Benefit Administration Basics

1. Benefit Administration Basics Benefit Administration Basics

2. Definitions • Benefits: A schedule of health care servicesthat an eligible member receives for the treatment of illness, injury, or other conditions allowed under the state plan. • Benefit Plan: A group of covered services (benefits) that are granted to a member who is deemed eligible for the services the benefit plan represents. • Assignment Plan: A group of covered services (benefits) where the member is assigned to a provider or provider organization in order to receive covered services (benefits). These services must be provided, or, in some cases, referred by the assigned provider. The services may be reimbursed on a fee for service or capitation basis. The services do not entitle members coverage. The member must also be enrolled in a Benefit Plan that covers the service. Service: Procedure, Diagnosis, NDC, Revenue Code, DRG. • Coverage Rules: Coverage restrictions for services within a Benefit Plan. For example a service may only be covered for specific age ranges. • Provider Contract: A classification of services a Provider can bill. • Provider Contract Billing Rules: Billable rules for a Provider within a contract. For example, a Provider can only bill certain claim types. Benefit Administration Basics

3. Definitions (continued) • Reimbursement Agreement: Rules for selecting a method to reimburse a Provider for services provided to an eligible member • Pricing Method: Rules for which to define the rate type and pricing algorithmfor a reimbursement agreement. For example, use theMax Feealgorithmwith a pediatric rate type for a specific Benefit Plan, Provider Contract, specific PT/PS and age (say under 12 years) combination.. • Benefit Plan Hierarchy: The order in which to process multiple Benefit Plans for a member who is enrolled in more than one plan concurrently. • HIPAA Payer: An entity responsible for the administration of a benefit plan and reimbursement of providers. In the case of Medicaid the State is usually the only other HIPAA payer. However, as an example, if the MMIS also pays benefits on behalf of Counties using county funds, then the Counties may be HIPAA payers as well. • HIPAA Multi-Payer: A system capable of administering and coordinating payments to providers of Health Services among multiple HIPAA Payers. • HIPAA Payer Hierarchy: The order in which to process multiple HIPAA Payer Hierarchy Payers for a member covered by both payers. For example, if two or more HIPAA payers coordinate benefits then the first payer on the hierarchy is the primary payer, the second is the secondary, and so on.. • Thread: A rule (so-to-speak) that dictates the order in which to process multiple Benefit Plans and multiple Payers. Benefit Administration Basics

4. Components: Three Basics Member Benefit Provider Benefit Administration Basics

5. Components: Three Basics Further Defined Member Payer Benefit Pan Covered Benefit HIPAA Payer Benefit Plan Coverage Rules Service Reimbursement Rules Provider Contract Provider Payer Provider Contract Contract Billing Rules HIPAA Payer Benefit Administration Basics

6. Member Payers • A Member may have multiple HIPAA Payers. • Since a Member may have multiple HIPAA Payers, a hierarchy is established to determine what order to process the Payers for the Member. The Hierarchy Thread dictates the order in which the Payers are processed. Payer Hierarchy (Thread) Member Payer Member’s HIPAA Payer Benefit Administration Basics

7. Member Benefit Plans Member’s Payer Payer Member’s Benefit Plan • A Member may have multiple Benefit Plans within the Member’s Payer. • Since a Member may have multiple Benefit Plans, a hierarchy is established to determine what order to process the Benefit Plans for the Member. A hierarchy Thread dictates the order in which the Benefit Plans are processed. • A payer may have multiple Benefit Plans, but a Benefit Plan can have only one payer. Benefit Plan Hierarchy (Thread) Member Member’s Payer Payer Member’s Benefit Plan Benefit Administration Basics

8. Benefit Plan Service Coverage Rules Benefit Plan • A Benefit may be under multiple Benefit Plan Rules within a Benefit Plan. • A Coverage Rule is “matched” by meeting ALL the conditions of the Coverage Rule. For example: • If the benefit is a match … AND • If the ICN processing date is before the inactive date … AND • If the FDOS is within the effective and end date … AND • If the claim type restriction is met … AND • If the Member Age is within the age restrictions … AND • If the POS restrictions are met … AND • If the modifier restrictions are met … AND • If POS PA restrictions are met … AND • If medical review restrictions are met • If a match is not found for ANY (there is at most one) Coverage Rule, the next Benefit Plan is evaluated for that member. Service Covered Benefit Coverage Rules Benefit Administration Basics

9. Provider Contracts • A Provider may have multiple Contracts. Provider Payer Provider Contract Benefit Administration Basics

10. Provider Contract Billing Rules Provider Contract • A Benefit may be under multiple Contract Billing Rules within a Provider Contract. • A Contract Billing Rule is “matched” by meeting ALL the conditions of the Contract Billing Rule. For example: • If the service is a match …AND • If the ICN processing date is before the inactive date … AND • If the FDOS is within the effective and end date … AND • If the claim type restriction is met … AND • If the POS restrictions are met … AND • If the modifier restrictions are met … AND • If medical review restrictions are met • If a match is not found for ANY (there is at most one) Contract Billing Rule, then it is considered that the Provider may not bill for this Benefit under this Contract. Service Payer Contract Billing Rules Benefit Administration Basics

11. Reimbursement Method Coverage Rules Contract Billing Rules • A service is reimbursed based on established reimbursement methods. • A Reimbursement Method can be set up by combinations of Claim Payer, Benefit Plan, Contract, age restrictions, PT/PS restrictions (as examples). Reimbursement Rules Benefit Administration Basics

12. Reimbursement Method Coverage Rules Contract Billing Rules • A Reimbursement Method is “matched” by meeting ALL the conditions of the Pricing Method. For example: • If the FDOS is within the effective and end date… AND • If the Claim Payer is a match … AND • If the Benefit Plan is a match… AND • If the Contract is a match… AND • If the age restrictions are a match… AND • If the PT and PS are a match • If a match is not found for the indicated pricing method then it is considered that the indicated reimbursement method used by the billing rule is not a match. Reimbursement Rules Benefit Administration Basics

13. Fund Code Effective/ End Dates Benefit Plan Provider Type/Specialty Group of Procedures Group of Diagnosis • Fund codes are mentioned here only because there is sometimes confusion between the difference between a benefit plan and a fund code. • Above are some of the variables (or a combination of variables) that have been used to determine Fund Code in Other States (as an example of Fund Code criteria). • Variables used to determine Fund Code for Oregon will be discussed in Financial workgroups. • Please refer to the glossary for the definitions of Fund Code, Fund Code Group, and Fund Payer. These definitions can help determine if the Fund Codes are what is needed versus benefit plans. Age Limits Group of ICD9s Member Level Of Care Billing Provider Family Planning Benefit Administration Basics