UB-04 Billing Medicare Replacement Plans
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Transcript of UB-04 Billing Medicare Replacement Plans
HP Provider Relations
October 2011
UB-04 Billing Medicare
Replacement Plans
UB-04 Billing Medicare Replacement Plans October 20112
Agenda
– Session Objectives
– Medicare Replacement Plans• Definition of a Medicare Replacement Plan
• The concept of the replacement plan
• Definition of the difference between a Medicare crossover and a replacement plan
– Billing Requirements (electronic/paper)• Supporting documentation
– Most Common Denials
– Helpful Tools
– Questions
UB-04 Billing Medicare Replacement Plans October 20113
Session Objectives
– Define what a Medicare Replacement Plan is and how it processes
– Clarify the difference between a Medicare crossover and a Medicare Replacement Plan
– Billing requirements for UB-04 electronic and paper claims submission
– What supporting documentation is required
– How to identify and notate the supporting documentation when necessary
LearnMedicare Replacement Plans
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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
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How Replacement Plans Work
– Plans are approved by Medicare but administered by private carriers
– Some plans require referrals to see specialists
– Premiums, copays, and deductibles often lower
– Covers 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
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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
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Reimbursement
– Reimbursement is the Medicaid allowed amount minus the payment from the Medicare Replacement Plan
– 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, the balance cannot be charged to the member
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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
UB-04 Billing Medicare Replacement Plans October 201110
Common Misconceptions about Replacement Plans – Crossover or TPL?
– Replacement plans are regarded as Third Party Liability (TPL) claims, not as 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 a claim billed to traditional Medicare Part A or Part B for a covered service
• Noncovered claims should be billed separately to Medicaid as a TPL
• Attach copies of the Medicare Remittance Notice if services are Medicare noncovered
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Common Misconceptions about Medicare Replacement Plans
– Standard Medicaid prior authorization rules apply • Medicare Replacement Plan claims are subject to prior authorization (PA)
guidelines
−Reminder: A Medicare Replacement is processed as a TPL secondary claim and not as a Medicare crossover; therefore, all PA criteria must be satisfied
– Standard Medicaid timely filing limits apply• Medicare Replacement Plans are subject to the 365-day filing limit
• If claims past the 365-day filing are submitted, past filing documentation must be included with the claim
BillElectronic Claims
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Electronic 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 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 Plan” must be written on the top of the attachment
• The words “Replacement Plan” should be entered in the Notes section of the attachment window
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UB-04 Billing – Medicare Replacement Plans
– The following slides illustrate how to access the Web interChange screens to enter benefit information at the header Medicare Replacement Plans, and to enter Attachment and Note information
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Web interChange – Claims Processing Menu
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Institutional Claim
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Coordination of Benefits
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Coordination of Benefits
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Attachment Information
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Claims Attachment Cover Sheet
BillPaper Claims
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UB-04 Billing – Medicare Replacement Plans
– Paper claims should be submitted to the regular IHCP claims address• P.O. Box 7271Indianapolis, IN 46207-7271
– Enter the words “Replacement Plan” in the Payer Name field 50B
– Do not enter any reference to Medicare in Payer Name field, as this causes the claim to be treated as a crossover claim
– Enter the payment received from the Medicare Replacement Plan in the Prior Payments field 54B
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UB-04 Paper Claim Submission Requirements
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UB-04 Billing – Medicare Replacement Plans
– Submit a copy of the Medicare Replacement plan EOB
– The words “Medicare Replacement Plan” must be written at the top of the claim form and on the attachment
– Standard Medicaid prior authorization rules apply to these claims
– Standard Medicaid timely filing limits apply to these claims
DenyCommon Denials
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Most Common Denial Codes
Edit 2502 – 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• Electronic
−Verify “Replacement Plan” is entered in the Notes section of the attachment window
−Verify the name of the replacement/HMO is entered in the Benefit Information window
• Paper
−Verify the Medicare Replacement Plan payment is indicated in field 54B
−Verify “Medicare Replacement Plan” is written at the top of the claim and the attached replacement plan EOB
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Most Common Denial Codes
Edit 2501 – Recipient Covered by Medicare Part A (with attachment)
– Cause
• The member is covered by Medicare Part A and has a Medicare Replacement Plan, but the attachment does not adequately document the replacement plan
– Resolution• Electronic
−Verify “Replacement Plan” is entered in the Notes section of the attachment window
−Verify the name of the replacement/HMO is entered in the Benefit Information window
• Paper
−Verify the Medicare Replacement Plan payment is indicated in field 54B
−Verify “Medicare Replacement Plan” is written at the top of the claim and the attached the replacement plan EOB
UB-04 Billing Medicare Replacement Plans October 201128
Most Common DenialCodes
– Cause• Coinsurance and deductible amount is missing indicating this is not a
crossover claim. The claim processed as a cross over due to a Medicare indicator on the claim
– Resolution• Remove any formatting of a Medicare payment from claim.
Remove coinsurance and/or deductible amounts in field 39 a-d
Write “Replacement Plan” in field 50 B
Do not write “Medicare” in field 50 A or B
Edit 0558 Coinsurance and deductible amount missing
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Edit 5001 – Exact Duplicate
– Cause
– A claim being submitted that has the same recipient number, rendering provider number, dates of service and procedure code of a claim that is in a current paid status
– Resolution
– Review Remittance Advices and/or Web Interchange to see if there is a claim in a paid status
Most Common Denial Codes
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Edit 0512 Claim Past Filing Limit
– Cause• When the days between the last date of service and the ICN date are greater than the filing limit
– Resolution • The provider should attach evidence of prior claim submission or inquiries
−Retroactive Eligibility
−Previous Submission History
−Late Third Party Liability Notification
−Retroactive Prior Authorization
Most Common Denials
Find HelpResources Available
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Helpful ToolsAvenues of resolution
– IHCP Web site 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
Q&A