**HFS would like to clarify the timely filing deadline information given to providers during the webinars, as new information has since become available (slides posted to the website are revised): Medicare crossovers WILL BE SUBJECT to the 180-day timely filing deadline. Any time a client has Medicare primary, Medicaid secondary, the claim must first be submitted to Medicare. Then, regardless of whether Medicare deems the claim payable (crossover) or denied, the claim must be submitted to Medicaid within 180 days of the Medicare adjudication date. **The provider handbooks and the Practitioner Fee Schedule referenced in the answers below may be viewed at: www.hfs.illinois.gov/medical. 1) If the patient presents for a "routine follow up visit" with no acute illness or problem and does not have the co-pay, is it OK to reschedule? This would not be refusing treatment just rescheduling for a future date. Rescheduling treatment on that date appears to be refusing treatment due to inability to pay the co-pay. Please refer to the co-pay Q&A document on the HFS web site at http://www.hfs.illinois.gov/billing/qa.html; 5A directly addresses this topic. Additionally, if there is no acute illness or problem, is this visit medically necessary? Please refer to the list of non-covered services in Topic 104 of the Chapter 100 General Policy and Procedures, specifically Items or services for which medical necessity is not clearly established. 2) You stated there is a 180 timely deadline for secondary claims that begins 180 days from the final adjudication from the primary payer. We have several liability claims that remain open for a few years and do not pay until the case is settled. Will this apply to them as well? The 180 days from final adjudication of the primary payer will apply if that TPL is listed on the patient s file (i.e. commercial insurance). In the case of pending lawsuits or settlements, it is the provider s decision to EITHER: 1.) Bill HFS within the 180 timely filing deadline, thereby accepting as final payment the reimbursement from HFS, OR 2.) Wait for reimbursement from the settlement, in which case the provider risks being past timely filing limits this is NOT an exception which meets the criteria for a time override, and no time override will be given. 3) Do we rebill claims that were suspended for review? First review the Status column on your paper remittance advice. Example is shown in Chapter 100 Appendix 8. Status SS means the claim truly was suspended at the time the remittance advice was generated. If your remit shows a suspended service and no further response is received within 30 days, resubmit on paper with supporting documentation per the explanation in Appendix 5 Error Code Explanations of the Chapter 100 Handbook of General Policies and Procedures.
4) How do we bill for vaccines provided by VFC? Use the CPT code applicable to the vaccine. Do we enter a charge amount? Yes. This charge represents your practice expense of obtaining the vaccine through VFC. Also, is the administration for the vaccine covered? Reimbursement for the practice expense of administering the injection is included in the office visit. We use 90471 and 90472 for administration but we get an error message saying procedure not covered, prior approval required. These codes are covered for QMBs only. Use the CPT code applicable to the vaccine, such as 90476-90749. **Please refer to the Chapter A-200 Handbook for Practitioners, Topic A-226 Vaccinations/Immunizations and Appendix A-8 for policy and billing procedures. 5) I received a D01 denial, on recipient ID XXXXXXXXX, date of service 03/15/12 for procedure 58150 modifier 80 (surgical assist) for $780.40. The assist was performed by P.S. (a physician assistant); however we billed under his collaborative supervisor Dr. H who was actually the surgeon. I understand why the D01 was sent. HFS saw the same procedure same day performed by the same provider. But if we are unable to bill under the assistant P.S., we should be allowed to bill under the collaborative supervisor. Can you please advise how I should be billing the assist when the surgeon is the same as the collaborative provider?? Is this information located in the handbook? Please see policy and billing procedures in Topic A-222.32 Surgical Assistance in the Chapter 200 Handbook for Practitioners Rendering Medical Service. Services provided by a physician assistant should be billed on a paper HFS 2360 claim, using the modifier AS and the physician assistant s name in the narrative portion of field 24C. 6) When a patient has spenddown, how does a provider find out the amount? HFS is unable to tell a provider the spenddown amount, but providers can check MEDI to see if spenddown is met or unmet. If spenddown is unmet, the patient does not have Medicaid and the provider may bill the patient. Please refer to Topic 113 Spenddown in the Chapter 100 Handbook of General Policies and Procedures. 7) Regarding the 99211, can we bill this code, along with the admin of injection, when only our nurse sees a patient? Yes. Please refer to Topic A-226 Vaccinations/Immunizations in the Chapter 200 Handbook for Practitioners Rendering Medical Services. 8) We bill for a Neurosurgeon and bill for multi-level fusions. We can get the primary procedures codes paid but the secondary codes are always denied. Is there a modifier we can put on the secondary codes to ensure that they will get paid? If you have already reviewed the remittance advice error code explanation in the Chapter 100 Appendix 5 and still are uncertain about the rejections, you may contact a physician billing consultant at 877-782-5565, option 3, option 1 with the specific provider number, recipient number, date of service, and codes that were rejected. As a general rule, add-on codes are hand-priced. Please bill these on a paper claim with supporting documentation. There is no modifier.
9) When HFS asks for additional information and the claim was originally submitted electronically, how do we submit the additional information? Do we need to send the claim again on paper with the information that was requested? Yes, submit a new, original paper claim with supporting documentation. HFS does not accept reproduced or faxed claims. Please refer to Appendix A-1 of the Chapter 200 Handbook for Practitioners Rendering Medical Services for detailed instructions regarding billing on paper claims. 10) Thanks for the Webinar it answered a lot of my questions but I do have a question. When a patient has Medicare, Medicaid shows that they have Medicare and Medicaid as a second payor but what happens when a Medicare recipient chooses a Medicare replacement policy such as Wellcare, Healthspring, Humana Gold or Aarp Medicare Complete. With any of these plans they have a copay with that ins it could be $5 or $10. Can we bill the patient for the $3.65 with these plans? There is no deductible or coinsurance they pay different then regular Medicare but for office visit they pay 100% and the patient for example pay $5. Can you clarify if the patient can be billed $3.65? Please refer to the Informational Notice dated June 29, 2010 re: Payment of Cost Sharing for Medicare Advantage Plan Members. A patient enrolled in a PFFS plan cannot be billed the HFS co-payment. 11) I have several claims that have denied for the X06 (surgical package previously paid). Our PCP admits and discharges the patient (99222, and 99239). We are not the surgeon billing for the surgery. Please advise on how these claims should be billed to be considered, or is this something that will not be considered for payment due to surgery being paid first. Error code X06 means the department believes the service you are billing has already been paid as a part of another service, either to you or to another provider. Your first step is to follow the instructions in the Chapter 100 Provider Handbook, Appendix 5, and resubmit your claim on paper with supporting documentation. If you continue to receive the rejection, you should contact a billing consultant at 877-782-5565, option 3 then option 1, for resolution to specific examples. 12) If a person has medicare primary & hfs secondary & medicare rejects the procedure code as non covered & we submit it to hfs on a 2360 form with medicare eob and the medicare noncovered letter, do we have 2 years to submit these claims also? No, these are subject to the 180 day timely filing limit. Is Medicare noncovered claims considered the same as Medicare crossover? No, Medicare will not crossover a denied claim. Medicare crossover claims go on a 3797 form. When Medicare says it s noncovered it goes on 2360 form would we still have 2 years or is it 180 days from when medicare responded to file the claim.? These are subject to the 180 day timely filing limit. Any time a client has Medicare primary, Medicaid secondary, the claim must first be submitted to Medicare. Then, regardless of whether Medicare deems the claim payable (crossover) or denied, the claim must be submitted to Medicaid within 180 days of the Medicare adjudication date.
13) Are immunizations for Adults covered by HFS? If so, what is the reimbursement amount on those, is it $6.40 like a child's vaccination? For a list of covered codes and reimbursement amounts please refer to the practitioner fee schedule at: http://www2.illinois.gov/hfs/sitecollectiondocuments/082112fee.pdf 14) If an adult comes in for an injection by the nurse, can we charge an admin injection fee 96372 or do we charge the injection with a nurse visit - a 99211? Please refer to Topic A- 226 Vaccinations/Immunizations in the Chapter 200 Handbook for Practitioners Rendering Medical Services. 15) I had the question about what documentation needs to be sent with a claim for an incomplete Essure (sterilization) procedure and what the appropriate modifier is for the 58565 CPT code. Please refer to Topic A-223.4 Sterilization in the Chapter 200 Handbook for Practitioners Rendering Medical Services for the policy and billing procedures. This claim must be submitted on paper with the appropriately completed sterilization form, as well as the documentation of the failure of the first procedure. There was some background discussion on the topic and it was difficult to discern what was said. If you could reiterate what was discussed on this topic I would be most grateful. 16) I was in the webinar on Sept 19. I m looking at the handout, 4 th screen. The address there for mailing timely filing overrides, is that for 2360 claims or all timely filing (UB04 and 2360 s). This address is for non-institutional claims only. I had thought that UB04 s go to my rep Aimee Isham. That is correct for institutional/hospital (UB04) claims. I was also told that on 2360 claims that a timely filing request was not allowed. An override may be requested for the exceptions to the 180 day timely filing deadline listed on slides 3-4. One additional exception to the slides is a claim submitted following an adjustment. A claim may be voided up to 12 months following the paid voucher date. The provider then has 90 days from the adjustment DCN date to resubmit a claim for payment reconsideration. Thanks for clarifying these things. Multiple questions about clarification on this. Supposedly, it was stated that yes Medicare- Medicaid clients could be charged the applicable HFS copay; and another time it was stated that no, these clients are exempt from copays. Please advise: 17) We were a little confused by the explanation in regards to Medicare/HFS patients. If Medicare is primary do we collect the $3.65 co-pay? No; services for which Medicare is the primary payer are exempt from copays. 18) Per the Webinar on 9/19/12 we can charge the 3.65 co-pay when the patient has a commercial insurance and IPA. Yes
19) Per the Webinar we can t charge the patient the 3.65 co-pay when the patient has Medicare and IPA. Correct My question is about the Medicare replacements. Per IPA memo we can t bill IPA for Medicare replacement plans unless they are PPFS. If we can t bill IPA for the reimbursement then why can t we bill for the 3.65 IPA co-pay for Medicare Replacement plan? Medicare recipients are exempt from being charged a co-payment when enrolled in a PFFS plan. 20) After attending the 09/19/2012 HFS webinar I was still not sure if the Medicaid co-payment should be collected when Medicare is primary. My understanding is that if Medicaid is secondary to an insurance plan the Medicaid co-payment should be collected, even if the insurance payment exceeds the Medicaid allowable and Medicaid pays nothing on the claim. Correct However, I thought I heard someone say that Medicare as primary is an exception. Could you please clarify? Medicare recipients are exempt from being charged a co-payment.