HP Provider Relations

1
Third Party Liability

• HP Provider Relations
• October 2010

2
Agenda

• Objectives
• Third Party Liability (TPL) Overview
• TPL Program Responsibilities
• Identifying TPL Resources
• Cost Avoidance
• Claims Processing Requirements
• TPL Update Procedures
• Disallowance Projects
• Questions Answers

3
Objectives

• Define TPL
• Explain the responsibilities of 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
• Answer any questions that may arise during the
  presentation

4
Introduce

• Third Party Liability

5
Introduction to Third Party Liability TPL

• 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
• TPL may be
• A commercial group plan through the members
  employer
• An individually purchased plan
• Medicare
• Insurance available as a result of an accident or
  injury

6
IHCP Payer of Last Resort

• Federal regulation (42 CFR 433.139) establishes
  the IHCP as the payer of last resort
• Exceptions
• Victim Assistance
• First Choice
• Childrens Special Health Care Services (CSHCS)
• These programs are secondary to Medicaid because
  they are fully funded by the State

7
TPL Program Responsibilities

• The IHCP TPL Program supports compliance with
  federal and state TPL regulations and has two
  primary purposes
• Identify IHCP members who have TPL resources
  available
• Ensure that those resources pay before the IHCP

8
Identifying TPL Resources

• The TPL Program has five primary sources of
  information to identify members who have other
  health insurance
• Caseworkers/Division of Family Resources (DFR)
• Member TPL information 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

9
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
• This process is known as cost avoidance

10
Services Exempt from TPL Cost Avoidance

• 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 of the diagnosis and procedure codes that
  are exempt from cost avoidance are listed in the
  IHCP Provider Manual, Chapter 5, Section 2

11
Services Rendered by Out-of-Network Providers

• 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 plans network
• Exception Court-ordered services, such as
  alcohol or drug rehabilitation
• If the primary carrier pays for out-of-network
  services, the IHCP may be billed

12
Liability Insurance

• Liability insurance generally reimburses Medicaid
  for claim payments only under certain
  circumstances
• Example Auto or homeowners 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

13
Liability Insurance

• 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 members
  attorney regarding a personal injury claim
• Contact information
• HP TPL Casualty Unit
• P.O. Box 7262
• Indianapolis, IN 46207-7262
• Telephone [phone] or 1-800-457-4510

14
TPL Credit Balance Letters and Worksheets

• 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 http//provider.indianamedicaid.com

15
Medicare Buy-in Overview

• 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

16
Medicare Buy-in Overview

• 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 individual (QI-1)

17
Medicare Buy-in Qualified Medicare Beneficiary

• QMB-Only
• The members benefits are limited to payment of
  the members Medicare Part A and Part B premiums,
  as well as deductibles and coinsurance for
  Medicare covered services
• Claims for services not covered by Medicare are
  denied as Medicaid non-covered services
• The member should be notified in advance if
  services will not be covered, and if they still
  want to have the service provided they should
  sign a waiver acknowledging they understand they
  will be billed
• QMB-Also
• The members benefits include payment of the
  members Medicare Part A and Part B premiums,
  deductibles and coinsurance, as well as
  traditional Medicaid benefits

18
Learn

• Claims processing requirements

19
TPL Claims Processing Requirements

• TPL identification

• 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

20
TPL Claims Processing Requirements

• 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

21
TPL Claims Processing Requirements

• Billing procedures

• 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 benefit (EOB) is not required
• 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

22
TPL Claims Processing Requirements

• Billing procedures

• 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))

23
TPL Claims Processing Requirements

• Blanket denials

• When a service that is repeatedly furnished to a
  member and repeatedly billed to the IHCP is not
  covered by a third-party insurer, a photocopy of
  the original denial EOB can be used for the
  remainder of the calendar year
• This eliminates unnecessary billing to the
  third-party insurer
• 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 and time frame of the new claim

24
TPL Claims Processing Requirements

• Remittance Advice information

• Claims denying for TPL reasons will have one of
  the following edits
• 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

25
TPL Claims Processing Requirements

• Third-party payer fails to respond (90-day
  provision)

• When a third-party payer fails to respond within
  90 days of a providers 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 )
• Providers NPI number
• 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

26
TPL Claims Processing Requirements

• Insurance carrier reimburses IHCP member

• 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
  Provider 1-800-382-1039

27
TPL Claims Processing Requirements

• TPL payments received after IHCP payments

• 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

28
Describe

• TPL update procedures

29
TPL Update Procedures

• TPL update request on Web interChange

• 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

30
Web interChange Eligibility Inquiry
31
TPL Update Request
32
TPL Update Procedures

• Division of Family Resources (DFR)

• The caseworker or State eligibility worker enters
  TPL information into ICES when members enroll in
  Medicaid
• This information is transmitted nightly to
  IndianaAIM and Web interChange
• Providers that receive TPL information that is
  different from what is in Web interChange should
  immediately report the information to the TPL Unit

33
TPL Update Procedures

• General update procedures

• When forwarding updated TPL information to the
  TPL Unit, include the members 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 [phone] or 1-800-457-4510
• Fax [phone]

34
TPL Update Procedures

• Medicaid Third Party Liability Questionnaire

• The questionnaire is available at the "Forms"
  link athttp//provider.indianamedicaid.com
• The completed questionnaire can be e-mailed to
  INXIXTPLRequests_at_hp.com

35
Detail

• TPL disallowance projects

36
TPL Disallowance Projects

• Medicare

• How the disallowance projects 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

37
TPL Disallowance Projects

• Commercial insurance

• How the Commercial Insurance disallowance
  projects work
• Focus is on hospital providers
• 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

38
Find Help

• Resources Available

39
Helpful Tools

• Avenues of resolution

• IHCP Web site at www.indianamedicaid.com
• IHCP Provider Manual (Web, CD-ROM, or paper)
• Chapter 5 Third Party Liability
• Customer Assistance
• Local [phone]
• All others 1-800-577-1278
• Written Correspondence
• HP Provider Written CorrespondenceP. O. Box
  7263Indianapolis, IN 46207-7263
• Provider field consultant
• TPL Department - [phone] [phone]

40
QA