UB-04 Medicare
Exhaust Claims
HP Provider Relations
October 2011
Agenda
– Objectives
– What is a Medicare Exhaust Claim
– Billing Part B Charges
– Billing Electronically
– Completing Paper Claim Form Fields
Correctly
– Support Documentation
– Common Denials
– Helpful Tools
– Questions
2
UB-04 – Medicare Exhaust Claims
October 2011
Objectives
At the end of this session, providers will understand:
– What constitutes a Medicare Exhaust claim
– How to bill the Part B charges
– How to bill a Benefit Exhaust claim electronically
– How to bill a Benefit Exhaust claim on the UB-04 claim form
– How to identify and notate the supporting documentation
– What denials are commonly associated with billing issues
associated with a Medicare Benefit Exhaust claim
3
UB-04 – Medicare Exhaust Claims
October 2011
Learn
Medicare Exhaust Claims
What Constitutes a Medicare Exhaust
Claim?
– Dually eligible member (Medicare and
Medicaid coverage)
– Indiana Health Coverage Programs
(IHCP) member has exhausted his or
her Medicare Part A benefits
– Benefits exhaust prior to the admission
for an inpatient stay
– Medicare Remittance Notification
(MRN) or online Florida Shared System
(FSS) printout indicating exhaust status
must accompany the claim to Medicaid
– Do not bill the IHCP for partial
inpatient stays
5
UB-04 – Medicare Exhaust Claims
October 2011
Part B Charges
– When Part B charges are billed to
Medicare before billing the
exhaust inpatient claim to IHCP
– Medicare Part B claims
automatically cross over
• Must void the Medicare B crossover claim
to prevent the Inpatient claim from
denying as a duplicate claim
– Must enter the Part B Medicare
payment as a third-party liability
(TPL) payment
6
UB-04 – Medicare Exhaust Claims
October 2011
Bill
Electronic Exhaust Claims
Billing Electronically
– Medicare Benefit Exhaust claims
may be submitted electronically
via Web interChange using the
Attachment feature
– The supporting documentation
required for the electronic claim is
the same as for the paper claim
8
UB-04 – Medicare Exhaust Claims
October 2011
Billing Information
9
UB-04 – Medicare Exhaust Claims
October 2011
Coordination of Benefits
10
UB-04 – Medicare Exhaust Claims
October 2011
Coordination of Benefits
11
UB-04 – Medicare Exhaust Claims
October 2011
Billing Information
12
UB-04 – Medicare Exhaust Claims
October 2011
Attachment Information
13
UB-04 – Medicare Exhaust Claims
October 2011
Claims Attachment Cover Sheet
Information entered
must match the
claim exactly
14
UB-04 – Medicare Exhaust Claims
October 2011
Bill
Paper Exhaust Claims
Paper Billing
Locators 50 through 55
– Part B payments are indicated by entering the
word, “Exhaust” in locator 50 on line b of the
UB-04 claim form
• Do not enter the word “Medicare” in field 50
– The payment is entered in field 54b from Part B
– Commercial payments are entered in the same
manner
– Use line c in fields 50 through 55 for the
Medicaid billing
16
UB-04 – Medicare Exhaust Claims
October 2011
Paper Billing
Locator 39
– Using value code 80, enter the
covered days
– Do not enter value codes for
deductible and coinsurance or
blood deductible
• A1, A2, or 06
– These claims are processed like
TPL claims
– All filing limit and prior authorization
rules apply
– All other UB-04 billing policies
apply
17
UB-04 – Medicare Exhaust Claims
October 2011
Paper Claim Billing/Benefits Exhausted
18
UB-04 – Medicare Exhaust Claims
October 2011
Benefits Exhausted
19
UB-04 – Medicare Exhaust Claims
October 2011
Benefits Exhausted
ACN # 1234567
Benefits Exhausted
Member 111222333999
20
UB-04 – Medicare Exhaust Claims
October 2011
Support Documentation
– In the top margin of the UB-04 claim form, boldly write the
words:
• “Benefits Exhausted”
– On the top or bottom of the MRN and/or FSS screen print,
boldly write:
• “Benefits Exhausted”
– The information on the supporting documentation must
match the information presented for Medicaid claim
21
UB-04 – Medicare Exhaust Claims
October 2011
Deny
Common Denials
Common Denials
0558 - Coinsurance and deductible amount missing
– Cause
• The word “Medicare” has been entered in field 50 on lines a or b
– Resolution
• Remove the word “Medicare” and enter the word “Exhaust” in
50B
23
UB-04 – Medicare Exhaust Claims
October 2011
Common Denials
2501 – This recipient is covered by Medicare Part A;
therefore, you must first file claims with Medicare
– Cause
• Claim has not been submitted indicating “Benefits Exhausted”
– Resolution
• Write the words “Benefits Exhausted” in the top margin of the UB-04
claim form and on all attachments
• Type the words “Benefits Exhausted” in the “Description” section of the
Attachment window
24
UB-04 – Medicare Exhaust Claims
October 2011
Find Help
Resources Available
Helpful Tools
Avenues of resolution
– IHCP website at
indianamedicaid.com
– Provider Enrollment
•
1-877-707-5750
– Customer Assistance
•
1-800-577-1278, or
•
(317) 655-3240 in the Indianapolis local area
– Written Correspondence
•
P.O. Box 7263
Indianapolis, IN 46207-7263
– Provider Relations field consultant
26
UB-04 – Medicare Exhaust Claims
October 2011
Q&A