Connecticut interchange MMIS

Transcription

1 Connecticut interchange MMIS Provider Manual Chapter 11 - Institutional Other Insurance/ Medicare Billing Guide Connecticut Department of Social Services (DSS) 55 Farmington Avenue Hartford, CT Hewlett Packard Enterprise 195 Scott Swamp Road Farmington, CT 06032

2 Amendment History Version Version Date Reason for Revision Section Page(s) /09/2010 Converted OI guide to Provider Manual Chapter format /22/2012 Removal of local call center number, updates to POS section, updates to timely filing, misc other updates. All All /12/2013 Misc updates /18/2013 Updated to reflect shutdown of Charter Oak Health Plan Program, effective January 1, 2014 All and decommissioning of PES, effective October 1, 2014, and updated for HIPAA 5010 changes. Also updated to reflect that Home Health Advance Beneficiary Notice (HHABN) will no longer be valid for dates of service December 9, 2013 forward /12/2014 Updated instructions for accessing a list of HIPAA Claim Adjustment Reason Codes /01/2015 Update to reimbursement of Medicare exhausted days. Removed references to Charter Oak 11.4 Program /01/ /30/2015 Updated procedures for reporting Medicare discrepancies. Updated timely filing guidelines and PES reference. Updated to reflect use of Provider Electronic Solutions Software for batch eligibility and long term care claim submission only All All 11 & & , 59, All ii

3 Version Version Date /01/2015 Reason for Revision Section Page(s) Updated to replace HP references/logo with Hewlett Packard Enterprise references/logo. All All iii

4 Table of Contents 11.1 Introduction Determining Other Coverage Private Insurance as Primary Billing Instructions - Other Insurance Payment... 9 UB-04 Claim Form Provider Electronic Solutions Software (for Long Term Care Claims only) Web Claim ASC X12N 837 I Health Care Claim Billing Instructions - Other Insurance Denial UB-04 Claim Form Provider Electronic Solutions Software (for Long Term Care Claims only) Web Claim ASC X12N 837 I Health Care Claim Billing Instructions Multiple Other Insurance Policies UB-04 Claim Form Provider Electronic Solutions Software (for Long Term Care Claims only) Web Claim ASC X12N 837 I Health Care Claim Medicare as Primary Billing Instructions - Medicare Payment UB-04 Claim Form Provider Electronic Solutions Software (for Long Term Care Claims only) Web Claim ASC X12N 837 I Health Care Claim Institutional Billing Instructions - Medicare Denial UB-04 Claim Form Provider Electronic Solutions Software (for Long Term Care Claims only) Web Claim ASC X12N 837 I Health Care Claim Billing Instructions - Medicare and Other Insurance UB-04 Claim Form Provider Electronic Solutions Software (for Long Term Care Claims only) Web Claim ASC X12N 837 I Health Care Claim Timely Filing Rules iv

5 11.1 Introduction 1

6 The Connecticut Medical Assistance Program is the payer of last resort for all covered services. Therefore, if a Connecticut Medical Assistance Program client has applicable other insurance coverage or Medicare, the benefits of these policies must be fully exhausted prior to claim submission to the Connecticut Medical Assistance Program. This guide instructs providers on how to successfully submit claims for clients who have either other insurance or Medicare. This guide includes instructions for each type of media, including paper claims, Provider Electronic Solutions software claims for long term care claims only, Web claims, and electronic claims submitted in the ASC X12N 837 Health Care Claim format. For additional information, please refer to the Provider Manual, Hewlett Packard Enterprise s Companion Guide, Provider Electronic Solutions Software billing instructions (for long term care claims only), or the Institutional Web Claim Submission Guide which are all located on the Web site. Chapter 8 of the Provider Manual offers field by field paper claim instructions and is located by clicking on Information, then Publications. The Companion Guide offers electronic claim submission guidelines and is located by clicking on Trading Partner, then EDI. The Provider Electronic Solutions Software billing instructions (for long term care claims only) are located by clicking on Trading Partner and scrolling to the bottom of the Web page. The Institutional Web Claim Submission Guide is accessed by logging on to the provider secure Web portal and by clicking on Claims, then Institutional. 2

7 11.2 Determining Other Coverage 3

8 Connecticut Medical Assistance Program providers must investigate the possibility that a client has other medical coverage and pursue payment from all other medical insurance plans. Providers are strongly encouraged to verify client eligibility prior to the service being rendered. If the provider is unaware that the client has other coverage, and the claim is submitted without other insurance information, the claim will be denied. In addition to asking the client, providers can determine other insurance coverage by accessing the Automated Eligibility Verification System (AEVS). The AEVS eligibility response will include the following data when the client has other insurance coverage: o o o o Carrier Code Carrier Name Policy Number Coverage Type A complete listing of insurance carrier codes can be accessed/downloaded from the Web site by clicking on Information, then Publications and locating the Carrier Listings under Provider Manuals Chapter 5. If the three-digit code for a specific insurance carrier does not appear on the carrier code list, the provider should enter 999. There are instances when a provider identifies a discrepancy between the Department s third party liability information (as found on AEVS) and what the client tells the provider; or as determined by the provider through their own health insurance verification processes. It is essential that the provider notify the Department s Third Party Liability contractor, Health Management Systems, Inc (HMS) of these changes in order to avoid having Medicaid claims unnecessarily denied based on these health insurance discrepancies. If other insurance is known, but not returned in the AEVS eligibility response, the other insurance payment or denial should still be indicated on the claim. Discrepancies regarding other insurance (such as private or employee sponsored health insurance or Medicare) should be reported to HMS via toll-free telephone number or via to ctinsurance@hms.com. Client third party liability update procedures can be accessed/downloaded from the Web site by clicking on Information, then Publications and clicking on Provider Manual Chapter 5. The AEVS eligibility response will include the following data when the client has Medicare coverage: o Coverage Type (Medicare Part A, B or D) o o o PDP Plan PDP Plan ID HIC 4

9 Hewlett Packard Enterprise has the following AEVS tools available for providers to verify eligibility: Web Eligibility Verification located at Enrolled providers may verify client eligibility through the Connecticut Medical Assistance Program Web site at Providers may verify a client s eligibility by logging on to their Provider Secure Web site using their Web User ID and password and clicking on the Eligibility tab. Please note, the Web site only accepts one submission at a time and the response is immediate. Other insurance and Medicare coverage that exists for the client will be returned for the specific date of service entered on the eligibility transaction. Automated Voice Response System Enrolled providers may verify client eligibility through the Hewlett Packard Enterprise Automated Voice Response System (AVRS) using a touch tone phone. Providers must be actively enrolled in the Connecticut Medical Assistance Program and must use their assigned AVRS ID and PIN # to utilize the automated system. The AVRS can be accessed by dialing the following: Toll free Provider Electronic Solutions Software Provider Electronic Solutions is free software provided by Hewlett Packard Enterprise to providers for the batch submission of eligibility verification and long term care claim transactions. The software allows users to print the eligibility response if desired. Point of Sale Device (POS) A POS device allows providers to verify client eligibility. Using the device, there are two options for submitting eligibility verification requests. The provider can swipe the client s gray CONNECT Card through the POS device which requires minimal data entry of client information and the device will print the response. If the CONNECT Card is not available or if the card is damaged and cannot be read by the device, the provider can submit the eligibility request by entering the client ID, and service date information using the POS device keypad. The POS device displays or prints the response. Providers interested in using a POS device must contact a third party vendor to obtain the device. ASC X12N 270/271 Health Care Eligibility Benefit Inquiry and Response Transaction The 270/271 is a HIPAA compliant paired transaction set used to send and receive eligibility verification requests and responses. Providers who wish to have this eligibility verification function incorporated into their vendor s software program may do so. The technical transaction specifications are available at Remittance Advice (RA) If a claim denies for lack of other insurance information, the Explanation of Benefit message on the Remittance Advice will report Bill Private Carrier First. The TPL Information section of the Remittance Advice will post the client s policies that are applicable to the service billed. 5

10 For additional information regarding these methods to verify client eligibility, please refer to Chapter 4 in the Connecticut Medical Assistance Program Manual. To view this chapter, go to and click on Information, then Publications. 6

11 11.3 Private Insurance as Primary 7

12 This section contains information regarding claim submission to the Connecticut Medical Assistance Program when the client has third-party insurance or other health benefit plan coverage. It includes the process for submitting claims after another insurance company has either made a payment or denied a claim. If applicable coverage is available from one or more third parties, the claim must first be submitted to each carrier for reimbursement of services, so long as the type of coverage applies to the claim. For example, if the type of coverage on the policy only provides Drug coverage, then only pharmacy claims are required to be billed to the private insurance company. Therefore, it is important to learn whether the client has applicable coverage when determining client eligibility via the Automated Eligibility Verification System (AEVS). The following table contains the coverage types that would appear in an AEVS response or spoken in an Automated Voice Response System (AVRS) response, which describes the type of other insurance coverage a client has. Coverage Types Hospital Inpatient Hospital Outpatient Doctor Major Medical Doctor Surgical Doctor Physician Doctor Diagnosis, X-Ray, Laboratory Doctor Anesthesia Dental Vision Drug Long Term Care Once it is determined that the client has applicable coverage, the claim must first be sent to the other insurance carrier. To determine the address to which to send the claim, providers should refer to the carrier listing located on the Web site by clicking on Information, then Publications, then chapter 5 of the Provider Manual. Once a response is received from the other insurance carrier, the claim can then be forwarded to Hewlett Packard Enterprise. Claims with prior payments or denials can be submitted electronically or through Web claim submission on the Web site The other insurance Explanation of Benefit (EOB) should not be submitted with the claim. Providers are required to retain a copy of the EOB in the client s file. For more information regarding procedures in updating a client s other insurance information, or assistance in obtaining payments from a third party resource, please refer to Chapter 5 of the Provider Manual located on the Web site by clicking on Information, then Publications. 8

13 11.4 Billing Instructions - Other Insurance Payment 9

14 The following billing instructions identify the required fields used to submit a claim with an other insurance payment for each type of media, including paper claims, Provider Electronic Solutions software claims (for long term care claims only), Web claims and electronic claims submitted in the ASC X12N 837 Health Care Claim format. UB-04 Claim Form NOTE: The other insurance Explanation of Benefit (EOB) should not be attached to the paper claim. If the EOB is attached to the claim, it will not be used to process the claim. The only exception to this policy is when submitting a claim that is over one year old. Providers have one year from the EOB date to submit claims (provided the claim was not denied for timely filing), with the following exception. For HUSKY A and HUSKY B behavioral health, providers have 120 days from the EOB date to submit the claim. In this case, the EOB must be submitted with the claim in order to override timely filing edits. Fields 50, 54 and 80 of the claim form must still be completed as follows. Failure to complete these fields will result in the claim being denied. Field Name Description No. 50. Payer Name Enter the 3-digit other insurance carrier code. 54. Prior Payments Enter the amount paid by the other insurance carrier. 80. Remarks Enter the other insurance paid date. The following example illustrates a single OI payment of $ from carrier code B04 with an OI paid date of 11/1/

15 Provider Electronic Solutions Software (for Long Term Care Claims only) Tab Field Name Description Header 3 (Nursing Home) Other Insurance Indicator Enter a Y in this field. OI Release of Medical Data Select the appropriate value from the drop down box that indicates whether the provider, has on file, a signed statement by the client authorizing the release of medical data to other organizations. This field defaults to Y. OI Benefits Assignment Select the appropriate value from the drop down box that identifies that the client, or authorized person, authorizes benefits to be assigned to the provider. This field defaults to Y. OI OI Claim Filing Indicator Code Adjustment Group Code Select the appropriate value from the drop down box that identifies the type of other insurance claim that is being submitted. Select the appropriate value from the drop down box that identifies the general category of payment adjustment by the other insurance company. OI Payer Responsibility Select the appropriate value from the drop down box that identifies the level of Payer responsibility (Primary, Secondary, Tertiary, etc.). OI Reason Codes Enter the code identifying the reason the other insurance carrier did not pay in full. At least one reason code and amount is required. The reason code can either be found on the Explanation of Benefit (EOB) from the other insurance carrier or in the Implementation Guide by accessing the following site: After accessing the Web site, click on Code List (viewable online at no cost), then Claim Adjustment Reason Codes. Providers are advised to verify reason codes on the Web site periodically to assure the codes used are still valid and appear on the list with no end date. OI Reason Amounts Enter the amount associated with the reason code. This represents the amount that the other insurance carrier did not pay. At least one reason code and amount is required. 11

16 Tab Field Name Description OI Paid Date Enter the date that the other insurance carrier paid the claim (Explanation of Benefit date). OI Paid Amount Enter the amount paid by the other insurance carrier. OI Policy Holder Group # Select the group number from the drop down list. If the appropriate group number is not present in the drop down list, double click inside the list and complete the Policy Holder screen. OI Policy Holder Group Name This field is auto-plugged when a group number is selected and contains the name of the policy holder group. OI OI OI Policy Holder Carrier Code Policy Holder Last Name Policy Holder First Name This field is auto-plugged when a group number is selected and contains the carrier code identifying the Other Insurance carrier. This field is auto-plugged when a group number is selected and contains the last name of the policyholder of the other insurance. This field is auto-plugged when a group number is selected and contains the first name of the policyholder of the other insurance. The following example illustrates an Institutional Nursing Home claim with a single OI payment of $ from carrier code 060 with an OI paid date of 11/01/2015. As a reminder, when billing a Nursing Home claim the Other Insurance Indicator is located on the Header 3 tab. 12

17 Header 3 tab: OI tab: 13

18 Web Claim Panel Field Name Description Claim Type Institutional Claim This is a drop down field that lists the valid claim type values. Select the appropriate claim type. Do not choose A Institutional Xover Claims or C - Outpatient Xover Claims unless Medicare has allowed the claim. See the Medicare Payment section of this guide for proper Crossover billing instructions. TPL Client Carriers This is a drop down field that lists the three digit carrier codes for all Other Insurance Carriers that are currently on the client s eligibility file or may have been on the client s file in the past. Select the appropriate carrier code from the drop down menu or, if you do not see the carrier code for the primary payer in this field, select Other and enter the three digit carrier code for the Other Insurance Payer in the next field titled Carrier Code. TPL Carrier Code Enter the 3-digit code that identifies the other insurance carrier. This field has a search option which allows the user to enter search parameters and select the desired code from the search results. TPL Plan Name When an existing 3-digit carrier code is entered, the plan name will automatically be populated. Otherwise, enter the other insurance policy holder s plan name. TPL Policy Number When a client s existing 3-digit carrier code is selected from the drop down list, the policy number, if present on the client s file, will automatically be populated. Otherwise, enter the policy number of the other insurance policy holder. TPL Paid Amount Enter the amount that has been paid by third party insurance. TPL Paid Date Enter the date that the claim is paid by third party insurance. TPL Adjustment Reason Code Enter the code identifying the reason the other insurance carrier did not pay in full. The reason code can either be found on the Explanation of Benefit (EOB) from the other insurance carrier or in the Implementation Guide by accessing the following site: After accessing the Web site, click on Code List (viewable online at no cost), then Claim Adjustment Reason Codes. This field has a search option which allows the user to enter search parameters and select the desired code from the search results. 14

19 Panel Field Name Description TPL Adjustment Amount Enter the amount associated with the adjustment reason code. This represents the amount that the other insurance carrier did not pay. TPL Relationship Enter the client s relationship to the other insurance policy holder. If Self is selected, the client s name and date of birth will automatically be populated. TPL Last Name Enter the last name of the other insurance policy holder. TPL First Name, MI Enter the first name and middle initial of the other insurance policy holder. TPL Date of Birth Enter the date of birth of the other insurance policy holder. The following example illustrates a single OI payment of $60.00 from carrier code B04 with an OI paid date of 11/1/

20 ASC X12N 837 I Health Care Claim Providers submitting claims containing Third Party Liability data must complete the following Loops and Segments as described for each policy noted. Loop Segment Description 2320 SBR Other Subscriber Information 2320 CAS Claim Adjustment 2320 AMT Coordination of Benefits Payer Paid Amount 2320 OI Other Insurance Coverage Information 2330A NM1 Other Subscriber Name 2330A N3 Other Subscriber Address 2330A N4 Other Subscriber City, State, Zip Code 2330B NM1 Other Payer Name 2330B NM109 Other Payer Primary Identifier - Enter the Connecticut Medical Assistance Program Carrier Code. These code values can be found at Information-Publications-Provider Manuals Chapter B DTP Claim Paid Date 2330B REF Other Payer Claim Control Number 2430 SVD Line Adjudication Information 2430 CAS Line Adjustment Information 2430 DTP Line Adjudication Date 16

21 11.5 Billing Instructions - Other Insurance Denial 17

22 The following billing instructions identify the required fields used to submit a claim with an other insurance denial for each type of media, including paper claims, Provider Electronic Solutions software claims (for long term care claims only), Web claims and electronic claims submitted in the ASC X12N 837 Health Care Claim format. UB-04 Claim Form NOTE: The other insurance Explanation of Benefit (EOB) should not be attached to the paper claim. If the EOB is attached to the claim, it will not be used to process the claim. The only exception to this policy is when submitting a claim that is over one year old. Providers have one year from the EOB date to submit claims (provided the claim was not denied for timely filing), with the following exception. For HUSKY A and HUSKY B behavioral health services, providers have 120 days from the EOB date to submit the claim. In this case, the EOB must be submitted with the claim in order to override timely filing edits. Fields and 50 of the claim form must still be completed as follows. Failure to complete these fields will result in the claim being denied. Field No Name Occurrence Code/Date Description Enter occurrence code 24 Date Insurance Denied, followed by the denial date. 50. Payer Name Enter the 3-digit other insurance carrier code followed by either Not Applicable or N/A. The following example illustrates a single OI denial from carrier code B04 with an OI denial date of 11/1/

23 Provider Electronic Solutions Software (for Long Term Care Claims only) Tab Field Name Description Header 3 (Nursing Home) Other Insurance Indicator Enter a Y in this field. OI Release of Medical Data Select the appropriate value from the drop down box that indicates whether the provider, has on file, a signed statement by the client authorizing the release of medical data to other organizations. This field defaults to Y. OI Benefits Assignment Select the appropriate value from the drop down box that identifies that the client, or authorized person, authorizes benefits to be assigned to the provider. This field defaults to Y. OI OI Claim Filing Indicator Code Adjustment Group Code Select the appropriate value from the drop down box that identifies the type of other insurance claim that is being submitted. Select the appropriate value from the drop down box that identifies the general category of payment adjustment by the other insurance company. OI Payer Responsibility Select the appropriate value from the drop down box that identifies the level of Payer responsibility (Primary, Secondary, Tertiary, etc.). OI Reason Codes Enter the code identifying the reason the other insurance carrier did not pay in full. At least one reason code and amount is required. The reason code can either be found on the Explanation of Benefit (EOB) from the other insurance carrier or in the Implementation Guide by accessing the following site: After accessing the Web site, click on Code List (viewable online at no cost), then Claim Adjustment Reason Codes. Providers are advised to verify reason codes on the Web site periodically to assure the codes used are still valid and appear on the list with no end date. OI Reason Amounts Enter the amount associated with the reason code. This represents the amount that the other insurance carrier did not pay. At least one reason code and amount is required. OI Paid Date Enter the date that the other insurance carrier denied the claim (Explanation of Benefit date). 19

24 Tab Field Name Description OI Paid Amount Enter zero paid amount. OI Policy Holder Group# Select the group number from the drop down list. If the appropriate group number is not present in the drop down list, double click inside the list and complete the Policy Holder screen. OI Policy Holder Group Name This field is auto-plugged when a group number is selected and contains the name of the policy holder group. OI OI OI Policy Holder Carrier Code Policy Holder Last Name Policy Holder First Name This field is auto-plugged when a group number is selected and contains the carrier code identifying the Other Insurance carrier. This field is auto-plugged when a group number is selected and contains the last name of the policyholder of the other insurance. This field is auto-plugged when a group number is selected and contains the first name of the policyholder of the other insurance. The following example illustrates an Institutional Nursing Home claim with a single OI denial from carrier code 060 with an OI denial date of 11/01/2015. As a reminder, when billing a Nursing Home claim the Other Insurance Indicator is located on the Header 3 tab. Header 3 tab: 20

25 OI tab: 21

26 Web Claim Panel Field Name Description Institutional Claim Claim Type This is a drop down field that lists the valid claim type values. Select the appropriate claim type. Do not choose A Institutional Xover Claims or C - Outpatient Xover Claims unless Medicare has allowed the claim. See the Medicare Payment section of this guide for proper Crossover billing instructions. TPL Client Carriers This is a drop down field that lists the three digit carrier codes for all Other Insurance Carriers that are currently on the client s eligibility file or may have been on the client s file in the past. Select the appropriate carrier code from the drop down menu or, if you do not see the carrier code for the primary payer in this field, select Other and enter the three digit carrier code for the Other Insurance Payer in the next field titled Carrier Code. TPL Carrier Code Enter the 3-digit code that identifies the other insurance carrier. This field has a search option which allows the user to enter search parameters and select the desired code from the search results. TPL Plan Name When an existing 3-digit carrier code is entered, the plan name will automatically be populated. Otherwise, enter the other insurance policy holder s plan name. TPL Policy Number When a client s existing 3-digit carrier code is selected from the drop down list, the policy number, if present on the client s file, will automatically be populated. Otherwise, enter the policy number of the other insurance policy holder. TPL Paid Amount Enter zero paid amount. TPL Paid Date Enter the date that the other insurance carrier denied the claim (Explanation of Benefit date). TPL Adjustment Reason Code Enter the code identifying the reason the other insurance carrier did not pay in full. The reason code can either be found on the Explanation of Benefit (EOB) from the other insurance carrier or in the Implementation Guide by accessing the following site: After accessing the Web site, click on Code List (viewable online at no cost), then Claim Adjustment Reason Codes. This field has a search option which allows the user to enter search parameters and select the desired code from the search results. 22

27 Panel Field Name Description TPL Adjustment Amount Enter the amount associated with the adjustment reason code. This represents the amount that the other insurance carrier did not pay. TPL Relationship Enter the client s relationship to the other insurance policy holder. If Self is selected, the client s name and date of birth will automatically be populated. TPL Last Name Enter the last name of the other insurance policy holder. TPL First Name, MI Enter the first name and middle initial of the other insurance policy holder. TPL Date of Birth Enter the date of birth of the other insurance policy holder. The following example illustrates a single OI denial from carrier code B04 with an OI denial date of 11/1/

28 ASC X12N 837 I Health Care Claim Providers submitting claims containing Third Party Liability data must complete the following Loops and Segments as described for each policy noted. Loop Segment Description 2320 SBR Other Subscriber Information 2320 CAS Claim Adjustment 2320 AMT Coordination of Benefits Payer Paid Amount 2320 OI Other Insurance Coverage Information 2330A NM1 Other Subscriber Name 2330A N3 Other Subscriber Address 2330A N4 Other Subscriber City, State, Zip Code 2330B NM1 Other Payer Name 2330B NM109 Other Payer Primary Identifier - Enter the Connecticut Medical Assistance Program Carrier Code. These code values can be found at Information, Publications, Provider Manuals, Chapter B DTP Claim Paid Date 2330B REF Other Payer Claim Control Number 2430 SVD Line Adjudication Information 2430 CAS Line Adjustment Information 2430 DTP Line Adjudication Date 24

29 11.6 Billing Instructions Multiple Other Insurance Policies 25

30 The Automated Eligibility Verification System (AEVS) may return a response that indicates that the client has multiple other insurance policies applicable to the service provided. The provider must bill each and every applicable policy before submitting the claim to the Connecticut Medical Assistance Program. The following billing instructions provide an example of claims with multiple other insurance payments and/or denials. Providers should refer to the previous sections of this guide for field by field instructions specific to other insurance payments or denials. UB-04 Claim Form The following example illustrates one OI payment of $ from carrier code B04 with an OI paid date of 11/1/2008 and one OI denial from carrier code 060 with an OI denial date of 11/10/2008. These instructions apply to Inpatient, Outpatient, Home Health and Nursing Home claims. 26

31 Provider Electronic Solutions Software (for Long Term Care Claims only) The following example illustrates an Institutional Nursing Home claim with one OI payment of $ from carrier code 060 with an OI paid date of 11/1/2015 and one OI denial from carrier code 008 with an OI denial date of 11/1/2015. As a reminder, when billing a Nursing Home claim the Other Insurance Indicator is located on the Header 3 tab. Header 3 tab: 27

32 First OI entry indicating OI Payment: 28

33 Second OI entry indicating OI Denial: 29

34 Web Claim The following example illustrates one OI payment of $ from carrier code B04 with an OI paid date of 11/1/2008 and one OI denial from carrier code 060 with an OI denial date of 11/10/2008. First TPL entry indicating OI Payment: Second TPL entry indicating OI Denial: 30

35 ASC X12N 837 I Health Care Claim Electronic claims with multiple other insurance payment and/or denials are created by repeating the same Loops and Segments for each of the other insurance policies. Loop Segment Description 2320 SBR Other Subscriber Information 2320 CAS Claim Adjustment 2320 AMT Coordination of Benefits Payer Paid Amount 2320 OI Other Insurance Coverage Information 2330A NM1 Other Subscriber Name 2330A N3 Other Subscriber Address 2330A N4 Other Subscriber City, State, Zip Code 2330B NM1 Other Payer Name 2330B NM109 Other Payer Primary Identifier - Enter the Connecticut Medical Assistance Program Carrier Code. These code values can be found at Information, Publications, Provider Manuals, Chapter B DTP Claim Paid Date 2330B REF Other Payer Claim Control Number 2430 SVD Line Adjudication Information 2430 CAS Line Adjustment Information 2430 DTP Line Adjudication Date 31

36 11.7 Medicare as Primary 32

37 This section contains information regarding claim submission to the Connecticut Medical Assistance Program when the client has Medicare coverage. It includes the process for submitting claims after Medicare has either made a payment or denied a claim. If Medicare coverage exists, the claim must first be submitted to Medicare for reimbursement of services. If Medicare made payment or allowed the claim, the claim should be automatically transmitted to Hewlett Packard Enterprise by Medicare. This should occur within 45 days of the provider s receipt of the Medicare Explanation of Medicare Benefit (EOMB). This claim is called a crossover claim. If this automatic transmission does not occur, the provider should submit the crossover claim to Hewlett Packard Enterprise. If a provider s crossover claims are not routinely submitted automatically to Hewlett Packard Enterprise by Medicare, the provider should contact Hewlett Packard Enterprise to determine the cause. If Medicare denied the claim, Medicare will not send the claim to Hewlett Packard Enterprise. The provider must submit this claim to Hewlett Packard Enterprise. This claim is no longer a crossover claim. A claim denied by Medicare is considered a straight Medicaid claim. If the claim is submitted to Hewlett Packard Enterprise on a UB-04 paper claim form, the EOMB must be sent with the claim when Medicare has made a payment. If Medicare has denied the claim, the EOMB should not be sent with the claim. Please note that crossover claims may be submitted to Hewlett Packard Enterprise electronically which is the most efficient method to submit this type of claim. The EOMB guidelines listed below must be followed: Providers must submit one paper claim attached to one EOMB when Medicare made a payment. No EOMB is required when Medicare denies the claim. Claims with multiple EOMBs attached to one claim or multiple claims attached to one EOMB will not be processed and will be returned to the provider. The patient name, dates of service and submitted charge on the EOMB must be exactly the same on the paper claim. The number of detail lines submitted on the claim must have corresponding detail lines on the EOMB. Columns that indicate Medicare billed amount, allowed amount, paid amount, coinsurance and deductible must appear on the EOMB. When submitting a UB-04 paper claim, providers must submit an original red claim form. Behavioral health rehabilitation services to individuals under the age of 21: Intensive In-home Child and Adolescent Psychiatric Services (IICAPS) Multisystemic Therapy (MST) Multidimensional Family Therapy (MDFT) Functional Family Therapy (FFT) Extended Day Treatment (EDT) The Department acknowledges that many primary insurance carriers do not cover the listed rehabilitation services. Therefore, the provider must obtain a denial letter that clearly articulates that the service rendered is not a covered service. This letter must be kept on file in the client s record. If the episode of care lasts longer than six months, the provider must pursue and obtain subsequent denial letters for each six month period of treatment. The denial letter from the primary insurance carrier will be accepted as evidence of pursuit of third party reimbursement for auditing purposes for the applicable six month period of treatment. Each six month period of treatment must have a denial letter. 33

38 A copy of denial letter from the primary carrier must be stored in the client s file for audit purposes and does not need to be submitted with the claim to Hewlett Packard Enterprise. The TPL denial date submitted on the claim would represent the date the letter was received from the primary carrier. 34

39 11.8 Billing Instructions - Medicare Payment 35

40 The following billing instructions identify the required fields used to submit a claim with a Medicare payment, for each type of media, including paper claims, Provider Electronic Solutions software claims (for long term care claims only), Web claims and electronic claims submitted in the ASC X12N 837 Health Care Claim format. UB-04 Claim Form NOTE: The Explanation of Medicare Benefit (EOMB), indicating a payment from Medicare or the Medicare HMO, must be attached to the paper claim. If the EOMB is not attached to the claim, the claim will deny. Field No Name Value Code Amounts Description Enter the appropriate value code and then dollar amount(s) for Medicare coinsurance and deductible only. The value codes should be selected from the list below and be consistent with the Medicare indicator on Line A, B or C in Field 50 (Payer Name). Institutional Part A Deductible Code A1 B1 C1 Description Deductible payer A Deductible payer B Deductible payer C Institutional Part A Coinsurance Code Description A2 Coinsurance payer A B2 Coinsurance payer B C2 Coinsurance payer C 08 Medicare lifetime reserve coinsurance amount in first calendar year 09 Medicare coinsurance amount in first calendar year 10 Medicare lifetime reserve coinsurance amount in second calendar year 11 Medicare coinsurance amount in second calendar year Professional Part B Deductible Code A1 B1 C1 Description Deductible payer A Deductible payer B Deductible payer C Professional Part B Coinsurance Code Description A2 Coinsurance payer A B2 Coinsurance payer B C2 Coinsurance payer C 36

41 Field No. Name Description 50. Payer Name Enter either Medicare Part A (or MPA), Medicare Part B (or MPB), or Medicare HMO 54. Prior Payments Enter the Medicare paid amount Medicare Part A Payment Inpatient/Nursing Home The following example illustrates an Inpatient crossover claim that contains Medicare Part A deductible in the amount of $1, and a Medicare paid amount of $2, Nursing Home Medicare Part A claims would reflect a co-insurance amount rather than the deductible as shown in this example. 37

42 Medicare Part B Payment Outpatient/Home Health/Nursing Home The following example illustrates an Outpatient, Home Health or Nursing Home crossover claim that contains Medicare Part B coinsurance in the amount of $ and a Medicare paid amount of $ Medicare HMO Payment Inpatient/Outpatient/Home Health/Nursing Home The following example illustrates an Inpatient, Outpatient, or Home Health crossover claim that contains Medicare HMO coinsurance in the amount of $ and a Medicare HMO paid amount of $ Nursing Home Medicare Part A claims would reflect a co-insurance amount rather than the deductible as shown in this example. 38

43 Provider Electronic Solutions Software (for Long Term Care Claims only) Tab Field Name Description Header 3 Crossover Indicator (Nursing Home) Enter a Y in this field. This action will add a Crossover tab to the claim. Crossover Release of Medical Data Select the appropriate value from the drop down box that indicates whether the provider, has on file, a signed statement by the client authorizing the release of medical data to other organizations. This field defaults to Y. Crossover Benefits Assignment Select the appropriate value from the drop down box that identifies that the client, or authorized person, authorizes benefits to be assigned to the provider. This field defaults to Y. Crossover Claim Filing Indicator Code Select the appropriate value from the drop down box that identifies the type of other insurance claim that is being submitted. Enter MA for Medicare Part A or MB for Medicare Part B. Crossover Medicare ICN Enter the claim number assigned to the claim by Medicare. Crossover Paid Amount Enter the dollar amount paid by Medicare. Crossover Paid Date Enter the date Medicare paid the claim (Medicare Explanation of Benefit date). Crossover Deductible Amount Enter the dollar amount of the deductible that applies to the claim. Crossover Coinsurance Amount Enter the total dollar amount of the coinsurance that applies to the claim. Crossover Crossover Policy Holder Carrier Code Policy Holder Last Name For Medicare Part A, select the MPA policy associated with the client who received services. For Medicare Part B, select the MPB policy associated with the client who received services. This field is auto-plugged when a carrier code is selected and contains the last name of the Medicare policyholder. Crossover Policy Holder First Name This field is auto-plugged when a carrier code is selected and contains the first name of the Medicare policyholder. 39

44 Medicare Part A Payment Nursing Home The following example illustrates an Institutional Nursing Home crossover claim that contains Medicare Part A coinsurance in the amount of $1, As a reminder, when billing a Nursing Home claim the Crossover Indicator is located on the Header 3 tab. Header 3 tab: 40

45 Crossover tab: Medicare Part B Payment Nursing Home The following example illustrates an Institutional Nursing Home crossover claim that contains Medicare Part B coinsurance in the amount of $ As a reminder, when billing a Nursing Home claim the Crossover Indicator is located on the Header 3 tab. Header 3 tab: 41

46 Crossover tab: Medicare HMO Payment Nursing Home The following example illustrates an Institutional Nursing Home crossover claim that contains Medicare HMO Part A coinsurance in the amount of $ , using claim filing code MA and carrier code MPA. When billing a Nursing Home crossover claim that contains Medicare HMO Part A coinsurance or deductible, the claim must contain claim filing code MA and carrier code MPA. As a reminder, when billing a Nursing Home claim the Crossover Indicator is located on the Header 3 tab. 42

47 Header 3 tab: Crossover tab : 43

48 Web Claim Panel Field Name Description Institutional Claim Medicare Information Claim Type Medicare Carrier This is a drop down field that lists the valid claim type values. When submitting a claim with Medicare Part A coverage, select A Institutional Xover Claims. When submitting a claim with Medicare Part B coverage, select C - Outpatient Xover Claims. When the A Institutional Xover Claims claim type is selected, Medicare Carrier MPA is automatically populated. When the C - Outpatient Xover Claims claim type is selected, Medicare Carrier MPB is automatically populated. Medicare Information Medicare Information Medicare Information Medicare Information Coinsurance Amount Medicare Paid Date Deductible Amount Medicare Paid Amount Enter the client s coinsurance amount due. Enter the Explanation of Medicare Benefit (EOMB) date. Format is MM/DD/CCYY. Enter the client s deductible amount due. Enter the amount paid by Medicare. 44

49 Medicare Part A Payment Inpatient/Nursing Home The following example illustrates an Inpatient crossover claim that contains Medicare Part A deductible in the amount of $1, and a Medicare paid amount of $2, Nursing Home Medicare Part A claims would reflect a co-insurance amount rather than the deductible as shown in the example. Institutional Crossover Claim Medicare Information 45

50 Medicare Part B Payment Outpatient/Home Health/Nursing Home The following example illustrates an Outpatient crossover claim that contains Medicare Part B coinsurance in the amount of $ and a Medicare paid amount of $ Outpatient Crossover Claim Medicare Information 46

51 Medicare HMO Payment Inpatient/Outpatient/Home Health/Nursing Home The following example illustrates an Outpatient crossover claim that contains Medicare HMO Part B coinsurance in the amount of $ and a Medicare HMO paid amount of $ Home Health and Nursing Home claims would also be billed in this manner. When billing an Inpatient or Nursing Home crossover claim that contains Medicare HMO Part A coinsurance or deductible, the Institutional Xover Claim type is selected and the Part A payment is entered into the Medicare information panel. Outpatient Crossover Claim Medicare Information 47

52 ASC X12N 837 I Health Care Claim Institutional Providers submitting claims containing Medicare data must complete the following Loops and Segments. Loop Segment Description 2320 SBR Other Subscriber Information 2320 CAS Claim Adjustment Enter the co-insurance (claim adjustment reason code = 2) or deductible (claim adjustment reason code = 1) for the claim AMT Coordination of Benefits Total Medicare Paid Amount (qualifier = D) 2320 OI Other Insurance Coverage Information 2330A NM1 Other Subscriber Name 2330A N3 Other Subscriber Address 2330A N4 Other Subscriber City, State, Zip Code 2330B NM1 Other Payer Name 2330B NM109 Other Payer Primary Identifier - Enter Carrier Code MPA for Medicare Part A or MPB for Medicare Part B. 2330B DTP Claim Paid Date 2330B REF Other Payer Claim Control Number 2430 SVD Line Adjudication Information 2430 CAS Line Adjustment Information Enter the co-insurance or deductible for the line item DTP Line Adjudication Date 48

53 11.9 Billing Instructions - Medicare Denial 49

54 The following billing instructions identify the required fields used to submit a claim with a Medicare denial, for each type of media, including paper claims, Provider Electronic Solutions software claims (for long term care claims only), Web claims and electronic claims submitted in the ASC X12N 837 Health Care Claim format. UB-04 Claim Form NOTE: The Explanation of Medicare Benefit (EOMB), indicating a denial from Medicare or the Medicare HMO should not be attached to the paper claim. The EOMB is no longer required to be attached to the claim. Field Name Description No. 50. Payer Name Enter either Medicare N/A, MPA N/A, MPB N/A, or Medicare HMO N/A, and the date of Medicare s denial located on the Explanation of Medicare Benefits. Medicare Part A or B Denial Inpatient/Outpatient/Nursing Home The following example illustrates a non-crossover claim where Medicare Part A denied payment on 11/1/2008. A Part B denial would reflect MPB N/A in field 50. These instructions apply to Inpatient, Outpatient, and Nursing Home claims. Medicare Part A Denial - Home Health Home Health providers are required to submit their Medicaid claims for dually eligible clients to Hewlett Packard Enterprise indicating the reason a Home Health Advanced Beneficiary Notice (HHABN)*, an Advanced Beneficiary Notice of Non coverage (ABN), or the MCO Notice of Medicare Non-Coverage (NOMNC) was issued to the client, using one of the HIPAA Adjustment Reason Codes indicated below. In addition, providers are required to indicate the date the HHABN, ABN, or NOMNC was issued. The HHABN or ABN issue date must be within one year of the date of service. As a result of these requirements, claims for dates of service April 1, 2010 and forward will deny if they do not correctly indicate the reason and the date the home health agency issued the HHABN, ABN, or NOMMC which determined the client s care does not meet specific Medicare coverage criteria, such as being homebound. Note: Home Health Providers must also document other TPL coverage as indicated on the client s eligibility file relating to payment or denial when submitting claims. *Please note that HHABNs can only be issued through December 8, Effective December 9, 2013, Home Health Agencies must use the ABN. HHABNs issued prior to December 9, 2013 for ongoing, repetitive services will remain in effect for the time period indicated on the notice, up to one calendar year from the date of issuance. 50

55 Field No. Name Description 30. Unlabeled Field Enter the HIPAA Adjustment Reason code. Valid values are: 150 Client determined to be not homebound; either at the start of care or after Medicare-covered services have been provided. 150 Client not receiving part-time or intermittent services from start of care or following the delivery of Medicarecovered services. 151 Client receiving thirty-five (35) hours per week of Medicare-covered skilled nursing and/or home health aide services combined. Medicaid being billed for additional skilled nursing and home health aide services over 35 hours/week. 150 Nursing, therapy and/or dependent services being provided do not meet Medicare coverage requirements, e.g. nursing visits are for medication pre-pours or the home health aide is not primarily performing hands-on personal care. 152 Client s continued care determined to not be Medicarecoverable. CMS required Annual HHABN, ABN, or NOMNC issued. 50. Payer Name Enter MPA N/A and the date the Home Health Advanced Beneficiary Notice (HHABN), Advanced Beneficiary Notice of Noncoverage (ABN), or MCO Notice of Medicare Non-Coverage (NOMNC) was issued. The following example illustrates a non-crossover claim where a Medicare Part A dually eligible client was issued a HHABN, ABN, or NOMNC on 04/10/2010. The Claim Adjustment Reason Code of 150 "Client determined to be not homebound; either at the start of care or after Medicare-covered services have been provided." is entered to indicate the reason the HHABN, ABN, or NOMNC was issued. 51

56 Medicare Part A Denial with Part B Payment Inpatient Effective with dates of admission on or after January 1, 2015, Medicaid s payment will be limited to the full coinsurance and/or deductible on an inpatient Medicare crossover claim where Medicare has been exhausted. When Medicare is exhausted during a hospital stay, it is no longer acceptable to cut back the dates of service on the crossover claim and then bill Medicaid directly, via an inpatient claim, for the dates of service after Medicare has been exhausted. The Medicare inpatient crossover claim should be submitted in its entirety to include the total stay. Medicaid s payment will only be for the Medicare coinsurance and/or deductible. Medicaid will continue to consider the Part B covered charges of an inpatient stay when Medicare is exhausted. There are no billing changes for these outpatient crossover claims. If Medicare Part A denies the entire stay and Medicare Part B makes a payment, the non-crossover inpatient claim must be billed by indicating the Part A denial as illustrated in the example below. The Part B payment must be reflected as another insurance payment in the TPL panel see below. The Part B payment in the paid amount field must equal the sum of the Medicare paid amount, coinsurance amount and the deductible amount located on the Explanation of Medicare Benefits. Field Name Description No. 50. Payer Name Line 1 - Enter MPA N/A and the denial date. Line 2 - Enter MPB 54. Prior Payments Line 1 - Leave Blank Line 2 - Enter the sum of the Medicare paid amount, the coinsurance amount and the deductible amount located on the Explanation of Medicare Benefits. 80. Remarks Enter the Medicare Part B paid date located on the Explanation of Medicare Benefits. 52