Third Party Liability. HP Provider Relations October 2012

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1 Third Party Liability HP Provider Relations October 2012

2 Agenda Objectives Third Party Liability (TPL) TPL Program Responsibilities TPL Resources Cost Avoidance Claims Processing Guidelines TPL Update Procedures Common Denials Questions and Answers 2

3 Objectives Define TPL Explain the TPL program Provide information on the sources of TPL information Give an overview of TPL claim processing requirements Illustrate how TPL information is updated 3

4 Define Third Party Liability

5 Third Party Liability What is TPL? A commercial group plan through the member s employer An individually purchased plan Insurance available as a result of an accident or injury Can a member have insurance in addition to Medicaid? Private insurance coverage does not preclude an individual from having Indiana Health Coverage Programs (IHCP) benefits The IHCP supplements other available coverage The IHCP is responsible for paying only the State plan authorized medical expenses that other insurance does not cover 5

6 Third Party Liability Is TPL the primary payer? Federal regulation (42 CFR ) establishes the IHCP (Medicaid) as the payer of last resort Exceptions: Victim Assistance First Choice Children s Special Health Care Services (CSHCS) These programs are secondary to Medicaid because they are fully funded by the State 6

7 TPL Program What are the responsibilities of the TPL program? Identify IHCP members who have TPL resources available Ensure that those resources pay before the IHCP Support compliance with federal and state TPL regulations 7

8 TPL Resources How are TPL resources identified? Caseworkers/Division of Family Resources (DFR) Members provide TPL information, which is updated in Indiana Client Eligibility System (ICES) and transferred to the IHCP Providers Providers report TPL information in writing, by telephone call, via Web interchange, or on claim forms Data Matches Data matches are performed with all major insurance companies and reported to the IHCP Hoosier Healthwise Managed Care Entity (MCEs) MCEs report information about members enrolled in their networks Medicaid Third Party Liability Questionnaire Providers and members may complete the questionnaire and , fax, or mail to the HP TPL Unit The questionnaire is available on the Forms page of indianamedicaid.com 8

9 Cost Avoidance What is cost avoidance? When a provider determines a member has a TPL resource, that resource must be billed first 9

10 Cost Avoidance Some services are exempt from cost avoidance Pregnancy care Prenatal care Preventative pediatric care, including Early and Periodic Screening, Diagnosis, and Treatment (EPSDT/HealthWatch) Medicaid Rehabilitation Option (MRO) Home and community-based waiver services State psychiatric hospitals Procedure codes listed on Medicare Bypass Table, which includes breast and cervical cancer 10

11 Cost Avoidance Are out-of-network provider services covered? The IHCP requires that a member follow the rules of the primary insurance carrier The IHCP does not reimburse for services rendered out of another plan s network Exception: Court-ordered services, such as alcohol or drug rehabilitation If the primary carrier pays for out-of-network services, the IHCP may be billed 11

12 Cost Avoidance Is liability insurance subject to cost avoidance? Liability insurance generally reimburses Medicaid for claim payments only under certain circumstances Example: Auto or homeowner s policies where liability is established If a provider is aware that a member has been in an accident, the provider may bill the IHCP or pursue payment from the liable party (the provider is encouraged to bill the third party first) If the IHCP is billed, the provider must indicate that the claim is for accident-related services When the IHCP pays accident-related claims, postpayment research is conducted to identify cases with potentially liable third parties 12

13 Cost Avoidance Is liability insurance subject to cost avoidance? When third parties are identified, the IHCP presents all paid claims associated with the accident to the third party for reimbursement Providers are not normally involved in or aware of this recovery process Providers are encouraged to report all identified TPL cases to the HP TPL Casualty Unit Notify the TPL Casualty Unit if a request for medical records is received by an IHCP member s attorney regarding a personal injury claim Contact information: HP TPL Casualty Unit P.O. Box 7262 Indianapolis, IN Telephone: (317) in the Indianapolis local area or

14 Cost Avoidance What is the Medicare Buy-In program? Allows states to pay Part B Medicare premiums for dually eligible members (members eligible for both Medicaid and Medicare) Automated data exchanges between HP and the Centers for Medicare & Medicaid Services (CMS) are conducted daily to identify, update, resolve differences, and monitor new and ongoing Medicare buy-in cases 14

15 Cost Avoidance What is the Medicare Buy-In program? The State is responsible for initiating Medicare buy-in for eligible members, and HP coordinates Medicare buy-in resolution with CMS Medicare is generally the primary payer Payment of Medicare premiums, coinsurance, and deductibles cost less than Medicaid benefits States receive Federal Financial Participation (FFP) for premiums paid for members eligible as: Qualified Medicare beneficiary (QMB) Qualified disabled working individual (QDWI) Specified low-income Medicare beneficiary (SLMB) Money grant members Social Security Income (SSI) Qualified individual (QI-1) 15

16 Cost Avoidance What is the difference between QMB-Only and QMB-Also? QMB-Only The member s benefits are limited to payment of the member s Medicare Part A and Part B premiums, as well as deductibles and coinsurance for Medicare covered services only Claims for services not covered by Medicare are denied Members should be notified in advance if services will not be covered; if they still want to have the service provided, they should sign a waiver acknowledging they understand they will be billed QMB-Also The member s benefits include payment of the member s Medicare Part A and Part B premiums, deductibles and coinsurance, and also traditional Medicaid benefits 16

17 Learn Claims Processing Requirements

18 TPL Claims Processing Guidelines How is TPL coverage identified? Prior to rendering service, the provider must verify Medicaid eligibility using the Eligibility Verification System (EVS) options: Web interchange Omni AVR (Automated Voice Response system) The EVS should also be used to verify TPL information to determine if another insurance is liable for the claim The EVS contains the most current TPL information, including health insurance carrier, benefit coverage, and policy numbers on file with the IHCP 18

19 TPL Claims Processing Guidelines Are TPL claims exempt from prior authorization? If a service requires prior authorization (PA) by the IHCP, that requirement must be satisfied, even if a third party has paid or will pay a portion of the charge Therefore, a provider may have to obtain PA from the third party and from the IHCP Exception: Medicare Part A or Part B covered charges 19

20 TPL Claims Processing Guidelines What information is needed for a TPL claim? When submitting claims, the amount paid by the third party must be entered in the appropriate field on the claim form or electronic transaction, even if the TPL payment is zero If a third party made a payment, the explanation of benefits (EOB) is not required If the primary insurance denies payment, or applies the payment in full to the deductible, a copy of the denial EOB must be attached to the claim If the claim is submitted electronically via Web interchange, the EOB may be submitted by using the "Attachment" feature 20

21 TPL Claims Processing Guidelines How are TPL claims paid? The IHCP payment will be the total Medicaid "allowable" amount, minus what was paid by the primary insurance If the primary insurance payment is equal to or greater than the total Medicaid "allowable" amount, the IHCP payment will be zero The member cannot be billed for any remaining balance, or copayments/deductibles (see 405 IAC (I)) 21

22 TPL Claims Processing Guidelines What is a blanket denial? When a service that is repeatedly furnished to a member and repeatedly billed to the IHCP, but is not covered by a third-party insurer, a photocopy of the original denial EOB can be used for the remainder of the calendar year The provider is not required to bill the TPL each time The provider should write "BLANKET DENIAL" on the original denial EOB and at the top of the claim form The denial reason must relate to the specific services on the claim 22

23 TPL Claims Processing Guidelines What is the 90-day provision? When a third-party payer fails to respond within 90 days of a provider s billing date, the provider can submit the claim to the IHCP Attach one of the following to the claim: Copies of unpaid bills or statements sent to the insurance company Written notification from the provider indicating the billing dates and explaining the third-party failed to respond within 90 days Boldly indicate the following on the attachments: Date of the filing attempts The words NO RESPONSE AFTER 90 DAYS Member identification number (RID) Provider s National Provider Identifier (NPI) Name of third party billed 90-Day No Response claims may be submitted on Web interchange using the "Notes" feature Provide the same information listed above 23

24 TPL Claims Processing Guidelines What if the member receives the TPL check? Request the member to forward the payment to the provider, or if necessary: Notify the insurance carrier the payment was made to the member in error Request the payment be reissued to the provider If unsuccessful, document the attempts made and submit the claim to the IHCP under the 90-day provision In future visits with the member, request the member sign an "assignment of benefits" authorization form Submit the assignment of benefits with the next claim to the insurance carrier Providers may report the member to the State contractor if member fraud is suspected Provider and Member Concern Line or

25 TPL Claims Processing Guidelines What are some of the edits applied to TPL claims? 2500 Recipient covered by Medicare A no attachment 2501 Recipient covered by Medicare A with attachment 2502 Recipient covered by Medicare B no attachment 2503 Recipient covered by Medicare B with attachment 2504 Recipient covered by private insurance no attachment 2505 Recipient covered by private Insurance with attachment 2510 Recipient covered by Medicare D 25

26 Describe TPL Update Procedures

27 TPL Update Procedures Can a provider update a member s TPL information? Providers can update TPL information via Web interchange From Eligibility Inquiry screen, Third Party Carrier Information section, click TPL Update Request Enter all information about TPL, including comments HP TPL Unit will verify and update information within 20 business days 27

28 Web interchange Eligibility Inquiry 28

29 TPL Update Request 29

30 TPL Update Procedures Can a provider update a member s TPL information? TPL can be updated by faxing or calling the TPL Unit Include the member s RID and any other pertinent data Send updated TPL information to: HP TPL Unit Third Party Liability Update P.O. Box 7262 Indianapolis, IN Telephone: (317) or Fax: (317)

31 TPL Update Procedures Frequently Asked Questions Once TPL has been updated, what causes the old information to appear back in the eligibility? The member has not updated the information with the DFR A redetermination is completed and the old information is put back in the Eligibility Verification System A TPL update has been sent in, why hasn t the information changed? The member may have the TPL coverage for services provided by other provider specialty types The verification of information with the TPL carrier is pending 31

32 TPL Update Procedures How do members update their TPL information? Through the DFR: The caseworker or State eligibility worker enters TPL information into ICES when members enroll in Medicaid The transfer of information from ICES to HP occurs within three business days This information is transmitted nightly to IndianaAIM and Web interchange Providers receiving TPL information that is different from what is in Web interchange should immediately report the information to the TPL Unit 32

33 TPL Update Procedures Is there a TPL update form that can be sent in? A Medicaid Third Party Liability Questionnaire is available at the "Forms" link at indianamedicaid.com The completed questionnaire can be ed to 33

34 Find Help Resources Available

35 Helpful Tools Avenues of resolution IHCP Web site at indianamedicaid.com IHCP Provider Manual Chapter 5 Third Party Liability (Web, CD, or paper) Customer Assistance or (317) in the Indianapolis local area HP Written Correspondence P.O. Box 7263 Indianapolis, IN Locate area consultant map on: indianamedicaid.com (provider home page> Contact Us> Provider Relations Field Consultants) or Web interchange > Help > Contact Us TPL Unit (317) or

36 Q&A

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