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IHCP Timely Filing Guidelines and Examples

Learn about the revised timely filing limit for IHCP claims, exclusions, and claim examples for Medicaid, Medicare, and TPL. Understand exceptions and correct filing procedures to avoid claim denials.

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IHCP Timely Filing Guidelines and Examples

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Presentation Transcript

  1. Tips and Reminders

  2. Agenda • Timely Filing • Presumptive Eligibility • Charging Members • Helpful Tools • Q&A

  3. Timely Filing

  4. Timely Filing BT201829 The Indiana Health Coverage Programs (IHCP) revised the timely filing limit on claims for services rendered through the fee-for-service (FFS) delivery system, with dates of service (DOS) on or after January 1, 2019, to 180 calendar days from DOS. NOTE: The current 1-year timely filing limit will continue to apply to claims with DOS or dates of discharge on or before December 31, 2018.

  5. Timely FilingExclusions • The circumstances excluded from the timely filing limit will remain unchanged: • Crossover claims – Medicare or Medicare Replacement Plan primary claims containing paid services (including services that paid at zero, due to deductibles) are not subject to the 180-day timely filing limit. • Note: If Medicare or a Medicare Replacement Plan denies a claim, the 180-day limitation applies to the Medicaid claim. • Overpayment adjustment requests – These requests are not subject to the 180-day timely filing limit. • Any overpayment identified by a provider must be returned to the IHCP, regardless of the 180-day filing limit. • The overpayment adjustment must be submitted with an explanation attached to justify partial recoupment; otherwise,the claim will be processed and recouped in its entirety.

  6. Timely FilingClaim Examples Medicaid Primary Claim Example: • Date of service on the claim: 1/15/2019 • Claim filed on 1/20/2019 – claim denied • Claim filed on 2/10/2019 – claim denied • Timely filing limit – 7/13/2019 – 180 days from date of service • Repeatedly filing the claim does not extend the timely filing. COUNT THE DAYS !!

  7. Timely FilingClaim Examples Medicare/Medicare Replacement Plan Medicaid Secondary Primary COVERED the service • Example: • Date of service on the claim: 1/15/2019 • No limit to timely filing

  8. Timely FilingClaim Examples TPL Primary Medicaid Secondary Primary COVERED the service Timely filing is 180 days from date of service. • Exception: When primary payment is made past 180 days from the date of service, the primary explanation of benefits (EOB) can be used to extend the timely filing – the EOB is required as an attachment. • Date on EOB should be circled – note on EOB “use this date to waive filing” • Add claim note stating “primary EOB attached to waive timely filing” • Claim will suspend for review of documentation.

  9. Timely FilingClaim Examples Medicare/Medicare Replacement Plan or TPL Medicaid Secondary Primary DENIED the service Timely filing is 180 days from date of service. • Exception: When date of primary denial is past 180 days from the date of service, the primary EOB can be used to extend the timely filing – the EOB is required as an attachment. • Date on EOB should be circled – note on EOB “use this date to waive filing” • Add claim note stating “primary EOB attached to waive timely filing” • Claim will suspend for review of documentation.

  10. Timely FilingClaim Examples Inpatient Claim Medicaid Primary • 180-day limit is based on the member’s date of discharge. • Claim example: • Inpatient admission – 1/1/2019 – discharge 1/15/2019 • Claim filed on 1/20/2019 – claim denied • Claim filed on 2/10/2019 – claim denied • Timely filing limit – 7/13/2019 – 180 days from date of discharge • Repeatedly filing the claim does not extend the timely filing • Inpatient admission 12/15/2018 – discharge 12/31/2018 • 365 days from the date of discharge

  11. Timely FilingClaim Examples Inpatient Claim Medicare/Medicare Replacement Plan Medicaid Secondary Primary COVERED the service • Example: • Inpatient admission 1/1/2019 – discharge 1/15/2019 • No limit to timely filing

  12. Timely FilingClaim Examples Inpatient Claim TPL Primary Medicaid Secondary Primary COVERED the service Timely filing is 180 days from date of discharge. • Exception: When primary payment is made past 180 days from the date of discharge, the primary EOB can be used to extend the timely filing – the EOB is required as an attachment. • Date on EOB should be circled – note on EOB “use this date to waive filing” • Add claim note stating “primary EOB attached to waive timely filing” • Claim will suspend for review of documentation.

  13. Timely FilingClaim Examples Inpatient Claim Medicare/Medicare Replacement Plan or TPL Medicaid Secondary Primary DENIED the service Timely filing is 180 days from date of discharge. • Exception: When date of primary denial is past 180 days from the date of discharge, the primary EOB can be used to extend the timely filing – the EOB is required as an attachment. • Date on EOB should be circled – note on EOB “use this date to waive filing” • Add claim note stating “primary EOB attached to waive timely filing” • Claim will suspend for review of documentation.

  14. Timely FilingReasons for Extending Timely Filing Reasons for extending the timely filing limit (beyond the 180 days) are unchanged: • Retroactive member eligibility • Timely filing limit is extended to 180 days from the date eligibility was established. Documentation must be submitted with the claim identifying retroactive eligibility. • Prior authorization (PA) for a service is approved retroactively • Timely filing limit is extended to 180 days from the date the PA was approved. A copy of the approved PA stating “retroactive prior authorization” must be included as an attachment to the claim. • IHCP policy change effective retroactively • Timely filing limit is extended to 180 days from the date of publication of the policy change. A copy of the publication must be included as an attachment to the claim.

  15. Timely FilingReasons for Extending Timely Filing • Waiver providers • Timely filing limit is extended to 180 days from the date a plan of care was issued. • Proof that a plan of care was issued late or copies of the review findings letter from an audit must be submitted. • Third-party payer notification is delayed • Timely filing limit is extended to 180 days from the date on the EOB from a primary payer. • A copy of the primary payer’s EOB must be included as an attachment to the claim. • Indicate the date to be used for timely filing • Lack of timely filing is due to an error or action by DXC Technology, OptumRx, or the State • Claim must be submitted with documentation that clearly identifies • the error or action that delayed proper adjudication of the claim.

  16. Timely Filing Timely filing limits associated with managed care claims for Healthy Indiana Plan (HIP), Hoosier Care Connect, and Hoosier Healthwise members are established and published by the managed care entities (MCEs). Related questions should be directed to the appropriate MCE.

  17. Presumptive Eligibility

  18. Presumptive Eligibility BT201862 • Effective January 1, 2019, PE Adults are served under fee- for-service (FFS): • PE Adult applications do not require a managed care entity (MCE) selection. • The PE Adult benefit plan mirrors Healthy Indiana Plan (HIP) Basic benefits. • As with HIP Basic, under the PE Adult benefit plan, copayments are required for many services. • Providers should refer to the Healthy Indiana Plan and Presumptive Eligibility provider reference modules at the IHCP Provider Reference Modules web page at in.gov/medicaid/providers for detailed benefit information.

  19. Presumptive Eligibility • Providers should be aware that any enhanced benefits that may have been covered for PE Adult members under the managed care delivery system will not be covered under the FFS delivery system: • Prenatal/maternity • Nonemergency medical transportation services • If a PE Adult member becomes pregnant, a provider can email PresumptiveEligibility@fssa.IN.gov so the member’s benefit plan can be changed to PE for Pregnant Women. Prenatal and maternity services will then be covered. • These services will also be covered retroactively if the member is ultimately determined to be eligible for this coverage based on her full IHCP application.

  20. Presumptive Eligibility • Prior authorization (PA) requests and claims for these members will be processed through the FFS vendors as follows: • Nonpharmacy claims will be processed by DXC Technology. • Nonpharmacy PA requests will be processed by Cooperative Managed Care Services (CMCS). • Pharmacy claims and PA requests will be processed by OptumRx.

  21. Charging Members

  22. Charging Members Covered Services • Medicaid reimbursement for covered services is considered to be payment in full. • Members, or their families, cannot be billed in excess of the amount paid by Medicaid, except for: • Applicable copayments • Home and Community-Based Services (HCBS) waiver liability (previously known as spend-down) • Nursing facility patient liability • Liability and copayments that can be billed to the member will be listed as “Patient Responsibility” on the Remittance Advice • Members cannot be charged for missed appointments, or copying of medical records.

  23. Charging Members Noncovered Services • A member may be charged for noncovered services (including covered services when the benefit has been exhausted), as long as they have been informed, before receiving the service, that the service will not be covered and they will be responsible for the charges. • The provider must maintain documentation in the member’s file that clearly demonstrates that the member voluntarily chose to receive the service, knowing it was not covered by Medicaid. • A “waiver” form is not specifically required, but is highly recommended. • If a waiver form is used, it must not include conditional language such as “if Medicaid does not cover the service, the member is financially responsible”.

  24. Charging MembersCertain Benefit Plans • For purposes of charging members, some benefit plans are not considered to be Medicaid programs, and providers may follow their standard “self-pay” billing and collection procedures, without following the advance notification and documentation requirements described on the previous slide. • These benefit plans include: • Medical Review Team (MRT) • Preadmission Screening and Resident Review (PASRR) • Qualified Disabled Working Individual (QDWI) • Qualified Individual (QI) • Specified Low-Income Medicare Beneficiary (SLMB)

  25. Charging Members Exceptions • Additional exceptions where a provider may bill the member without the advance notification and documentation requirements would include: • Situations where the provider took appropriate action to ascertain and identify a responsible payer of service • Situations when a member fails to advise the provider of Medicaid eligibility • Providers should refer to the Provider Enrollment provider reference module for additional information on charging members.

  26. Helpful Tools

  27. Helpful Tools Provider Relations Consultants

  28. Helpful Tools • IN.Gov: • IHCP Provider Reference Modules • Medical Policy Manual • Contact Us – Provider Relations Field Consultants • Customer Assistance available: • Monday – Friday, 8 a.m. – 6 p.m. Eastern Time • 1-800-457-4584 • Secure Correspondence: • Via the Provider Healthcare Portal • Written Correspondence: • DXC Technology Provider Written CorrespondenceP.O. Box 7263Indianapolis, In 46207-7263

  29. Questions

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