CMS-1500 Billing Medicare Replacement Plans

1. CMS-1500 BillingMedicare Replacement Plans HP Provider Relations October 2010

2. Agenda Session Objectives What is a Medicare Replacement Plan? How Medicare Replacement Plans Work Who May be included in Medicare Replacement Plans Medicare Replacements - TPL or Crossover? Eligibility Verification CMS-1500 Billing for Replacement Plans Related Web interChange Features Reimbursement for Replacement Plans Helpful Tools Questions

3. Session Objectives Following this session, providers will be able to: • Provide a clear definition of Medicare Replacement Plans and how they work • Explain the critical differences between Medicare Crossovers and Medicare Replacement Plans • Clearly define the CMS-1500 electronic and paper billing requirements for replacement plans

4. Learn Medicare Replacement Plans

5. What Is a Medicare Replacement Plan? • 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, Medicare Advantage Plan, or Medicare HMO

6. How 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

7. 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

8. Medicare Replacement Plans – TPL or Crossover? • Replacement plans must be submitted with the Remittance Advice • These claims are not Medicare Crossovers • This is a critical distinction, as billing requirements and reimbursement are different for TPL vs. crossover claims • A Medicare crossover is defined as allowed line items billed to Traditional Medicare Part A and/or Part B • Medicare Replacement Plans and all other private insurances are considered TPL

9. 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

10. Bill CMS-1500 Claims

11. CMS-1500 Billing – 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 Medicare Remittance Notice (EOB) as an attachment, along with an Attachment Cover Sheet • The words “Medicare Replacement Policy” must be written on the attachment

12. CMS-1500 Billing – Medicare Replacement Plans • Paper claims should be submitted to the regular IHCP claims address, not to the crossover address • HP CMS-1500 ClaimsP.O. Box 7269Indianapolis, IN 46207-7269 • Enter the payment received from the Medicare Replacement Plan in field 29 • If payment is zero, enter 0.00 in field 29 • Field 28 minus field 29 must equal field 30 • Field 22 should be totally blank; do not put 0.00

13. CMS-1500 Billing – Medicare Replacement Plans • Attach a copy of the Replacement plan EOB • The words “Medicare Replacement ” must be written at the top of the claim form and at the top of the attachments • Standard Medicaid prior authorization rules apply to these claims • Standard Medicaid timely filing limits apply to these claims

14. CMS-1500 Billing – Medicare Replacement Plans • The following slides illustrate how to access the Web interChange screens to enter benefit information for Medicare Replacement Plans and Attachment and Description information

15. Claims Processing Menu

16. Professional Claim

17. Coordination of Benefits

18. Coordination of Benefits

19. Attachment Information

20. Claims Attachment Cover Sheet

21. Reimbursement for Replacement Plan • Medicare Replacement Plan reimbursement is equal to the Medicaid “allowable” minus the payment from the Medicare Replacement Plan carrier • Reimbursement is based on the aggregate (totals), not line-by-line calculations • The excess of the provider’s charges over the combined Medicare and Medicaid payments must be written off; it cannot be charged to the member

22. Deny Most Common Denial

23. Most Common Denial Code Edit 2503 – Recipient Covered by Medicare Part B or D (with attachment) • Cause – The member is covered by Medicare Part B and has a Medicare Replacement Plan, but the attachment does not adequately document the replacement plan • Resolution • On electronic claims • Make sure the attachment process was followed • Indicate payment and all other information in the benefits information section • On paper claims • Indicate Medicare Replacement Plan payment is in field 29 • Write “Medicare Replacement Policy” at the top of the claim and the attached Medicare remittance notice • Make sure field 22 is entirely blank

24. Find Help Resources Available

25. Helpful Tools Avenues of resolution IHCP Web site at www.indianamedicaid.com IHCP Provider Manual (Web, CD-ROM, or paper) Customer Assistance • 1-800-577-1278, or • (317) 655-3240 in the Indianapolis local area Written Correspondence • P.O. Box 7263Indianapolis, IN 46207-7263 Provider field consultant

26. Q&A