Chapter 10: Claims Processing Procedures

I N D I A N A H E A L T H C O V E R A G E P R O G R A M S P R O V I D E R M A N U A L Chapter 10: Claims Processing Procedures Library Reference Number: PRPR10004 10-1

Chapter 10: Revision History Version Date Reason for Revisions Completed By 1.0 September 1999 Policies and procedures are current as of March 1, 1999 2.0 June 2001 Policies and procedures are current as of June 1, 2000 3.0 April 2002 Policies and procedures are current as of August 1, 2001 4.0 April 2003 Policies and procedures are current as of April 1, 2002 5.0 July 2004 Policies and procedures are current as of January 1, 2004 5.1 March 2005 Policies and procedures current as of January 1, 2005 6.0 December 2006 Policies and procedures current as of April 1, 2006 7.1 February 2008 Policies and procedures as of October 1, 2007 8.0 June 2008 Policies and procedures as of April 1, 2008 8.1 January 2009 Policies and procedures as of October 1, 2008 9.0 May 2009 Policies and procedures as of April 1, 2009 New Manual Chapters 1, 2, 3, 6, 7, 8, 9, 10, 13, 14, and Appendix A All Chapters All Chapters All Chapters Quarterly Update Quarterly Update Semiannual Update Semiannual Update Semiannual Update Semiannual Update EDS Document Management Unit EDS Document Management Unit EDS Publications Unit EDS Client Services Unit EDS Client Services Unit EDS Publications Unit EDS Publications Unit EDS Provider Relations and Publications Units EDS Provider Relations and Publications Units EDS Provider Relations and Publications Units EDS Provider Relations and Publications Units 10-2 Library Reference Number: PRPR10004

Revision History Version Date Reason for Revisions Completed By 9.1 November 2009 Policies and procedures as of October 1, 2009 10.0 September 14, 2010 Policies and procedures as of April 1, 2010 10.1 February 3, 2011 Policies and procedures as of October 1, 2010 11.0 August 16, 2011 Policies and procedures as of April 1, 2011 11.1 Policies and procedures as of October 1, 2011 Published: December 29, 2011 12.0 Policies and procedures as of May 1, 2012 Published: August 21, 2012 12.1 Policies and procedures as of November 1, 2012 Published: January 15, 2013 13.0 Policies and procedures as of May 24, 2013 Published: July 11, 2013 13.1 Policies and procedures as of November 1, 2013 Published: February 13, 2014 14.0 Policies and procedures as of April 1, 2014 Published: June 12, 2014 14.1 Policies and procedures as of October 1, 2014 Published: December 18, 2014 15.0 Policies and procedures as of January 1, 2015 Semiannual Update Semiannual Update Semiannual Update Semiannual Update Semiannual Update Semiannual Update Semiannual Update Semiannual Update Semiannual Update Semiannual Update Semiannual Update Semiannual Update Updated Batch Range Descriptions table Removed Submitting Medicare Replacement Plan before August 9, 2012 section Updated Provider Responsibilities section Updated NCCI Claims Administrative Review section HP Provider Relations and Publications Units HP Provider Relations and Publications Units HP Provider Relations and Publications Units HP Provider Relations and Publications Units HP Provider Relations and Publications Units HP Provider Relations and Publications Units HP Provider Relations and Publications Units HP Provider Relations and Publications Units HP Provider Relations and Publications Units HP Provider Relations and Publications Units HP Provider Relations and Publications Units HP Provider Relations and Publications Units Library Reference Number: PRPR10004 10-3

Chapter 10: Table of Contents Chapter 10: Revision History... 10-2 Chapter 10: Table of Contents... 10-4 Section 1: Introduction to Claims Processing Procedures... 10-6 General Information... 10-6 Managed Care Considerations... 10-6 Care Select... 10-6 Risk-Based Managed Care... 10-6 Section 2: Claims Processing Overview... 10-8 General Information... 10-8 Internal Control Number... 10-8 Internal Control Number... 10-8 Region Codes... 10-9 Julian Dates... 10-10 Batch Ranges... 10-11 Internal Control Number Examples... 10-12 Paper Claims... 10-12 Electronic Claims... 10-16 Attachments for Electronic Claims... 10-17 Claim Notes Accepted as Documentation... 10-17 Pharmacy POS Claim Submission... 10-19 Section 3: Suspended Claim Resolution... 10-20 General Information... 10-20 Suspended Claim Location... 10-20 Suspended Claims Processing... 10-21 Suspended Claim Guidelines for Processing... 10-21 Section 4: Crossover Claims Processing Procedures... 10-22 General Information... 10-22 Automatic Crossovers... 10-22 Claims That Do Not Cross Over Automatically... 10-22 Submitting a Medicare Remittance Notice... 10-23 Submitting Medicare HMO Replacement Professional-Web interchange10-23 Submitting Medicare HMO Replacement Institutional or Outpatient-Web interchange... 10-24 Submitting Medicare HMO Replacement Plans... 10-26 Medicare Denied Details for Crossover Claims Processing... 10-26 Medicare Exhaust Claims... 10-28 Section 5: Claim Filing Limitations... 10-29 General Information... 10-29 Provider Responsibilities... 10-29 Extenuating Circumstances to Waive the Filing Limit... 10-30 Timely Filing Limit Documentation... 10-31 How to Submit Claims for Filing Limit Waiver... 10-31 Section 6: Claim Reimbursement Administrative Review and Appeal Procedures... 10-33 Claims Administrative Review Policy... 10-33 Steps Taken Prior to the Administrative Review Process... 10-33 Filing Administrative Review... 10-33 Library Reference Number: PRPR10004 10-4

Table of Contents Administrative Review Responses... 10-34 Appeals... 10-34 Other Administrative Reviews and Appeals... 10-34 NCCI Claims Administrative Review... 10-34 NCCI Claim Appeals... 10-35 Surveillance and Utilization Review and Prior Authorization Appeals 10-36 Managed Care Considerations... 10-36 Care Select... 10-36 Risk-Based Managed Care... 10-36 Section 7: Submission Summary Report... 10-37 Overview... 10-37 Submission Summary Report... 10-37 Description of Information... 10-37 Purpose of Report... 10-37 Index... 10-38 Library Reference Number: PRPR10004 10-5 Policies and Procedures as of October 1, 2014 Version: 14.1

Section 1: Introduction to Claims Processing Procedures General Information This chapter provides information about claims processing. The following items are covered in this chapter: Claims Processing Overview Provides step-by-step procedures of how a claim is processed through IndianaAIM. Suspended Claim Resolution Provides an overview of the HP Enterprise Services Resolutions Unit, why and how a claim suspends, resolution procedures, and processing timeliness guidelines. Crossover Claims Processing Procedures Outlines what happens when a claim automatically crosses over from a Medicare carrier and what to do when the claim does not automatically cross over. Claim Filing Limitations Summarizes provider responsibilities concerning filing limitations, eligible claims, and filing limit waiver documentation. Claim Reimbursement Administrative Review and Appeals Procedures Describes avenues of resolution when a provider disagrees with a claim denial or payment amount. Submission Summary Report Provides information about the Submission Summary Report specific to the 837I, 837P, or 837D transactions. Managed Care Considerations Care Select Claims for members enrolled in Care Select are subject to all applicable procedures described in this chapter. Risk-Based Managed Care Claims for members enrolled with a managed care entity (MCE) in the risk-based managed care (RBMC) delivery system, other than the carved-out services, are submitted to and processed by the MCE in which the member is enrolled. Carved-out services include the following: Dental services rendered by providers enrolled in an IHCP dental specialty: Endodontist General dentistry practitioner Oral surgeon Orthodontist Pediatric dentist Periodontist Mobile dentist Prosthodontist Dental clinic Library Reference Number: PRPR10004 10-6

Section 1: Introduction to Claims Processing Procedures Services provided by a school corporation as part of a student s Individualized Education Plan (IEP) Psychiatric Residential Treatment Facility (PRTF) and Medicaid Rehabilitation Option (MRO) services Pharmacy point-of-sale (POS) services along with certain procedure-coded drugs and supplies when billed by a pharmacy (specialty 240) or durable medical equipment (DME) provider (specialty 250), billed on a CMS-1500, as listed in the Drug-Related Medical Supplies and Medical Devices table in Chapter 8: Billing Instructions. For pharmacy POS billing procedures, see Chapter 9: IHCP Pharmacy Services Benefit. When a provider submits a claim to the MCE, the MCE processes the claim and submits the encounter data to the state of Indiana. This claim data is used to track and trend the overall cost and utilization of the services provided to the Indiana Medicaid population and gives the State the data it needs to accurately report overall state Medicaid costs to the federal government. The compiled data has an impact on capitation payments to the MCEs and helps the State better understand the total medical costs involved in each case. Each MCE may establish and communicate its own criteria for claim submission and processing. Questions about claims processing for members in the RBMC delivery system should be directed to the MCE in which the member is enrolled. MCE contact information is included in Chapter 1: General Information, Section 2. Library Reference Number: PRPR10004 10-7 Policies and Procedures as of October 1, 2014 Version: 14.1

Section 2: Claims Processing Overview General Information This section describes internal claims processing procedures after HP receives a claim. Claims may be submitted for payment consideration on standardized paper claim forms or by electronic submission. Information about each type of claim submission is outlined in this section. For information about electronic claims formatting, see the Indiana Health Coverage Programs (IHCP) Companion Guides on the EDI Solutions page at indianamedicaid.com. The claims processing procedures in this chapter are for all IHCP claim types except pharmacy. Information about pharmacy claims is included in Chapter 9: IHCP Pharmacy Services Benefit. Internal Control Number IHCP claims are identified, tracked, and controlled using a unique 13-digit internal control number (ICN) assigned to each claim. The ICN numbering sequence identifies when HP received the claim, the claim submission media used, and the claim type. This information assists providers with tracking claims, as well as tracking Remittance Advices (RAs) or 835 transaction reconciliations. Internal Control Number Table 10.1 describes the ICN format codes R R, Y Y, J J J, B B B, and S S S. Table 10.1 ICN Format Code R R Y Y J J J B B B S S S Description These two digits refer to the region code or the submission source assigned to a particular type of claim. Region codes are explained later in this chapter. These two digits refer to the calendar year the claim was received. For example, all claims received in calendar year 2014 would have 14 in this field. These three digits refer to the Julian date the claim was received. Julian dates are shown on many calendars as days elapsed since January 1. There are 365 days in a year, 366 in a leap year. Tables 10.3 and 10.4 display the Julian dates for a regular year and a leap year. These three digits refer to the batch range of the particular claim. Different claim types are assigned specific batch ranges to assist in identifying, tracking, and controlling claim inputs. Batch ranges are explained later in this chapter. These three digits refer to the specific number of a particular claim within a specific batch range. Paper claim batches have a maximum of 100 individual claims within a batch; electronic claims have a maximum of 1,000 individual claims within a batch. Note: The first claim in a batch is given a specific number of 00, or 000 for electronic claims. Thus, the last claim in a batch is numbered 99 or 999 for electronic claims. Library Reference Number: PRPR10004 10-8

Section 2: Claims Processing Overview Region Codes Table 10.2 describes region codes for specific claim types. Code 10 Paper without attachments 11 Paper with attachments 13 Paper attachment cover sheets Table 10.2 Region Codes Description 20 Electronic claims without attachments 21 Electronic claims with attachments 22 Encounter claim 23 Electronic crossover claims submitted by the provider 25 Pharmacy point of sale (POS)* 40 Conversion claim [Medicaid Management Information System (MMIS) to IndianaAIM] 49 Recipient linking Claims 50 Adjustments, non-check-related 51 Adjustments, check-related 52 Encounter claim replacements 53 Encounter claim void 54 Mass adjustments, void transactions 55 Mass adjustments, institutional retroactive rate 56 Mass adjustments, system generated 57 Adjustments reprocessed by HP systems engineers 59 Pharmacy POS reversal replacement* 60 Non-claim-specific financial transactions 61 Provider replacement Electronic with an attachment or claim note 62 Provider replacement Electronic without an attachment or claim note 63 Provider-initiated electronic void 64 Spend-down end of month (EOM) auto-initiated mass replacement 67 Mass adjustments, encounter claims 70 MCE capped 80 Claim reprocessed by HP systems engineers 82 Encounter claims reprocessed by HP 90 Special projects Note: *These codes are referring to pharmacy claims previous to May 24, 2013. Library Reference Number: PRPR10004 10-9

Chapter 10 Section 2: Claims Processing Overview Indiana Health Coverage Programs Provider Manual Julian Dates Julian dates and corresponding calendar dates for a regular year and a leap year are listed in Tables 10.3 and 10.4. Table 10.3 Julian Dates Regular Year DAY JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC DAY 1 001 032 060 091 121 152 182 213 244 274 305 335 1 2 002 033 061 092 122 153 183 214 245 275 306 336 2 3 003 034 062 093 123 154 184 215 246 276 307 337 3 4 004 035 063 094 124 155 185 216 247 277 308 338 4 5 005 036 064 095 125 156 186 217 248 278 309 339 5 6 006 037 065 096 126 157 187 218 249 279 310 340 6 7 007 038 066 097 127 158 188 219 250 280 311 341 7 8 008 039 067 098 128 159 189 220 251 281 312 342 8 9 009 040 068 099 129 160 190 221 252 282 313 343 9 10 010 041 069 100 130 161 191 222 253 283 314 344 10 11 011 042 070 101 131 162 192 223 254 284 315 345 11 12 012 043 071 102 132 163 193 224 255 285 316 346 12 13 013 044 072 103 133 164 194 225 256 286 317 347 13 14 014 045 073 104 134 165 195 226 257 287 318 348 14 15 015 046 074 105 135 166 196 227 258 288 319 349 15 16 016 047 075 106 136 167 197 228 259 289 320 350 16 17 017 048 076 107 137 168 198 229 260 290 321 351 17 18 018 049 077 108 138 169 199 230 261 291 322 352 18 19 019 050 078 109 139 170 200 231 262 292 323 353 19 20 020 051 079 110 140 171 201 232 263 293 324 354 20 21 021 052 080 111 141 172 202 233 264 294 325 355 21 22 022 053 081 112 142 173 203 234 265 295 326 356 22 23 023 054 082 113 143 174 204 235 266 296 327 357 23 24 024 055 083 114 144 175 205 236 267 297 328 358 24 25 025 056 084 115 145 176 206 237 268 298 329 359 25 26 026 057 085 116 146 177 207 238 269 299 330 360 26 27 027 058 086 117 147 178 208 239 270 300 331 361 27 28 028 059 087 118 148 179 209 240 271 301 332 362 28 29 029 088 119 149 180 210 241 272 302 333 363 29 30 030 089 120 150 181 211 242 273 303 334 364 30 31 031 090 151 212 243 304 365 31 10-10 Library Reference Number: PRPR10004

Section 2: Claims Processing Overview Table 10.4 Julian Dates Leap Year DAY JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC DAY 1 001 032 061 092 122 153 183 214 245 275 306 336 1 2 002 033 062 093 123 154 184 215 246 276 307 337 2 3 003 034 063 094 124 155 185 216 247 277 308 338 3 4 004 035 064 095 125 156 186 217 248 278 309 339 4 5 005 036 065 096 126 157 187 218 249 279 310 340 5 6 006 037 066 097 127 158 188 219 250 280 311 341 6 7 007 038 067 098 128 159 189 220 251 281 312 342 7 8 008 039 068 099 129 160 190 221 252 282 313 343 8 9 009 040 069 100 130 161 191 222 253 283 314 344 9 10 010 041 070 101 131 162 192 223 254 284 315 345 10 11 011 042 071 102 132 163 193 224 255 285 316 346 11 12 012 043 072 103 133 164 194 225 256 286 317 347 12 13 013 044 073 104 134 165 195 226 257 287 318 348 13 14 014 045 074 105 135 166 196 227 258 288 319 349 14 15 015 046 075 106 136 167 197 228 259 289 320 350 15 16 016 047 076 107 137 168 198 229 260 290 321 351 16 17 017 048 077 108 138 169 199 230 261 291 322 352 17 18 018 049 078 109 139 170 200 231 262 292 323 353 18 19 019 050 079 110 140 171 201 232 263 293 324 354 19 20 020 051 080 111 141 172 202 233 264 294 325 355 20 21 021 052 081 112 142 173 203 234 265 295 326 356 21 22 022 053 082 113 143 174 204 235 266 296 327 357 22 23 023 054 083 114 144 175 205 236 267 297 328 358 23 24 024 055 084 115 145 176 206 237 268 298 329 359 24 25 025 056 085 116 146 177 207 238 269 299 330 360 25 26 026 057 086 117 147 178 208 239 270 300 331 361 26 27 027 058 087 118 148 179 209 240 271 301 332 362 27 28 028 059 088 119 149 180 210 241 272 302 333 363 28 29 029 060 089 120 150 181 211 242 273 303 334 364 29 30 030 090 121 151 182 212 243 274 304 335 365 30 31 031 091 152 213 244 305 366 31 Batch Ranges Adjustments and encounters use the same claim-type batch range. Library Reference Number: PRPR10004 10-11

Chapter 10 Section 2: Claims Processing Overview Indiana Health Coverage Programs Provider Manual Table 10.5 Batch Range Descriptions Claim Type Batch Range UB-04 Inpatient Crossover 000-009 UB-04 Outpatient Crossover 010-029 CMS-1500 Crossover 030-089 American Dental Association (ADA) 2006 Dental Claim Form 090-109 Inpatient 110-139 Outpatient 140-199 Long-Term Care 200-279 Home Health 280-299 CMS-1500 600-899 Financial 900-999 Internal Control Number Examples The following examples illustrate the ICN sequence on the RA: A paper dental claim with no attachments received in 2014, is assigned the ICN 1014JJJ099CCC. This is a claim within batch 099, received in 2014, as a paper claim submission with no attachments. An 837 Professional (837P) claim transaction with no attachments received in 2014, is assigned the ICN 2014JJJ699CCC. This is a claim within batch 699, received in 2014, as an electronic claim submission. A paper UB-04 outpatient claim with attachments received in 2014, is assigned the ICN 1114JJJ147CCC. This is a claim within batch 147, received in 2014, as a paper claim submission that also included attached information. Paper Claims To assist providers using paper claims, the IHCP has identified specific billing errors that may cause processing delays or increased paper claims processing errors. To avoid these errors, providers should adhere to the following paper claim billing processes: Submit paper claims on standard Centers for Medicare & Medicaid Services (CMS)-approved claim forms. Use Helvetica, Times New Roman, or Courier font type with 12-point or 14-point font size. Avoid using handwritten information on the claim forms unless directed to do so. Ensure information is documented in the appropriate boxes on the form and is aligned correctly in those boxes. Add data within the boxes on the form. Data outside the boxes can cause errors and delay processing. Do not enter commas or dashes. Diagnosis pointers on the detail lines should read up to four of the following: A-L. 10-12 Library Reference Number: PRPR10004

Section 2: Claims Processing Overview Do not write or type any information, other than the appropriate address, on the claim form above the redline box. Do not put stray marks or X s on the claim form. Paper claims that require attachments must include the attachments with the claim form. Do not add stamps or stickers. Submit attachments on standard 8 ½-by-11-inch paper. Do not use paper clips or staples on claim forms or attachments. Write in only blue or black ink. Note: Claims submitted electronically or on the standard red-ink form expedite claims processing and improve the accuracy of claim scanning and data entry. This section outlines paper claim processing procedures. A step-by-step review of paper claims processing, also known as manual or hard-copy claims processing, follows: 1. The provider completes claims according to the instructions in Chapter 8: Billing Instructions of this manual and mails them to the appropriate claim-processing address. Mailing addresses are found in Chapter 1: General Information and on the Quick Reference Guide, which can be found on the Contact Us page at indianamedicaid.com. 2. The United States Postal Service delivers claims to HP by routine mail, special delivery, overnight mail, and courier. Claims are assigned a Julian date that corresponds to the date of receipt at HP. 3. The mailroom sorts claims by claim type with attachments or without attachments. Sending claims to the correct P.O. Box significantly speeds sorting time. 4. When a claim form is received for processing, specific form field locators are reviewed and validated for completion. If it is determined that the form field locators are completed incorrectly or blank, the claim form and any attachments are returned to the provider, which prevents processing of the claim. The provider should review the reasons the claim was returned, make the appropriate corrections, and then resubmit the claim for processing consideration. Claims that are reviewed in the mailroom may be returned for the reasons listed in Table 10.6. Library Reference Number: PRPR10004 10-13

Chapter 10 Section 2: Claims Processing Overview Indiana Health Coverage Programs Provider Manual Table 10.6 Claims Returned to Provider Return To Provider (RTP) Letter Language For healthcare providers: Please resubmit claims with a valid National Provider Identifier (NPI). For atypical providers: Please resubmit claims with a valid IHCP provider number. All provider numbers require nine numerical digits and one alpha character to denote the service location code (123456789X). Explanation The NPI is required for healthcare providers and the taxonomy code is optional. Verify that the billing provider NPI and qualifiers are located in the correct field and are entered in the proper format. The correct field for each claim form is as follows: UB-04 Form field 56 CMS-1500 Form field 33a Dental Form field 49 Atypical providers continue to bill with the Legacy Provider Identifier (LPI). UB-04 CMS-1500 Form Field 57A Form Field 33b Note: Qualifiers are 1D = IHCP provider number (LPI) Or ZZ = Taxonomy Medicare information not submitted in field 22. Services were not submitted on an approved claim form. Please submit request for payment on the appropriate IHCP claim form. Provider must submit Medicare information on the UB-04 claim form in field 54A. Continuous paper claims are not accepted. The attachment control number (ACN) is not at the top of the attachment(s). Dental Form Field 50 For crossover claims and Medicare Replacement Plans, the combined total of the Medicare coinsurance or copayment, deductible, and psychiatric reduction must be reported on the left side of field 22 under the heading Code on the CMS-1500 claim form. The Medicare paid amount (actual dollars received from Medicare) must be submitted on the right side of field 22 under the heading Original Ref No. The IHCP accepts the UB-04 claim form, the CMS-1500 claim form, the ADA 2006 Dental Claim form, the National Council for Prescription Drug Programs, Inc. IHCP Drug Claim Form, and the IHCP Compounded Prescription Claim Form. Use form field 54A to indicate the Medicare paid amount. Do not include the Medicare-allowed amount or contract adjustment amount in field 54. Only six detail lines are billable on a CMS-1500 claim form. Only 10 detail lines are billable on an ADA 2006 form. Continuous paper claims are not accepted for dental and CMS claims. Each individual claim must have a total. The ACN allows the IHCP to match the attachment to the submitted claim and must be written at the top of each page of the attachment. 10-14 Library Reference Number: PRPR10004

Section 2: Claims Processing Overview Return To Provider (RTP) Letter Language The maximum number of detail lines has been exceeded for this claim form. Submit additional details on a separate claim form. The total billed amount on each claim form must equal the sum of the detail lines for each individual claim. An invalid or missing type of bill was submitted. Please correct and resubmit claim. Duplicate ACN was submitted for attachment. Must resubmit a new claim. The Attachment Cover Sheet has an invalid NPI or is missing a member identification number, or dates of service. A Medicare Remittance Notice (MRN) must be submitted for each claim filed for denied charges. It is optional for paid services. Crossover and Medicare Replacement Plan payment information can be indicated in field 22 on the CMS- 1500 form and fields 39-41 on the UB-04 form. Diagnosis submitted on claim without a valid ICD indicator Explanation This is sent whenever the allowable number of detail lines is exceeded. The CMS-1500 claim form has a maximum of six details that can be billed on one claim form. The UB-04 claim form has a maximum of 66 details (three-page continuation claim). The type of bill in form field 4 of the UB-04 claim form is required and must be three digits. It must also be an appropriate type of bill for the claim being submitted. Valid type of bill (TOB) codes may be found in Chapter8: Billing Instructions of this manual or on indianamedicaid.com. Each claim submitted with attachments must have a unique ACN. The Attachment Cover Sheet must be filled in completely. There are two instances when a provider submits a crossover claim on paper: When the claim does not cross over, the entire claim and MRN are submitted. The MRN is needed only if the claim is denied or paid at zero (applied to the deductible) by Medicare. Paid line items and denied line items must be submitted on separate claim forms. When submitting a paper claim for denied detail lines, the MRN must be attached. The ICD version indicator is missing from the claim or the ICD version indicator is invalid. A valid ICD indicator is 9 for ICD-9 or 0 for ICD-10. Claims may not be submitted without an ICD version indicator on or after April 1, 2014. Please submit with appropriate ICD version indicator. Note: Claims received without an NPI or LPI (for atypical providers only), a provider name, and return address cannot be processed by HP and cannot be returned. These claims are destroyed. 5. Claims are grouped together; for example, all CMS-1500 claims without attachments are sorted into batches of 100 and transferred to the scanning area. 6. All claims and attachments are scanned. During the scanning process, claims are assigned a specific ICN based on the claim type, region code, and receipt date. Claim attachments receive the same ICN as the claim. 7. Hard-copy batches are transferred to the data entry area, where the information is typed into the claims processing system. 8. Medical and dental batches are maintained in storage for 30 calendar days, and UB-04 batches are maintained in storage for 60 calendar days for potential review by claim examiners. After the Library Reference Number: PRPR10004 10-15

Chapter 10 Section 2: Claims Processing Overview Indiana Health Coverage Programs Provider Manual storage limit has been reached, the hard-copy batches are destroyed, because claims are stored electronically. 9. Claim data is stored in IndianaAIM. IndianaAIM claims processing has three possible results: All claims data complies with the correct format and IHCP policy rules and results in a paid claim. Claims data does not comply with the correct format or IHCP policy rules and results in a denied claim. A claim examiner must review a particular aspect of the claim because the claim is suspended. For example, a sterilization procedure suspends a claim for review of the required sterilization consent form. A claim examiner approves the claim for payment, if appropriate, and if the correct information was sent with the claim. Otherwise, the claim is denied. Suspended claim resolution is discussed in more detail in the Suspended Claim Resolution section in this chapter. Weekly, IndianaAIM generates an RA that contains the status of each processed claim: The electronic RA in the 835 format contains paid and denied claims. The Web interchange RA lists paid, denied, in process, and adjusted claims. The last Web interchange RA of the month includes information about all claims and adjustments not processed to a paid or denied status. Adjusted claims show one time on the RA when they are paid or denied. Remittance Advice information is presented in Chapter 12: Financial Services of this manual. Electronic Claims This section outlines electronic claims processing procedures. Electronic claims must be submitted in the 837 American National Standards Institute (ANSI) formats or through the direct data entry (DDE)- compliant web portal called Web interchange. See Chapter 3: Electronic Solutions of this manual for more information about electronic claim submission using the 837 format or Web interchange. A stepby-step review of electronic claims processing follows: 1. Claims data is compiled according to the instructions in this manual, the IHCP companion guides, and the National Electronic Data Interchange Transaction Set Implementation Guides located at wpc-edi.com. The data is transmitted electronically to HP, using secure file transfer protocols and in accordance with the specifications of hardware and software systems. An intermediary can also be involved in transmitting electronic claims. 2. HP receives electronic claims from multiple transmission sources, 24 hours a day, seven days a week: HP receives and immediately sorts claims by claim type, such as 837I (institutional), 837D (dental), or 837P (professional) formatted electronic claims. o Claims formatted incorrectly are rejected during pre-cycle editing. o A 999 Acknowledgement and Submission Summary Report (SSR) is available approximately two hours after claims submission between 6 a.m. and 4 p.m. The SSR contains error codes and claim specific descriptions for rejected claims. A list of SSR error code definitions is located in the IHCP companion guide titled 999 Acknowledgement and Submission Summary Report. o Accepted information is transferred to IndianaAIM, an ICN is assigned, and pre-edit functions are performed. IndianaAIM processes these claims. 10-16 Library Reference Number: PRPR10004

Section 2: Claims Processing Overview Electronic claims cannot be reprocessed in the event of denial. The provider must resubmit the claim for processing. Attachments for Electronic Claims The following list describes how to append attachments to electronic claims and how those attachments are processed: The provider indicates on the 837 claim transaction that additional documentation will be submitted. The provider must complete an IHCP Attachment Cover Sheet for each set of attachments associated with a specific claim. A unique attachment control number of up to 30 characters must be sent in loop 2300, segment PWK on the 837 and must match the paper Attachment Cover Sheet sent by mail. The Attachment Cover Sheet can be found on the Forms page at indianamedicaid.com. Each paper attachment submitted for an 837 transaction must include the ACN. The provider must include a unique ACN on each attachment. If an attachment has more than one page, the ACN must be written on each page of the document. The provider may submit a maximum of 20 ACNs with each cover sheet. When reporting the number of pages for the attachment, providers should not include the cover sheet in the count. The United States Postal Service delivers attachments to the HP mailroom by routine mail, special delivery, overnight mail, and courier, or attachments can be hand delivered. Attachments are assigned a Julian date that corresponds to the date of arrival in the HP mailroom. HP staff members briefly review the attachments for completeness and accuracy of the number of ACNs to the number of attachments. If errors are found, the cover sheets and attachments are returned to the provider for correction and resubmission. Batches are transferred to the data entry area, and data entry analysts enter the ACNs into the claims processing system. Providers must submit attachments within 45 calendar days of the Julian date the electronic claim is received or the claim denies. Note: Write in only blue or black ink on the attachments. Claim Notes Accepted as Documentation Third-Party Payer Fails To Respond (90 Day Provision) When a third-party insurance carrier fails to respond within 90 calendar days of the billing date, the provider can submit the claim to the IHCP for payment consideration. However, to substantiate attempts to bill the third party, the following must be documented in the claim note segment of the 837 transaction: Dates of the filing attempts The phrase no response after 90 days Member s RID Provider s IHCP provider number Name of primary insurance carrier billed Library Reference Number: PRPR10004 10-17

Chapter 10 Section 2: Claims Processing Overview Indiana Health Coverage Programs Provider Manual If submitting unpaid bills or statements, providers should include the third-party insurance carrier s name. Likewise, if providing a written notification with billing dates, providers need to include the name of the third-party insurance company. Consultations Billed 15 Days Before or After Another Consultation In the claim note, the provider can indicate the medical reason for a second opinion during the 15 days before or after the billed consultation. Joint Injections Four per Month In the claim note, the provider can document that the injections are performed on different joints and indicate the sites of the injections. Surgery Payable at Reduced Amount when Related Postoperative Care Paid, Postoperative Care within 00-90 Days of Surgery, Preoperative Care on Day of Surgery, or Surgery Payable at Reduced Amount when Preoperative Care Paid Same Date of Service In the claim note, the IHCP accepts the following: Information that documents the medical reason and unusual circumstances for the separate evaluation and management (E/M) visit Information that supports that the medical visit occurred due to a complication, such as cardiovascular complications, comatose conditions, elevated temperature for two or more consecutive days, medical complications other than nausea and vomiting due to anesthesia, postoperative wound infection requiring specialized treatment, or renal failure Pacemaker Analysis Two within Six Months The provider should use the claim note to document the medical reason for the second analysis in the six-month time frame, such as a dysfunctional pacemaker. Assistant Surgeon Not Payable when Cosurgeon Paid In the claim note, the IHCP accepts information that documents the medical reason for the assistant surgeon, such as the situational problem requiring assistance. Excessive Nursing Home Visits or More than One per 27 Days In the claim note, the IHCP accepts documentation supporting the treatment of emergent, urgent, or acute conditions or symptoms with the new diagnosis code. Retroactive Eligibility Use claim notes when billing a claim that is past the filing limit and the member was awarded retroactive eligibility. In the case of retroactive member eligibility, claims must be submitted within one year of the eligibility determination date. Follow these steps to submit a claim on Web interchange: 1. Complete the claim as you would normally, using Web interchange. 2. Click Notes in header of claim and under Note Reference Code, type ADD. 3. In Note text, type Member has retroactive eligibility. Please waive timely filing. 10-18 Library Reference Number: PRPR10004

Section 2: Claims Processing Overview Mental Health HE or HO modifier and Edit 2503 Provider not approved to bill Medicare Mental health providers that submit claims with procedure codes and append modifier HE or HO when the member is dually eligible for Medicare and Medicaid may use claim notes for billing purposes to indicate the provider that performed the service is not approved to bill services to Medicare. Previously, providers were required to submit this documentation as a paper attachment. Therefore, with this change, providers can submit these types of claims electronically in an effort to expedite claim payment. Claims submitted with the appropriate claim notes must include the following text in the claim notes: Provider not approved to bill services to Medicare. The use of claim notes allows the claim to suspend for review of the claim note and be adjudicated appropriately. Pharmacy POS Claim Submission The pharmacy submits the drug claim at point of sale (POS). The claims are adjudicated immediately, as long as all information is included and correct. Additional information about pharmacy claims processing is contained in Chapter 9: IHCP Pharmacy Services Benefit of this manual. Library Reference Number: PRPR10004 10-19

Section 3: Suspended Claim Resolution General Information Edits and audits are designed to monitor and enforce federal and state laws, regulations, and program requirements. During the claims adjudication process, claims that fail an edit or audit do one of the following: Systematically deny Systematically cut back or reduce the number of units billed on the claim Suspend the claim When a claim suspends, processing is suspended until the error causing the failure is reviewed, corrected, or otherwise resolved. The process of reviewing, correcting, and resolving claim errors is performed in multiple areas including the following: HP Claims Resolution Unit, HP Adjustments Unit, the Medical Policy Departments at the managed care entities (MCEs), and the Indiana Health Coverage Programs (IHCP) Program Integrity Department. The examiners in these organizations follow written guidelines in adjudicating claims that fail defined edits or audits. Suspended Claim Location Claims data that fails edits and audits (suspend disposition) is routed to a suspense location within the claims processing system. Depending on the edit or audit that caused the failure, claims are routed to a specific claim location that identifies the type of edit or audit failed. These location codes are assigned to specific departments within HP, ADVANTAGE Health Solutions fee-for-service (FFS), MDwise- Care Select (CS), or ADVANTAGE Health Solutions-CS. ADVANTAGE and MDwise participate as the care management organization (CMO) vendors for the IHCP and are responsible for resolving certain claim errors or edit and audit failures. Adjustments that fail any edit or audit are routed to the Adjustments Unit at HP or the appropriate Medical Policy Department. Medical policy edit and audit failures are routed to the Medical Policy Department at ADVANTAGE Health Solutions-FFS, ADVANTAGE Health Solutions-CS, or MDwise-CS. Claims that fail for members on the Right Choices Program are routed to ADVANTAGE Health Solutions-FFS, ADVANTAGE Health Solutions-CS, or MDwise-CS. Prepayment provider review edits are routed to the Prepayment Review (PPR) Unit located within the IHCP Program Integrity Department. The remaining edit and audit failures are routed to the Claims Resolution Unit at HP. Library Reference Number: PRPR10004 10-20

Section 3: Suspended Claim Resolution Suspended Claims Processing IndianaAIM distributes claims in suspense to the appropriate resolution examiner, distributing the oldest suspended claim to the examiner first. This process ensures that older claims are processed first. Suspended claims, along with the error codes and descriptions, are displayed to the examiners in a format similar to the claim form. The screen provides examiners with a field to apply claims processing transactions, claim location for routing, or explanation of benefits (EOB) messages for claim denials. The screen allows examiners to access various reference files necessary to effectively process suspended claims. Examiners have the option of applying the following transactions when processing suspended claims, depending on the edit or audit failure: ADD/CHANGE The examiners can correct typing errors. Examiners cannot change reimbursement data except in the case of manual pricing. FORCE/OVERRIDE The edits and audits are overridden to force the claim to go through the claims processing cycle regardless of the presence of the overridden error. DENY The claim can be denied if called for by the edit or audit. ROUTE The claim may be routed to a different claim location. RESUBMIT The claim can be resubmitted. This action is applied if the claim failed an edit or audit that was set in error and has since been corrected. When resubmitted, the claim goes through the same processing procedures. Suspended claims display all the error codes that caused the claims to suspend, up to a maximum of 20 error codes. The process follows: 1. The examiner clears all the error codes applicable to the claim location. 2. The claim is routed to the next applicable location if there are other errors that require correction. 3. The claim is resubmitted for processing and is again subjected to all the edits and audits. Overrides applied to any errors are captured to prevent the claim from suspending again for the same error. These overrides stay with the claim record history. Suspended Claim Guidelines for Processing HP must adjudicate clean paper claims within 30 calendar days of receipt. Clean electronic claims must be adjudicated within 21 calendar days of receipt. These guidelines apply to all claims, even those that suspend for review. All suspended claims are processed according to IC 12-15-21-3(7)(A). The exceptions to the guidelines are as follows: Claims suspended for medical review Claims submitted by a provider subject to prepayment review Paper claims that are not adjudicated within 30 days and electronic claims that are not adjudicated within 21 days are subject to interest accrual, as outlined in this chapter. Electronic claims followed by attachments must contain the provider-assigned attachment control numbers (ACNs) corresponding to the ACNs on the attachment cover sheet and the pages of each attachment to match with the claim for review. Library Reference Number: PRPR10004 10-21

Section 4: Crossover Claims Processing Procedures General Information Claims for members eligible for Medicare and Traditional Medicaid, or for dually eligible members for whom Medicare has previously made payment, are called crossover claims. This section describes crossover claims processing procedures. Crossover and Medicare Replacement Plan claims can be submitted electronically in the 837 format or through Web interchange or on the appropriate institutional or medical paper claim forms. Claim billing procedures are outlined in Chapter 8: Billing Instructions of this manual. Information about reimbursement of crossover and Medicare Replacement Plan claims is located in Chapter 7: Reimbursement Methodologies of this manual. Automatic Crossovers Claims that meet certain criteria cross over automatically from Medicare and are reflected on the Indiana Health Coverage Programs (IHCP) Remittance Advice (RA) statement or 835 transaction. Wisconsin Physician Services (WPS) is the contractor for Coordination of Benefits Agreement (COBA). The basic criteria follow: Medicare makes a payment for the billed services. WPS validates against the member file submitted by Indiana Medicaid and submits claims based on the member information. Providers can also submit claims directly to Indiana Medicaid by indicating secondary payer information in the coordination of benefits (COB) loop for Indiana Medicaid. WPS is set up as a trading partner and approved to transmit claims data to HP. IndianaAIM has all Medicare codes on file. If the Medicaid allowed amount for the services billed exceeds the Medicare paid amount for the services, Traditional Medicaid pays the lesser of the coinsurance or copayment plus deductible amounts, or the difference between the Medicaidallowed amount and Medicare-paid amount. There is no Traditional Medicaid filing time limit for paid crossover claims from Medicare. Electronic crossover claims are received electronically in batch 837 files from WPS. Individual providers or billing agents can bill crossover claims electronically to Traditional Medicaid using the appropriate electronic 837 format or Web interchange. Claims That Do Not Cross Over Automatically Medicare crossover and Medicare Replacement Plan claims that do not automatically cross over to Traditional Medicaid must be submitted to the IHCP for adjudication. They can be submitted electronically using Web interchange or the 837 format, using approved software, or via paper claim form containing the payment information from Medicare and any other payer. For all crossover and Medicare Replacement Plan claims, the provider s National Provider Identifier (NPI) must be on file Library Reference Number: PRPR10004 10-22

Section 4: Crossover Claims Processing Procedures with the IHCP. If a Medicaid member has Medicare coverage and the Medicare payment amount on the claim being submitted is greater than zero, the Medicare Remittance Notice (MRN) is not required. However, if zero dollars is indicated in the Medicare-paid amount field on the claim, the MRN must be attached. Submitting a Medicare Remittance Notice If the Medicare paid amount in field 22 of the CMS-1500 claim form or field 54A of the UB-04 claim form is zero, providers must attach the MRN to claims when submitting them to the IHCP. The attachment verifies that the reason for Medicare nonpayment is due to the amount being applied to the deductible. These claims are treated like any other third-party liability (TPL) claim. If the attachment does not show that the amount entered in field 22 on the CMS-1500 claim form or in fields 39 through 41 on the UB-04 claim form was applied to the deductible, the claim is denied. Submitting Medicare HMO Replacement Professional-Web interchange Claim Submission Type Professional Web interchange Professional crossover claims submitted via Web interchange, including Medicare Replacement Plan claims, must contain information regarding the payment amount, coinsurance or copayment and/or deductibles. Failure to include this information in the correct fields will result in claims being denied or processed incorrectly. To submit Medicare Replacement Plan claims for professional services via Web interchange: Select Medical Crossover on the Claim Processing Menu. In the Coordination of Benefits section at the claim header, click Benefit Information to display the Coordination of Benefits window. In the Other Payer Information section of the window, enter the appropriate Payer ID of the Medicare Replacement Plan in the Payer ID field. In the Payer Name field, enter the name of the Medicare Replacement Plan. In the TPL/Medicare Paid Amount field, enter the paid amount for the entire claim. In the Other Payer Payment Adjustments section, complete the Group Code, Reason Code, and Amount information. In the Other Payer Subscriber Information section of the window, complete the required fields; Member Name, Primary ID, Relationship Code and Claim Filing Code. Enter 16 - Health Maintenance Organization (HMO) Medicare Risk for a Medicare Replacement Plan. Library Reference Number: PRPR10004 10-23

Chapter 10 Section 4: Crossover Claims Processing Procedures Indiana Health Coverage Programs Provider Manual Figure 10.1 Coordination of Benefits Window For the full instructions regarding Web interchange claim completion for professional claims, see the Quick Reference for Billing Medical Claims located in the Reference Materials section of the Web interchange Help. Submitting Medicare HMO Replacement Institutional or Outpatient-Web interchange Claim Submission Type Institutional/Outpatient Web interchange Institutional/Outpatient crossover claims submitted electronically via Web interchange, including Medicare Replacement Plan claims, must contain information regarding the Medicare Replacement Plan payment amount, coinsurance or copayment, and/or deductibles. Failure to include this information will result in claims being denied or processed incorrectly. To submit institutional/outpatient crossover claims: Select Institutional Crossover or Outpatient Crossover on the Claim Processing Menu, as applicable. 10-24 Library Reference Number: PRPR10004

Section 4: Crossover Claims Processing Procedures Under the Coordination of Benefits section, click Benefit Information to display the Coordination of Benefits window. In the Other Payer Information section of the window, enter the appropriate Payer ID of the Medicare Replacement Plan in the Payer ID field. In the Payer Name field, enter the name of the Medicare Replacement Plan. In the TPL/Medicare Paid Amount field, enter the amount that the Medicare Replacement Plan paid for the entire claim. In the Other Payer Payment Adjustments section complete the Group Code, Reason Code, and Amount information. In the Other Payer Subscriber Information section of the window, complete the required fields; Member Name, Primary ID, Relationship Code and the Claim Filing Code. Enter 16 Health Maintenance Organization (HMO) Medicare Risk for Medicare Replacement Plan claims. Figure 10.2 Coordination of Benefits Window For the full instructions regarding Web interchange claim completion for Institutional/Outpatient claims, see the Quick Reference for Billing Institutional Claims in the Reference Materials section of Web interchange Help. Library Reference Number: PRPR10004 10-25

Chapter 10 Section 4: Crossover Claims Processing Procedures Indiana Health Coverage Programs Provider Manual Submitting Medicare HMO Replacement Plans Medicare Replacement Plan claims are processed as Medicare crossover claims. The IHCP reimburses covered services for Medicare crossover claims only when the Medicaid-allowed amount exceeds the amount paid by Medicare. If the Medicaid-allowed amount exceeds the Medicare Replacement Plan paid amount, the IHCP reimburses using the lesser of the coinsurance or copayment plus deductible or the Medicaid-allowed amount minus the Medicare Replacement Plan paid amount. This change also affects claims paid at zero when the amount allowed has been allocated to the member s deductible. To process as a crossover claim, providers must include additional information on claims submitted on the CMS-1500 claim form. The combined total of the Medicare, coinsurance or copayment, deductible, and psychiatric reduction must be reported on the left side of field 22 under the heading Medicare Resubmission Code. The Medicare Replacement Plan paid amount, meaning the actual dollars received from Medicare, must be indicated in field 22 on the right side under the heading Original Ref No. All institutional and outpatient UB-04 claims must identify information from the Medicare Replacement Plan explanation of benefits (EOB) in Fields 39a-41d. The following value codes must be used, along with the appropriate dollar or unit amounts for each. These fields are required, if applicable: Value Code A1 Medicare deductible amount Value Code A2 Medicare coinsurance or copayment amount Value Code 06 Medicare blood deductible amount Field 50A must indicate Medicare as the payer Field 54A must contain the Medicare Replacement Plan paid amount, meaning the actual dollars received from Medicare. (Do not include the Medicare-allowed amount or contractual adjustment amount in field 54A.) Medicare Replacement Plan denials Please note that Medicare-denied services are not crossover services, and the submission procedures for Medicare-denied services have not changed. If a claim has been denied by the Medicare Replacement Plan, the EOB or Remittance Advice (RA) must be attached to the claim with Medicare Replacement Plan written on the top of the attachment. Medicare-denied services must be filed on a separate claim form from paid services, and the appropriate EOB or RA must be attached for reimbursement consideration. Medicare-denied services may be submitted via Web interchange. Follow the Attachments instructions to send the Medicare Replacement Plan EOB. Medicare Denied Details for Crossover Claims Processing Denied details for crossover claims processing deny with Edit 593 Medicare denied details. Web interchange allows providers to enter denied service lines for crossover claims. Crossover and Medicare Replacement Plan A (Inpatient and LTC) Claims Submitted through Web interchange For crossover and Medicare Replacement Plan A claims, providers may report coordination of benefits (COB) adjustment information at the header and detail levels, but this information must appear at the header level for claims adjudication. If only detail COB adjustment information is present, it is not recognized by Web interchange. 10-26 Library Reference Number: PRPR10004