October 2009 Presentation by EDS Provider Relations Field Consultants UB-04 Billing Medicare Replacement Plans.

October 2009

Presentation by

EDS Provider Relations Field Consultants

UB-04 BillingMedicare Replacement Plans

UB-04 Billing – Medicare Replacement Plans2 / October 2009

Agenda

•Session Objectives•Definition of Medicare Replacement

Plans•How Medicare Replacement Plans Work•Contrast of Medicare Crossover and

Replacement Plans•Billing Requirements for Crossovers and

Replacement Plans•Related Web interChange Features•Clarification of Crossover and

Replacement Plan Reimbursement •Eligibility Verification•Most Common Denials•Helpful Tools•Questions

UB-04 Billing – Medicare Replacement Plans3 / October 2009

Session Objectives

•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 UB-04 electronic and paper billing requirements for crossovers and replacement plans

•Provide the knowledge necessary for providers to improve their billing processes with respect to crossovers and replacement plans

UB-04 Billing – Medicare Replacement Plans4 / October 2009

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, Part C, Medicare Advantage Plan, or Medicare HMO

UB-04 Billing – Medicare Replacement Plans5 / October 2009

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

UB-04 Billing – Medicare Replacement Plans6 / October 2009

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

UB-04 Billing – Medicare Replacement Plans7 / October 2009

Medicare Replacement Plans - TPL or Crossover?

•Replacement plans are considered TPL (Third Party Liability); not Medicare Crossovers

•This is a critical distinction, as billing requirements and reimbursement are different for TPL vs. Crossover

•A Medicare crossover is defined as a claim billed to the original Part A and Part B plan, which is covered– Noncovered claims, should be billed separately to

Medicaid as a TPL– Attach copies of the Medicare Remittance Notice

•Medicare Replacement Plans, and all other insurances, other than the original Medicare Part A and Part B plans, are considered TPL

UB-04 Billing – Medicare Replacement Plans8 / October 2009

UB-04 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

– The words “Medicare Replacement Policy” should be entered in the Notes section

UB-04 Billing – Medicare Replacement Plans9 / October 2009

UB-04 Billing – Medicare Replacement Plans

•Paper claims should be submitted to the regular IHCP claims address– P.O. Box 7271

– Indianapolis, IN 46207-7271

•Enter the payment received from the Medicare Replacement Plan in the Prior Payments field 54 A-C

•Enter the words “Replacement Plan” in the Payer Name field 50 A-C

•Do not enter any reference to Medicare in Payer Name field, as this causes the claim to be treated as a crossover claim

UB-04 Billing – Medicare Replacement Plans10 / October 2009

UB-04 Billing – Medicare Replacement Plans

•Submit a copy of the Medicare Remittance Notice

•The words “Medicare Replacement Policy” 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– No filing limit for Medicare crossovers

UB-04 Billing – Medicare Replacement Plans11 / October 2009

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

UB-04 Billing – Medicare Replacement Plans12 / October 2009

Web interChange – Claims Processing Menu

UB-04 Billing – Medicare Replacement Plans13 / October 2009

Institutional Claim

UB-04 Billing – Medicare Replacement Plans14 / October 2009

Coordination of Benefits

UB-04 Billing – Medicare Replacement Plans15 / October 2009

Coordination of Benefits

UB-04 Billing – Medicare Replacement Plans16 / October 2009

Attachment Information

UB-04 Billing – Medicare Replacement Plans17 / October 2009

Claims Attachment Cover Sheet

UB-04 Billing – Medicare Replacement Plans18 / October 2009

Reimbursement

•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, for both crossovers and replacement plans

•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

UB-04 Billing – Medicare Replacement Plans19 / October 2009

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 Plans20 / October 2009

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 “Medicare Replacement Policy” is entered in the Notes section

• 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 54 A-C• Verify “Medicare Replacement Policy” is written at the top of

the claim and the attached Medicare Remittance Notice

UB-04 Billing – Medicare Replacement Plans21 / October 2009

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 “Medicare Replacement Policy” is entered in the Notes section

• 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 54 A-C• Verify “Medicare Replacement Policy” is written at the top of

the claim and the attached Medicare remittance notice

UB-04 Billing – Medicare Replacement Plans22 / October 2009

Helpful Tools

• IHCP Web site at www.indianamedicaid.com

• IHCP Provider Manual (Web, CD-ROM, or paper)

•Customer Assistance

•Written Correspondence

•Provider field consultant

Avenues of Resolution

UB-04 Billing – Medicare Replacement Plans23 / October 2009

Questions

October 2009

Office of Medicaid Policy and Planning (OMPP)

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Indianapolis, IN 46204

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