Home Health Medicare Secondary Payer Claims

Transcription

1 Home Health Medicare Secondary Payer Claims Attention: Per CR8486 effective January 1, 2016 MSP claims for Medicare Part A will be accepted via DDE. MM8486 ( Learning-Network-MLN/MLNMattersArticles/Downloads/MM8486.pdf) details how to enter these MSP claims via DDE. As an alternative to entering via DDE, follow the steps below to create MSP claims in HBS. One-time setup: 1. Create a new MSP insurance called Medicare Secondary Payor under File>File Maintenance>Entity>Insurance Type. It should match your existing Medicare insurance setup except on the Insurance tab leave PPS Billing unchecked. Agencies utilizing clinical software should add the new insurance there and complete the setup in HAS after it comes over. Patients with Medicare Secondary Payer should have this insurance added to their patient record. 2. Create a RAP option set for billing MSP RAPs: Go to Billing>Electronic Claims, select your Medicare option set and click "Options. Click "Copy," select a Destination ID # and enter the description as MSP RAP. Close HAS and reopen. Go to Billing > Electronic Claims, select the MSP RAP option set, click Options and change the following locators: CLM05 Type of Bill set to ' Bill Processing Type set to PPS Secondary 3. Save and exit the options wizard. 3. Create a Final claim option set for billing MSP Finals: Go to Billing>Electronic Claims, select your Medicare option set and click "Options. Click "Copy," select a Destination ID # and enter the description as MSP Finals. Close HAS and reopen. Go to Billing > Electronic Claims, select the MSP Finals option set, click Options and change the following locators: CLM05 Type of Bill set to ' NTE*ADD Comments set to Pat-Ins Bill Data BillNote HI*BE Value Code Amount B set to Pat-Ins bill Data Value2 (Code/Amount) HI*BG Condition Code 1 set to Pat-Ins Bill Data Condition HI*BH Occurrence Code/Date A set to Pat-Ins Bill Data Occurrence1 (Code/Date) HI*BH Occurrence Code/Date C set to Pat-Ins Bill Data Occurrence3 (Code/Date) Coordination of Benefit COB Loops (Secondary Ins) set to First Other Insurance w/co-pay Amt from Billed Insurance (use for Hospice) COB Insurance is Primary set to Billed Insurance is secondary (COB insurance is primary) COB SBR*09 Claim Indicator set to Bypass this Data Element (system will use OASIS Type from primary insurance Insurance tab to determine claim indicator) 716 Newman Springs Road Lincroft, NJ Tel Page 1 of 7

2 CAS*01/02 Claim Adjustment Group/Reason set to Pat-Ins Bill Data AdjReason NM1*PR COB Insurance Payor ID set to Insurance Submitter Number Bill Processing Type set to PPS Secondary 13. Save and exit the options wizard. Billing Instructions: 1. Bill the primary insurance and apply payments received. 2. Transfer the remaining due amounts for each charge to the MSP insurance. In AR > Payments/Transfers, select the primary insurance bill record and click the Detail tab. Check Allow Transfer and enter a Bill Date (defaults to Today s Date) and confirm MSP is listed as the To Insurance. In the Transfer column, enter the dollar amount being transferred for each charge line. Repeat this process for all charges that fall within the Medicare certification From/To dates. Do not enter a transfer amount on charges that fall outside the Medicare episode being billed. (Note, performing the Transfer process takes the place of running/posting a Billing Audit). 3. Enter the claim specific codes and amounts needed for MSP claims under the Patient>Insurance screen. Select the MSP insurance. In the Co-Pay Amount field, enter the total payment amount received from the primary insurance plus a penny. (Note: you must add the penny to the primary insurance paid amount due to the fact that Medicare Final claims have an extra penny as a result of the Q-code line penny amount which causes a claim balancing issue if not present). If no payment was received, enter Newman Springs Road Lincroft, NJ Tel Page 2 of 7

3 4. Click the Bill Data tab and add any Value, Occurrence, Condition Codes, Bill Notes and Adjustment Reason codes/amounts for the MSP Process being followed. CGS has an online tool for assistance with determining which process should be followed and can be accessed at their website. Value Codes: to add a value code and amount, click the + add button. Set Type to Value2, enter the value code in the Code field and the dollar amount in the Amount field (amount is amount primary insurance paid plus one penny). Enter zero as the amount if no payment received from the primary insurance. Repeat this step if an additional value code/amount is needed, but select Value3 in the Type field. (Note: Do not use the Value1 option on the Bill Data tab for MSP as Value1 is reserved for CBSA codes on Medicare claims.) Condition codes (only used for Process D): to add a condition code and date, click the + add button. Set Type to Condition1 and enter the 2 digit condition code. Occurrence Codes: to add an occurrence code and date, click the + add button. Set Type to Occurrence1, enter the occurrence code in the Code field and the occurrence date in the Date field. Repeat this step if an additional occurrence code is needed, but select Occurrence3 in the Type field. Remark: to add a claim note, click the + add button. Set Type to BillNote1 and in the Note/Text field enter the remark as required by the MSP Process. Adjustment Reason: to add the primary insurance s adjustment reason and amount (writes to the CAS segment of the electronic claim), click the + button and set Type to AdjReason. The adjustment reason and amount gets entered in the Note/Text field. The adjustment amount is the difference between the billed amount and what the primary insurance paid. Refer to the primary insurance EOB for the adjustment reason to be used. If unavailable, utilize the WPC-EDI website for a list of Adjustment Reason Codes Newman Springs Road Lincroft, NJ Tel Page 3 of 7

4 If following MSP Billing Process A and using Value 44 on the claim, add a second Adjustment Reason code by adding a new row and setting the Type to AdjReason2. For Type AdjReason, enter CO*45* followed by the primary insurance allowed amount. For Type AdjReason2, enter PR* followed by the primary insurance adjustment reason code from the EOB and the amount being billed to MSP (see example Bill Data tab information below) Enter the MSP claim Bill-Date for each bill data type only if the data being entered is for a specific claim (the Bill-Date is the date used during the transfer process in Step 2). Leave the Bill-Date blank if you want the information to flow to all claims for this patient/insurance. 5. Go to Billing>Electronic Claims, select the MSP option set (MSP RAP or MSP Final) and create an electronic claim following the standard process for creating claims. The Bill Date is the Transfer To date used in step 2, or view the Payments screen to confirm the Bill Date that should be used. The Electronic Claim Submission report will show the Value, Condition, Occurrence codes and Bill Note from the Bill Data tab as well as the COB payer name. 716 Newman Springs Road Lincroft, NJ Tel Page 4 of 7

5 Example 5010 Electronic Claim File: CLM segment shows the total charge amount (must match AMT*EAF) NTE shows the Bill Note/Comment/Remarks from Patient > Insurance > Bill Data HI*BE segment shows the Value Codes and amounts CAS segment(s) shows the Adjustment Reason line(s) from Patient > Insurance > Bill Data tab. AMT*D is the primary insurance paid amount from the CoPay field of Patient > Insurance > Guarantor Info AMT*EAF shows the total charge amount (must match CLM*02) Note: The COB information must balance or the Final claim will reject. The CAS line(s) must equal the total charge amount minus what the primary insurance paid. In the example claim output below: (CAS*CO) + (CAS*PR) = (AMT*EAF) (AMT*D) $430 + $150 = $ $ $580 = $580 (Claim balances) 716 Newman Springs Road Lincroft, NJ Tel Page 5 of 7

6 Special Billing Instructions: Scenario 1 - Adjustment MSP Claims. Billing an adjustment MSP requires setting up a new option set. In the Adjustment option set, change Locator CLM05 Type of Bill to 327. Change Locator REF*F8 Original Reference Code to Constant value (Entered) and in the text box, enter the DCN for the adjustment claim. NOTE: This step must be done prior to creating each adjustment MSP claim. 716 Newman Springs Road Lincroft, NJ Tel Page 6 of 7

7 Scenario 2 - Patient was billed as Medicare primary and they were determined to have alternate primary insurance; payment is expected from the primary insurance. Add the primary insurance for this patient to the patient record. Un-bill the charges from Medicare via the Payments screen and bill them to the primary insurance following normal billing procedures. If a balance needs to be billed to Medicare after the primary pays, follow the MSP process as described under Billing Instructions. NOTE: The MSP insurance will need to be added to the patient record if balance billing. Scenario 3 - Patient was billed as Medicare primary and they were determined to have alternate primary insurance; payment is not expected from the primary insurance. Add the primary insurance for this patient to the patient record. Go to AR>Payments/Transfers and transfer the charges to the primary using a 0 amount for each charge. Submit the claim to the primary insurance and bill Medicare secondary after the denial is received. A new option set will need to be setup for use in this scenario OR you may use your MSP Final option set but change Locator Bill Processing Type to PPS (Contact HAS Support for assistance if needed). NOTE: the Bill Processing Type should be set back to PPS Secondary when done if using this method. Scenario 4 - Patient RAP was billed to Medicare but Final needs to billed as MSP; patient s primary insurance is not going to be billed from HAS. Add the primary insurance for this patient to the patient record. Create a Final electronic claim using the MSP Finals option set but first change Locator Bill Processing Type to PPS (Contact HAS Support for assistance if needed). NOTE: the Bill Processing Type should be set back to PPS Secondary when done. 716 Newman Springs Road Lincroft, NJ Tel Page 7 of 7