Thursday, April 28, 2016

Submitting secondary cliams with Medicare EOB


MEDICARE/MEDICAL ASSISTANCE CROSSOVER CLAIMS

When a Medical Assistance provider bills Medicare Part B for services rendered to a MA recipient, and the provider accepts assignment on the claim (Block #27), Medical Assistance pays the provider the Medicare coinsurance and/or deductible amount(s) in full less any other third party payments (i.e., Medigap). In order for claims to be accurately cross-referenced to your Medicaid provider number, be sure to advise the Claims Processing/Medicare Crossover Unit of your Medicare provider number and NPI number so that all provider numbers can be properly linked in the Medicaid system. Requests to add, change, or delete information on the Medicare crossover file must be sent in writing to the address below Attention: Jack Collins or call 410-767-5559.


PROCEDURES FOR SUBMITTING HARDCOPY MEDICARE CLAIMS

Billing a CMS-1500 with a Medicare EOMB:

On the Medicare EOMB, each individual claim is generally designated by two horizontal lines. Therefore, you should complete one CMS-1500 form per set of horizontal lines.

• When billing Medical Assistance, the information on the CMS-1500 must be identical to the information that is between the two horizontal lines on the Medicare EOMB.

o Dates of service must match

o Procedure codes must match

o Amount(s) on line #24F of the CMS-1500 must match the “amount billed” on the EOMB.

• When submitting your Medicare claims for payment, the writing should be legible. In addition, when attaching a copy of the Medicare EOMB make sure it is clear and that the entire EOMB, including the information on the top and the glossary is included on the copy. In order for MA to pay for co-insurance and deductibles, the CMS-1500 and the Medicare EOMB must be submitted. Claims
should be sent to the original claims address:

                                               Maryland Medical Assistance
                                                   Claims Processing
                                                     P.O. Box 1935
                                                 Baltimore, MD 21203

Friday, April 22, 2016

CMS 1500 Filling Guideline for Hospital date, EPSDT, and patient amount

The Center of Medicaid and Medicare Services (CMS) form 1500 must be used to bill SFHP for
medical services. The form is used by Physicians and Allied Health Professionals to submit
claims for medical services. All items must be completed unless otherwise noted in these

instructions. A CMS 1500 with field descriptions and instructions is included in the link below:

Box 18 If Applicable Hospitalization Dates Related to Current Services - Enter the date of hospital admission and discharge if the services billed are related to hospitalization. If the patient has not been discharged, leave the discharge date blank.

Box 20 If Applicable Outside Lab? - Check "yes" when diagnostic test was performed by any entity other that the provider billing the service. If this claim includes charges for laboratory work performed by a licensed laboratory, enter and "X". "Outside Laboratory refers to a laboratory not affiliated with the billing provider. State in Box 19 that a specimen was sent to an unaffiliated laboratory.

Box 24H If Applicable EPSDT Family Plan - Enter code “1” or “2” if the services rendered are related to family planning (FP). Enter code “3” if the services rendered are Child Health and Disability Prevention (CHDP) screening related

Box 26 optional Patient's Account Number -Enter the patient’s medical record number or account number in this field. This number will be reflected on Explanation of Benefits (EOB) if populated

Box 29 If Applicable Amount Paid - Enter the amount of payment received from the Other Health Coverage. Enter the full dollar amount and cents. Do not enter Medicare payments in this box. Do not enter decimals.

Box 30 If Applicable Balance Due - Enter the difference between the Total Charges and the Amount Paid in full dollar amount and cents. Do not enter decimals.

Saturday, April 16, 2016

For What box 19 - Reserved for local use box used.

Box 19 If Applicable Reserved for Local Use - 

Use this area for procedures that require additional information, justification or an Emergency Certification Statement.

• This section may be used for an unlisted procedure code when explanation is required and clinical review is required.

• If modifier “-99” multiple modifiers is entered in section 24d, they should be itemized in this section.

All applicable modifiers for each line item should be listed.

• Claims for “By Report” codes and complicated procedures should be detailed in this section if space permits.

• All multiple procedures that could be mistaken for duplicate services performed should be detailed in this section.

• Anesthesia start and stop times.

• Itemization of miscellaneous supplies, etc.



Box 2. Services rendered to an infant may be billed with the mother’s ID for the month of birth and the month after only. Enter “Newborn using Mother’s ID”/ “(twin a) or (twin b)” in the Reserved for Local Use field (Box 19).





Tuesday, April 12, 2016

UB 04 Medicare Crossover for Other Blue Plan Members


(UB-04)

Completing a claim correctly when a member from another Blue Cross and/or Blue Shield Plan has primary coverage with Medicare will decrease your chance of receiving claim denials. The following instructions apply to items on the UB-04 form or its electronic counterpart that require specific Medicare Supplement information:

Form Locator 50 – Payer

• Enter “Medicare” as the primary payer on line A.

• Enter the appropriate Blue Plan name as the secondary payer on line B.

o Not entering the member’s actual Blue Plan as the correct secondary payer will result in claim issues. A claim crossed over in error to BCBSF cannot be processed and you may not receive a remittance notice. Therefore, be sure to enter the correct Blue Plan when you submit the claim to Medicare. If your system is set-up to automatically populate BCBSF, please change it to the correct Blue Plan.

o If you do not know the member’s Blue Plan, call BlueCard Eligibility at (800) 676-BLUE (2583), speak the alpha prefix and you will be routed to the member’s Blue Plan.


Form Locator 53 – ASG BEN

• A “Y “indicating benefits were assigned must be entered in order for you to receive payment from the Blue Plan.

• This indicator authorizes payment of mandated Medigap benefits to you if required Medicare Supplement information is included on the claim.

• The member or representative’s signature must be on file as a separate Medigap authorization.

• The Medigap assignment on file must specify the insurer. It may state that the authorization applies to all occasions of service until it is revoked.



Form Locator 54 – Prior Payments

• Enter the amount you have received toward payment of this bill from Medicare on line A.


Form Locator 58 – Insured’s Name

• Enter the last name, first name and middle initial of the insured. The name must be entered exactly as it is on the ID card.

Form Locator 59 – P. Rel

• Enter the appropriate code indicating the relationship of the patient to the insured (e.g., code 18 = self).


Form Locator 60 – Insured’s Unique ID

• Enter the patient’s Medicare HIC number as shown on the ID card on line A.

• Enter the patient’s complete Blue Plan ID number, including three-digit alpha prefix on line B. Member IDs for other Blue plans include the alpha prefix in the first three positions and can contain any combination of numbers and letters up to 17 characters.
Form Locator 61 – Group Name

• Enter the name of the group or plan through which the insurance is provided to the member.

Form Locator 62 – Insurance Group No.

• Enter the group number as identified on the ID card.

Friday, April 8, 2016

Medicare Crossover for Other Blue Plan Members (CMS-1500) - What box to fill out

Completing a claim correctly when a member has primary coverage with Medicare and secondary coverage (Medicare Supplement) from another Blue Plan will decrease your chance of receiving claim denials. The following instructions apply to items on the CMS-1500 form or its electronic counterpart that require specific Medicare Supplement information:

Item 9

• Enter the last name, first name and middle initial of the member if it is different from that shown in Item 2. Otherwise, you may enter the word “SAME”. If no Medigap benefits are assigned, leave blank.

Item 9a

• Enter the Medicare Supplement member’s policy and/or group number preceded by MEDIGAP, MG, or MGAP.

• Item 9d must be completed if you enter a policy and/or group number in 9a.


Item 9b

• Enter the birth date (MM/DD/YYYY) and gender of the member.

Item 9c

• Leave this field blank if the Blue Plan secondary payer’s name is entered in 9d.

• Enter the correct Blue Plan name as the secondary carrier in 9c. For example, if the member has a Medicare Supplement with Blue Cross and Blue Shield (BCBS) of Michigan, then BCBS of Michigan should be indicated as the secondary carrier, not Blue Cross and Blue Shield of Florida (BCBSF). Use an abbreviated street address, two letter postal code, and zip code copied from the member’s Medicare Supplement ID card. For example: 1234 Anywhere St, MD 12345.

Item 9d

• Enter the correct Blue Plan name as the secondary carrier.

Note: All information must be complete and accurate in items 9, 9a, 9b, 9c and 9d of the CMS-1500 form in order for the Medicare carrier to be able to forward claim information. If prior arrangements have been made with the private insurer, the carrier will forward the Medicare information electronically. Otherwise, the carrier will forward a hard copy of the claim to the private insurer.

Item 11d

• If you submit a claim with a Medicare Remittance Notice attached, always mark “YES” in 11d.

• If you mark “NO” in 11d, the claim will pass through the system but attachments will not be reviewed.

• If your billing system is hard-coded to mark “NO” automatically in 11d, please manually override your system to mark “YES” when submitting a claim with the Medicare Remittance Notice attached.


Item 13

• The signature in this item authorizes payment of mandated Medigap benefits to a participating physician or supplier if required Medicare Supplement information is included in items 9 through 9d.

• The member or member’s representative must sign this item or the signature must be on file as a separate Medigap authorization.

• The Medigap assignment on file in the participating physician or supplier’s office must specify the insurer. It may state that the authorization applies to all occasions of service until it is revoked.

Monday, April 4, 2016

Why Medicare cross over not happening automatically - some basic reason to check.

MEDICARE CROSSOVER CLAIMS

Medicare/MO HealthNet (crossover) claims that do not automatically cross from Medicare to MO HealthNet must be filed through the MO HealthNet billing Web site, www.emomed.com or through the 837 electronic claims transaction. It is advised providers wait sixty (60) days from the date of Medicare’s explanation of benefits (EOMB) showing payment before filing an electronic claim. This will avoid possible duplicate payments from MO HealthNet.

Claims may not cross over from Medicare to MO HealthNet for various reasons. Two of the most common reasons are as follows:

• Invalid participant information on file causes many claims to not cross over electronically from Medicare. Participants not going by the same name with Medicare as they do with MO HealthNet will not cross over electronically. Additionally, the participant’s Medicare Health Insurance Claim number (HIC) in the MO HealthNet eligibility file must match the HIC number used by the provider to submit to Medicare. It is the responsibility of the participant to keep this information updated with their Family Support Division Eligibility Specialist.

• MO HealthNet enrolled providers who have not provided their National Provider Identifier (NPI) used to bill Medicare to the Missouri Medicaid Audit Compliance (MMAC), Provider Enrollment Section, also causes claims to not cross over electronically from Medicare. Providers in doubt as to what NPI is on file should contact Provider Enrollment by e-mail at mmac.providerenrollment@dss.mo.gov.

Providers who have not submitted their Medicare NPI may fax a copy of their Medicare approval letter showing their NPI, provider name and address to Provider Enrollment at 573-526-2054.



Following are tips to assist you in successfully filing crossover claims on the MO HealthNet billing Web site at www.emomed.com:

• From Claim Management choose the Medicare CMS-1500 Part B Professional format under the ‘New Xover Claim’ column.

• Providers must submit claims to MO HealthNet with the same NPI they used to bill Medicare.

• There is a ‘Help’ feature available by clicking on the question mark in the upper right hand corner of the screen.

• Select MB-Medicare as the ‘Filing Indicator’ from the drop down box.

• On the Header Summary screen, the ‘Other Payer ID’ is a unique identifier on the other payer remittance advice. If not provided, it is suggested using a simple, easy to remember ID. This field may contain numeric and/or alpha-numeric data up to 20 characters.

• All fields with an asterisk are required and should be completed with the same information submitted to Medicare. Data entered should be taken directly from your Medicare EOB with the exception of the participant’s name and HIC; these should be stated as they appear in the MO HealthNet eligibility file.

• The Other Payer Detail Summary must contain the same number of line items as detail lines that were entered. Do not check the ‘Payer at Header Level’ box on the Header Summary for Medicare crossover claims.


MEDICARE ADVANTAGE/PART C CROSSOVER CLAIMS FOR QMB OR QMB PLUS PARTICIPANTS

Medicare Advantage/Part C plans do not forward electronic crossover claims to MO HealthNet, therefore providers must submit these claims through the MO HealthNet billing Web site, www.emomed.com. The following tips will assist you in successfully
filing your Medicare Advantage/Part C crossover claims:

• From Claim Management choose the CMS-1500 Part C Professional format under the ‘New Xover Claim’ column.

• Select 16-Medicare Part C Professional as the ‘Filing Indicator’ from the drop down box on the Header Summary screen.

• Always verify eligibility either through the ‘Participant Eligibility’ link on www.emomed.com or access the Interactive Voice Response (IVR) at

• 573-751-2896 to see if the participant is a Qualified Medicare Beneficiary (QMB) on the date of service. Eligibility needs to be checked for each date of service. The Part C format can only be used if the participant is QMB eligible on the date of service.


Providers are not to submit crossover claims for participants enrolled in a Medicare Advantage/Part C plan who are non-QMB. These services are to be filed as Medical claims.

Monday, March 28, 2016

Can we submit UB04 Claim without CPT Codes

Note: Tufts Health Plan has identified that the following Revenue Codes will be accepted when submitted electronically without a corresponding CPT and/or HCPCS procedure code if one cannot be found (however, EDI acceptance does not guarantee payment):

0250 – Pharmacy
0525 – RHC/FQHC visit to facility (not 4)
0251 – Generic
0527 – Visit Nurse to Home HH short area
0252 – Non-Generic
0528 – RHC/FQHC visit to other (not 4, 5)
0258 – IV Solutions
0621 – Incident to Radiology
0259 – Pharmacy — Other
0622 – Incident to other Diagnostics
0270 – M&S Supplies
0656 – Hospice — Inpatient General Care
0271 – Non-sterile Supplies
0659 – Hospice — Other
0272 – Sterile Supplies
0663 – Daily Respite Care
0274 – Prosthetic/ Orthopedic Devices
0681 – Level I Trauma Response
0275 – Pacemaker Supplies
0682 – Level II Trauma Response
0276 – Intraocular Lens
0683 – Level III Trauma Response
0278 – Other Implants
0684 – Level IV Trauma Response
0279 – M&S Supplies – Other
0689 – Other Trauma Response
0370 – Anesthesia
0710 – Recovery Room
0371 – Incident to Radiology
0719 – Recovery Room — Other
0372 – Incident to Other Diagnostic
1000 – General Classification - Behavioral Health
0379 – Anesthesia — Other
1001 – Residential Psychiatric
0392 – Processing and Storage
1002 – Residential Chemical
0524 – RHC/FQHC visit to SNF (Part A)