Medicare-Related Institutional
Claim Filing
HP Provider Relations
May 2010
Agenda
– Objectives
– What is a Medicare Benefit Exhaust Claim
– Billing Part B Charges
– What is a Medicare Replacement Claim
– What is a Medicare Crossover Claim
– Billing Electronically
– Paper Billing Locators 50 through 54
– Paper Billing Locator 39
– Supporting Documentation
– Helpful Tools
– Questions
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Medicare-Related Institutional Claim Filing
May 2010
Session Objectives
At the end of this session, providers will understand:
– What constitutes a Medicare benefit exhaust claim
– How to bill the Part B charges
– What constitutes a replacement claim
– What constitutes a Medicare crossover claim
– What supporting documentation is required
– How to identify and notate the supporting documentation
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Medicare-Related Institutional Claim Filing
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MEDICARE
EXHAUST
CLAIMS
What Constitutes A Medicare Exhaust
Claim
– Dually eligible member (Medicare and
Medicaid coverage)
– 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
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Medicare-Related Institutional Claim Filing
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Part B Charges
– Part B charges must be billed to
Medicare before billing the exhaust
inpatient claim to IHCP
– Medicare Part B claims automatically
crossover
– Medicare B crossover claim must be
voided before billing the exhaust claim
• Inpatient claim will deny as a duplicate claim if
Part B claim is not voided
– Part B payment must be listed as a
third-party liability (TPL) payment
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Medicare-Related Institutional Claim Filing
May 2010
Electronic Billing Of Medicare Benefit
Exhaust Claim?
– Medicare benefit exhaust claims may be
submitted electronically via Web
interChange using the Attachment feature
– “Benefits Exhausted” must be typed in the
Notes field of the claim submission screen
– The supporting documentation required for
the electronic claim is the same as for the
paper claim
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Medicare-Related Institutional Claim Filing
May 2010
Billing Information
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Medicare-Related Institutional Claim Filing
May 2010
Coordination Of Benefits
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Medicare-Related Institutional Claim Filing
May 2010
Coordination Of Benefits
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Medicare-Related Institutional Claim Filing
May 2010
Claim Note Information
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Medicare-Related Institutional Claim Filing
May 2010
Attachment Information
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Medicare-Related Institutional Claim Filing
May 2010
Attachment Cover Sheet
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Medicare-Related Institutional Claim Filing
May 2010
Benefits Exhausted
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Medicare-Related Institutional Claim Filing
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PAPER
MEDICARE
EXHAUST
CLAIMS
Paper Billing Of Medicare Exhaust Claims
Locators 50 Through 55
– Providers must verify member eligibility to
determine if the patient is enrolled in Traditional
Medicaid including Care Select
– These claims are billed on the UB-04 claim form
– Part B payments are indicated by entering the
word, “Exhaust” in locator 50 on lines a or b
• Do not enter the word “Medicare” on the claim in line 50
– The payment is entered in field 54
– Other commercial payments are entered in the
same manner on line b fields 50 through 55
– Use line c in fields 50 through 55 for the
Medicaid billing
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Medicare-Related Institutional Claim Filing
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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 TPL claims
– All other UB-04 billing policies
apply
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Medicare-Related Institutional Claim Filing
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Medicare Exhaust Claim Address
– Paper claims should be submitted to
the regular IHCP claims address:
HP Institutional Claims
P. O. Box 7271
Indianapolis, IN 46207-7271
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Medicare-Related Institutional Claim Filing
May 2010
Supporting Documentation
– In the top or bottom margin of the UB-04 claim form
boldly write the words:
• “Benefits Exhausted”
– On the top of the MRN or FSS screen print boldly print:
• “Benefits Exhausted”
– The information on the supporting documentation must
match the information presented for Medicaid claim
– Claims are Medicaid primary; all filing limit and prior
authorization rules apply to these claims
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Medicare-Related Institutional Claim Filing
May 2010
Benefits Exhausted
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Medicare-Related Institutional Claim Filing
May 2010
Benefits Exhausted
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Medicare-Related Institutional Claim Filing
May 2010
Benefits Exhausted
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Medicare-Related Institutional Claim Filing
May 2010
MEDICARE
REPLACEMENT
CLAIM
What Is A Medicare Replacement Claim?
– Created by the Balanced Budget
Act of 1997
– Medicare beneficiaries given the
option to receive Medicare benefits
through private health insurance
plans
– Replacement of original Part A and
Part B plan
– Sometimes referred to as
Medicare+Choice, Part C,
Medicare Advantage Plan, or
Medicare HMO
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Medicare-Related Institutional Claim Filing
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How Medicare Replacement
Plans Work
– Plans are approved by Medicare but run by private companies
– Some plans require referrals to see specialists
– Premiums, copays, and deductibles often lower
– Cover all Part A and Part B services
– Often have networks requiring member to use certain doctors and
hospitals
– Offer extra benefits, such as prescription drug coverage
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Medicare-Related Institutional Claim Filing
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Medicare Replacement Plans
– Health Maintenance Organizations (HMOs)
– Preferred Provider Organizations (PPOs)
– Private Fee-for-Service Plans (PFFS)
– Medicare Medical Savings Account (MSA)
– Medicare Special Needs Plans
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Medicare-Related Institutional Claim Filing
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Eligibility Verification
– For a member with a Medicare
Replacement Plan, the Web
interChange Eligibility Inquiry screen
will indicate that the member has
Medicare Part A and Medicare Part B
– No information will appear about the
Medicare Replacement Plan in the
Third Party Carrier section
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Medicare-Related Institutional Claim Filing
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Medicare Replacement Plans – TPL or
Crossover?
– Replacement plans are considered TPL
(Third Party Liability); not Medicare
Crossovers
– This is a critical distinction, as billing
requirements and reimbursement are
different for TPL vs. Crossover
– A Medicare crossover is defined as a claim
billed to the original Part A and Part B plan,
which is covered
– Medicare Replacement Plans, and all other
insurances, other than the original Medicare
Part A and Part B plans, are considered TPL
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Medicare-Related Institutional Claim Filing
May 2010
Electronic Billing Of Medicare Replacement
Plans
– Medicare Replacement Plans will not automatically cross over
from the Medicare carrier to Medicaid
– Medicare Replacement Plans can be submitted via Web
interChange
• Coordination of Benefits information must be entered at the “header” level,
but not required at the “detail” level
• Must use the “Attachment” feature, and mail the replacement policy EOB as
an attachment, along with an Attachment Cover Sheet
• The words “Medicare Replacement Policy” must be written on the
attachment and mailed to HP with an Attachment Cover Sheet
• The words “Medicare Replacement Policy” should be entered in the Notes
section
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Medicare-Related Institutional Claim Filing
May 2010
Electronic Billing Of Medicare Replacement
Plans
– Submit a copy of the Private Insurance EOB
– Standard Medicaid prior authorization rules apply to these
claims
– Standard Medicaid timely filing limits apply to these
claims
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Medicare-Related Institutional Claim Filing
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Web interChange
Claims Processing Menu
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Medicare-Related Institutional Claim Filing
May 2010
Billing Information
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Medicare-Related Institutional Claim Filing
May 2010
Coordination Of Benefits
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Medicare-Related Institutional Claim Filing
May 2010
Coordination Of Benefits
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Medicare-Related Institutional Claim Filing
May 2010
Attachment Information
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Medicare-Related Institutional Claim Filing
May 2010
Claims Attachment Cover Sheet
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Medicare-Related Institutional Claim Filing
May 2010
PAPER
REPLACEMENT
CLAIMS
Paper Billing Of Replacement Claims
Locators 50 Through 55
– Providers must verify member eligibility to
determine if the patient is enrolled in Traditional
Medicaid including Care Select
– These claims are billed on the UB-04 claim form
– The private insurer name or the word
“Replacement” is indicated by entering the
information in locator 50 on lines A or B
• Do not enter the word “Medicare” on the claim
– The payment is entered in field 54
– Other commercial payments are entered in the
same manner on line B in fields 50 through 55
– Use line C in fields 50 through 55 for the
Medicaid billing
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Medicare-Related Institutional Claim Filing
May 2010
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 TPL claims
– All other UB-04 billing policies apply
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Medicare-Related Institutional Claim Filing
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UB-04 Billing – Medicare Replacement
Plans
– Paper claims should be submitted to the regular IHCP
claims address
HP Institutional Claims
P. O. Box 7271
Indianapolis, IN 46207-7271
– Enter the payment received from the Medicare
Replacement Plan in the Prior Payments field 54 A or
B
– Enter the replacement plan name or the word
“replacement” in the Payer Name field 50 A or B
– Do not enter any reference to Medicare in Payer
Name field, as this causes the claim to be treated as a
crossover claim
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Medicare-Related Institutional Claim Filing
May 2010
Support Documentation
– In the top or bottom margin of the UB-04 claim form
boldly write the words:
• “Medicare Replacement Policy”
– On the top of the Commercial EOB boldly print:
• “Medicare Replacement Policy”
• IHCP Member ID number
– The information on the supporting documentation must
match the information presented on the Medicaid claim
– Claims are Medicaid primary; all filing limit and prior
authorization rules apply to these claims
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Medicare-Related Institutional Claim Filing
May 2010
Replacement Claim
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Medicare-Related Institutional Claim Filing
May 2010
Replacement Claim
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Medicare-Related Institutional Claim Filing
May 2010
Replacement Claim
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Medicare-Related Institutional Claim Filing
May 2010
MEDICARE
CROSSOVER
CLAIM
Medicare Crossover Claim Defined
The term, “crossover claim” applies when a member has Medicare as
the primary insurance, and:
– The Medicare coverage is from traditional Medicare, not one of the
Medicare Replacement (or Medicare HMO) plans
– Medicare issued a payment of any amount, or the entire payment
was applied to the deductible
A claim is not a crossover claim when:
– The member’s primary insurance is not traditional Medicare
– Medicare denied the entire claim
– It is a Medicare benefit exhaust claim
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Medicare-Related Institutional Claim Filing
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Why Claims Do Not Automatically Cross
Over
Following are some of the reasons why claims fail to
cross over from Medicare automatically
– The Medicare intermediary is not National
Government Services (NGS) or is not an
intermediary that has a partnership agreement with
HP
– Ambulatory surgical center (ASC) claims billed to
Medicare on a CMS-1500 claim form with the SG
modifier
– Data errors on the crossover file
• Examples include incorrect Social Security
number (SSN) or spelling of member name
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Medicare-Related Institutional Claim Filing
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Claim Filing Limit
– The standard filing limit for Medicaid
claims is one year from the date of
service
– Crossover claims are not subject to the
one-year filing limit
• Crossover claims may be submitted and
processed irrespective of the age of the claim
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Medicare-Related Institutional Claim Filing
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Claims Partially Paid By Medicare
When Medicare allows only some of the services on a
non-surgical outpatient claim:
–Only the Medicare-allowed services apply to
crossover logic
•
These services should be billed to Medicaid separately from the
Medicare-denied services
•
Providers should not send the Medicare Remittance Notice
(MRN) to Medicaid when billing these services
–Only the Medicare-allowed services are exempt from
the one-year filing limit
–Services denied by Medicare are subject to the oneyear filing limit
•
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These services should be billed separately to Medicaid with a
copy of the MRN
Medicare-Related Institutional Claim Filing
May 2010
Web interChange – Claims Processing
Menu
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Medicare-Related Institutional Claim Filing
May 2010
Institutional Claim
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Medicare-Related Institutional Claim Filing
May 2010
Coordination Of Benefits
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Medicare-Related Institutional Claim Filing
May 2010
Coordination Of Benefits
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Medicare-Related Institutional Claim Filing
May 2010
PAPER
CROSSOVER
CLAIMS
How To Bill A Crossover Claim
– Identify Medicare Remittance Notice (MRN) information in field 39 as
follows:
• Value Code A1 – Medicare deductible amount
• Value Code A2 – Medicare coinsurance amount
• Value Code 06 – Medicare blood deductible amount
• Value Code 80 – IHCP covered days
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Medicare-Related Institutional Claim Filing
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Crossover Claim
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Medicare-Related Institutional Claim Filing
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HELPFUL TOOLS
Avenues of resolution
Helpful Tools
Avenues of resolution
– IHCP Web site at
www.indianamedicaid.com
– IHCP Provider Manual (Web, CD-
ROM, or paper)
– Customer Assistance
• Local (317) 655-3240
• All others 1-800-577-1278
• Written Correspondence
• HP Provider Written Correspondence
P. O. Box 7263
Indianapolis, IN 46207-7263
• Provider field consultant
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Medicare-Related Institutional Claim Filing
May 2010
Q&A
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