• Prior authorizations (278)

• Managed Care enrollment (834)

• Capitation payments (820)


What You Need To Do

– If you bill IHCP directly

• Begin the process to upgrade to the ANSI 5010 or NCPDP D.0 versions

– If you are using a billing service or clearinghouse

• Monitor their progress in preparing for the HIPAA upgrades to ANSI v5010 and NCPDP vD.0

– Questions should be directed to [email protected]

OR

– Call the EDI Solutions Service Desk• 1-877-877-5182 or (317) 488-5160

DenyCommon Denials


Common Denials

0558 – Coinsurance and deductible amount is missing indicating that this is not a crossover claim

–Cause • No coinsurance or deductible information is present on the claim

–Resolution • Electronic – Complete the Benefit Information window on the Web interChange

• Paper – Add A1 or A2 and amount in Field Locator 39


Common Denials

2501 – This recipient is covered by Medicare Part A; therefore, you must first file claims with Medicare

–Cause• Claim has not been submitted indicating the coinsurance and deductible amount in

Field 39, no attachment

–Resolution• Electronic – Complete the Benefit Information window on the Web interChange



Common Denials

2007 – Qualified Medicare Beneficiary (QMB) recipient – Please bill Medicare first

–Cause • Member is a QMB and no Medicare payment is indicated on the claim

–Resolution • Electronic – Complete the Benefit Information window on the Web interChange


Find HelpResources Available


Helpful ToolsAvenues of resolution

– IHCP website at indianamedicaid.com

– Provider Enrollment• 1-877-707-5750

– 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 Relations field consultant

http://www.indianamedicaid.com/

HP Provider Relations October 2011 UB-04 Medicare Crossover Claims.

Documents

Transcript of HP Provider Relations October 2011 UB-04 Medicare Crossover Claims.