Third Party Liability
HP Provider Relations
October 2011
Agenda
– Objectives
– Third Party Liability (TPL)
– TPL Program Responsibilities
– TPL Resources
– Cost Avoidance
– Claims Processing Guidelines
– TPL Update Procedures
– Disallowance Projects
– Common Denials
– Questions and Answers
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Third Party Liability
October 2011
Objectives
– Define TPL
– Explain the TPL program
– Provide information on the
sources of TPL information
– Give an overview of TPL claim
processing requirements
– Illustrate how TPL information is
updated
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Third Party Liability
October 2011
Define
Third Party Liability
Third Party Liability – TPL
What is TPL?
– TPL may be:
• A commercial group plan through the member’s employer
• An individually purchased plan
• Medicare
• Insurance available as a result of an accident or injury
Can a member have another insurance in addition to Medicaid?
– Private insurance coverage does not preclude an individual from
having Indiana Health Coverage Programs (IHCP) benefits
• The IHCP supplements other available coverage
• The IHCP is responsible for paying only the State plan authorized medical expenses
that other insurance does not cover
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Third Party Liability
October 2011
Third Party Liability – TPL
Is TPL the primary payer?
Federal regulation (42 CFR 433.139)
establishes the IHCP (Medicaid) as the
payer of last resort
– Exceptions:
• Victim Assistance
• First Choice
• Children’s Special Health Care Services
(CSHCS)
− These programs are secondary to Medicaid
because they are fully funded by the State
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Third Party Liability
October 2011
TPL Program
What are the responsibilities of the TPL program?
– Identify IHCP members who have
TPL resources available
– Ensure that those resources pay
before the IHCP
– Support compliance with federal
and state TPL regulations
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Third Party Liability
October 2011
TPL Resources
How are TPL resources identified?
– Caseworkers/Division of Family Resources (DFR)
• Members provide TPL information, which is updated in Indiana Client Eligibility
System (ICES) and transferred to IHCP
– Providers
•
Providers can report TPL information in writing, by telephone call, via Web
interChange, or by information submitted on claim forms
– Data Matches
•
Data matches are performed with all major insurance companies and reported to
the IHCP
– Hoosier Healthwise Managed Care Entity (MCEs)
•
MCEs report information about members enrolled in their networks
– Medicaid Third Party Liability Questionnaire
•
Providers and members may complete the questionnaire and e-mail, fax, or mail
to the HP TPL Unit
 provider.indianamedicaid.com
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Third Party Liability
October 2011
Cost Avoidance
What is cost avoidance?
– When a provider determines a
member has a TPL resource, that
resource must be billed first
– If the provider bills the IHCP without
proper documentation that the TPL
was billed first, the claim will deny
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Third Party Liability
October 2011
Cost Avoidance
Are all services subject to cost avoidance?
Some services are exempt:
– Pregnancy care
– Prenatal care
– Preventative pediatric care, including Early and Periodic Screening,
Diagnosis, and Treatment (EPSDT/HealthWatch)
– Medicaid Rehabilitation Option (MRO)
– Home and community-based waiver services
– State psychiatric hospitals
– Procedure codes listed on Medicare Bypass Table
• Some diagnosis and procedure codes are exempt from cost avoidance; these
codes are listed in IHCP Provider Manual, Chapter 5, Section 2
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Third Party Liability
October 2011
Cost Avoidance
Are out-of-network provider services covered?
– The IHCP requires that a
member follow the rules of the
primary insurance carrier
– The IHCP does not reimburse for
services rendered out of another
plan’s network
• Exception: Court-ordered services, such
as alcohol or drug rehabilitation
– If the primary carrier pays for outof-network services, the IHCP
may be billed
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Third Party Liability
October 2011
Cost Avoidance
Is liability insurance subject to cost avoidance?
– Liability insurance generally reimburses Medicaid for claim
payments only under certain circumstances
• Example: Auto or homeowner’s policies where liability is established
– Due to the circumstantial nature of this coverage, the IHCP does
not cost-avoid claims based on liability coverage
– If a provider is aware that a member has been in an accident,
the provider may bill the IHCP or pursue payment from the liable
party (the provider is encouraged to bill the third party first)
– If the IHCP is billed, the provider must indicate that the claim is
for accident-related services
– When the IHCP pays accident-related claims, postpayment
research is conducted to identify cases with potentially liable
third parties
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Third Party Liability
October 2011
Cost Avoidance
Is liability insurance subject to cost avoidance?
– When third parties are identified, the IHCP presents all paid claims
associated with the accident to the third party for reimbursement
– Providers are not normally involved in or aware of this recovery
process
– Providers are encouraged to report all identified TPL cases to the HP
TPL Casualty Unit
• Notify the TPL Casualty Unit if a request for medical records is received by an IHCP
member’s attorney regarding a personal injury claim
– Contact information:
HP TPL Casualty Unit
P.O. Box 7262
Indianapolis, IN 46207-7262
Telephone (317) 488-5046 or 1-800-457-4510
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Third Party Liability
October 2011
Cost Avoidance
How are TPL credit balances resolved?
– HP partners with HMS to collect credit balances due to the IHCP
– HMS mails letters and credit balance worksheets to select providers
quarterly
– Refunds are due 60 days from the date of the letter
– Adjustments are processed weekly for providers that want credit
balances subtracted from future payments
– Although letters are sent to selected providers, the credit balance
worksheets can be used by any provider to return overpayments
– Contact HMS Provider Relations at 1-877-264-4854 with questions
– Credit Balance Worksheets and instructions are available at
provider.indianamedicaid.com
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Third Party Liability
October 2011
Cost Avoidance
What is the Medicare Buy-In program?
The state is responsible for initiating Medicare buy-in for eligible
members, and HP coordinates Medicare buy-in resolution with CMS
–
Medicare is generally the primary payer
• Payment of Medicare premiums, coinsurance, and deductibles cost less than
Medicaid benefits
• States receive Federal Financial Participation (FFP) for premiums paid for
members eligible as:
 Qualified
Medicare beneficiary (QMB)
 Qualified
disabled working individual (QDWI)
 Specified
low-income Medicare beneficiary (SLMB)
 Money
grant members Social Security Income (SSI)
 Qualified
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Third Party Liability
individual (QI-1)
October 2011
Cost Avoidance
What is the Medicare Buy-In program?
– Allows states to pay Part B
Medicare premiums for dually
eligible members (members
eligible for both Medicaid and
Medicare)
– Automated data exchanges
between HP and the Centers for
Medicare & Medicaid Services
(CMS) are conducted daily to
identify, update, resolve
differences, and monitor new and
ongoing Medicare buy-in cases
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Third Party Liability
October 2011
Cost Avoidance
What is the difference between QMB only and QMB also?
–
QMB-Only
• The member’s benefits are limited to payment of the member’s Medicare
Part A and Part B premiums, as well as deductibles and coinsurance for
Medicare covered services only
• Claims for services not covered by Medicare are denied
• Members should be notified in advance if services will not be covered; if
they still want to have the service provided, they should sign a waiver
acknowledging they understand they will be billed
–
QMB-Also
• The member’s benefits include payment of the member’s Medicare Part A
and Part B premiums, deductibles and coinsurance, and also traditional
Medicaid benefits
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Third Party Liability
October 2011
Learn
Claims Processing Requirements
TPL Claims Processing Guidelines
How is TPL coverage identified?
– Prior to rendering service, the
provider must verify Medicaid
eligibility using the Eligibility
Verification System (EVS) options:
• Web interChange
• Omni
• AVR (Automated Voice Response system)
– The EVS should also be used to
verify TPL information to determine
if another insurance is liable for the
claim
– The EVS contains the most current
TPL information, including health
insurance carrier, benefit coverage,
and policy numbers on file with the
IHCP
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Third Party Liability
October 2011
TPL Claims Processing Guidelines
Are TPL claims exempt from prior authorization?
– If a service requires prior
authorization by the IHCP, that
requirement must be satisfied,
even if a third party has paid or will
pay a portion of the charge
– Therefore, a provider may have to
obtain prior authorization from the
third party and from the IHCP
– Exception:
• Medicare Part A or Part B covered
charges
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Third Party Liability
October 2011
TPL Claims Processing Guidelines
What information is needed for a TPL claim?
– When submitting claims, the amount paid by the third party
must be entered in the appropriate field on the claim form or
electronic transaction, even if the TPL payment is zero
– If a third party made a payment, the explanation of benefits
(EOB) is not required
• Medicare Replacement Plans always require an EOB
– If the primary insurance denies payment, or applies the
payment in full to the deductible, a copy of the denial EOB
must be attached to the claim
• If the claim is submitted electronically via Web interChange, the EOB may be
submitted by using the "Attachment" feature
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Third Party Liability
October 2011
TPL Claims Processing Guidelines
How are TPL claims paid?
– The IHCP payment will be the total
Medicaid "allowable" amount, minus
what was paid by the primary
insurance
– If the primary insurance payment is
equal to or greater than the total
Medicaid "allowable" amount, the
IHCP payment will be zero
• The member cannot be billed for any
remaining balance, or copayments/
deductibles (refer to 405 IAC 1-1-3 (I))
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Third Party Liability
October 2011
TPL Claims Processing Guidelines
What is a blanket denial?
– When a service that is repeatedly furnished to a member and
repeatedly billed to the IHCP, but is not covered by a thirdparty insurer, a photocopy of the original denial EOB can be
used for the remainder of the calendar year
– The provider is not required to bill the TPL each time
– The provider should write "BLANKET DENIAL" on the original
denial EOB and at the top of the claim form
– The denial reason must relate to the specific services on the
claim
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Third Party Liability
October 2011
TPL Claims Processing Guidelines
What is the 90-day provision?
When a third-party payer fails to respond within 90 days of a
provider’s billing date, the provider can submit the claim to the
IHCP
– Attach one of the following to the claim:
• Copies of unpaid bills or statements sent to the insurance company
• Written notification from the provider indicating the billing dates and explaining
the third-party failed to respond within 90 days
– Boldly indicate the following on the attachments:
• Date of the filing attempts
• The words NO RESPONSE AFTER 90 DAYS
• Member identification number (RID)
• Provider’s National Provider Identifier (NPI)
• Name of TPL billed
– 90-Day No Response claims may be submitted on Web
interChange using the "Notes" feature
• Provide the same information above, as on paper attachments
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Third Party Liability
October 2011
TPL Claims Processing Guidelines
What is the 90-day provision? (Cont.)
– 90-Day No Response claims may be submitted on Web
interChange using the "Notes" feature
• Enter “90 Days No Response” in the note
• Include the name of the TPL that was billed
• List the dates the claim was billed to the TPL
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Third Party Liability
October 2011
TPL Claims Processing Guidelines
What if the member receives the TPL check?
When the insurance carrier reimburses the member:
• Request the member to forward the payment to the provider, or if necessary:
 Notify the insurance carrier the payment was made to the member in error
and request the payment be reissued to the provider
 If unsuccessful, document the attempts made and submit the claim to the
IHCP under the 90-day provision
• In future visits with the member, request the member sign an "assignment of
benefits" authorization form
• Submit the assignment of benefits with the next claim to the insurance carrier
• Providers may report the member to the State contractor if member fraud is
suspected
• Telephone: Member 1-800-446-1993
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Third Party Liability
October 2011
Provider 1-800-382-1039
TPL Claims Processing Guidelines
What if a third party or the member makes payment after IHCP has paid
the claim?
– The provider should submit a
replacement claim via Web
interChange or use the paper
adjustment form
or
– The provider can use the credit
balance reporting process
administered by HMS
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Third Party Liability
October 2011
TPL Claims Processing Guidelines
What are some of the edits applied to TPL claims?
– 2500 – Recipient covered by Medicare A – no attachment
– 2501 – Recipient covered by Medicare A – with attachment
– 2502 – Recipient covered by Medicare B – no attachment
– 2503 – Recipient covered by Medicare B – with attachment
– 2504 – Recipient covered by private insurance – no attachment
– 2505 – Recipient covered by private Insurance – with attachment
– 2510 – Recipient covered by Medicare D
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Third Party Liability
October 2011
Describe
TPL Update Procedures
TPL Update Procedures
Can a provider update a member’s TPL information?
Providers can update TPL information via Web interChange
– From Eligibility Inquiry screen, Third Party Carrier Information
section, click TPL Update Request
– Enter all information about TPL, including "Comments"
– HP TPL Unit will verify and update information within 20
business days
Note: Sending a TPL denial with a claim does NOT update TPL
information in the eligibility system
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Third Party Liability
October 2011
Web interChange – Eligibility Inquiry
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Third Party Liability
October 2011
TPL Update Request
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Third Party Liability
October 2011
TPL Update Procedures
Can a provider update a member’s TPL information?
TPL can be updated by faxing or
calling the TPL Unit
– Include the member’s RID and any
other pertinent data
• Remittance Advice (RA), explanation of
benefits (EOB), carrier letters
– Send updated TPL information to:
HP TPL Unit
Third Party Liability Update
P.O. Box 7262
Indianapolis, IN 46207-7262
Telephone:
(317) 488-5046 or 1-800-457-4510
Fax: (317) 488-5217
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Third Party Liability
October 2011
TPL Update Procedures
Once TPL has been updated, what causes the old information to appear
back in the eligibility?
– The member has not updated the information with the
Division of Family Resources
– A redetermination is completed and the old information is put
back in the Eligibility Verification System
A TPL update has been sent in, why hasn’t the information changed?
– The member may have the TPL coverage for services
provided by other provider specialty types
– The verification of information is pending from the TPL carrier
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Third Party Liability
October 2011
TPL Update Procedures
How do members update their TPL information?
Through the Division of Family Resources (DFR):
– The caseworker or State eligibility worker enters TPL
information into ICES (Indiana Client Eligibility Services)
when members enroll in Medicaid
• The ICES transfer of information occurs within three business days
– This information is transmitted nightly to IndianaAIM and
Web interChange
– Providers receiving TPL information that is different from what
is in Web interChange should immediately report the
information to the TPL Unit
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Third Party Liability
October 2011
TPL Update Procedures
Is there a TPL update form that can be sent in?
– A Medicaid Third Party Liability
Questionnaire is available at the "Forms"
link at
provider.indianamedicaid.com
– The completed questionnaire can be
emailed to INXIXTPLRequests@hp.com
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Third Party Liability
October 2011
Detail
TPL Disallowance Projects
TPL Disallowance Projects
How does the Medicare disallowance project work?
– IHCP identifies Medicaid paid claims that should have been
billed to Medicare as primary
– IHCP will send listings of paid Medicaid claims to providers with
instructions asking them to bill Medicare for the claims paid by
Medicaid and respond within 60 days
– Providers are to report back to IHCP within 60 days by
submitting a Credit Balance Worksheet and to notify Medicaid
as to which claims have been paid by Medicare and which have
been denied
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Third Party Liability
October 2011
TPL Disallowance Projects
How does the Commercial Insurance disallowance project work?
– IHCP identifies Medicaid paid claims that should have been
billed to commercial carriers
– IHCP will send listings of paid Medicaid claims to providers with
instructions asking them to bill the commercial carriers for the
claims paid by Medicaid and respond within 60 days
– Providers are to report back to IHCP within 60 days and notify
Medicaid as to which claims have been paid by the commercial
carrier and which have been denied
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Third Party Liability
October 2011
TPL - Common Denials
What are the top TPL denial codes?
2504 – Recipient is covered by private insurance which must be billed prior to
Medicaid
Claim was filed without information from primary payer
Resubmit claim with TPL information. Verify the claim was filed to the TPL
carrier listed on the eligibility verification
2508 – Your service has been denied. The code billed to Medicaid is not the code
billed to the primary carrier/insurer
Information on the EOB from the primary carrier does not match information
submitted to Medicaid
File claim with the appropriate code
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Third Party Liability
October 2011
Find Help
Resources Available
Helpful Tools
Avenues of resolution
– IHCP Web site at indianamedicaid.com
– IHCP Provider Manual (Web, CD, or paper)
•
Chapter 5 – Third Party Liability
– 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
– TPL Unit
•
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(317) 488-5046 or 1-800-457-4510
Third Party Liability
October 2011
Q&A