FSSA OMPP PPT Template - IN.gov secondary... · 2019. 5. 31. · • When TPL has applied the entire amount to the copay, coinsurance, or deductible, and no ... 38 Residential substance

Indiana Health Coverage Programs

DXC Technology

Submitting Secondary

CMS-1500 Claims

and IHCP Updates

Summer Workshop 2018

2

Agenda• When is the primary explanation of

benefits (EOB) required for third-party

liability (TPL) insurance ‒ commercial

versus Medicare/Medicare Replacement

Plan?

• How to complete Other Insurance or TPL

on the IHCP Provider Healthcare Portal

(Portal)

• How to complete Medicare crossover

claims on the IHCP Portal

• How to add attachments on the

IHCP Portal

• IHCP updates

• IHCP vendors and stakeholders

• APR-DRG update

• Helpful tools

• Questions

3

When is the primary EOB required

for TPL insurance – commercial?

4

When is the primary EOB required for TPL

insurance – commercial?

EOB needed

• When the TPL has

denied the service as

noncovered

• When TPL has applied

the entire amount to

the copay,

coinsurance, or

deductible, and no

payment is made.

When a member has other insurance, and the primary

insurer denies payment for any reason or applies the

payment in full to the deductible, the provider must

provide proof that the service was submitted to the

primary payer by attaching the EOB.

EOB not needed

• The primary insurance COVERS the service and has PAID on the claim.

• Actual dollars were received.

5

How to complete Other Insurance

(TPL) on the IHCP Portal

6

Step 1: Other Insurance (TPL)

at the header

IMPORTANT – If the primary insurance does not cover the services

rendered, do NOT check the Include Other Insurance box.

7

Step 2: Other Insurance (TPL) header

If the primary insurance is listed, click on the line-item number to open

the window.

8


If insurance is not listed, click on the “+” sign to add the insurance payment to

be reported.

9


• When the Other Insurance Details window opens, complete

all items that have asterisks.

NOTE: The TPL/Medicare Paid Amount field does not have

an asterisk but is a required field.

“*”

10


After you save and see the information in the Other Insurance Details

window, click Continue.

11

Step 1: Other Insurance (TPL) detail

• Click on the Service Detail line and complete service information

• Click Add

• The Service Detail lines will collapse

12


Click on the “1” for the service detail to open the “Other Insurance

Details” window

13


Use the drop-down menu to choose the insurance that was added at the header

level, then add the payment received for that detail line and date of primary EOB.

*Red asterisks indicate required fields.

14

Other Insurance (TPL)

additional details

Repeat these steps for EACH detail line to report the payment for each

detail individually.

15

When is the primary EOB required

for TPL insurance – Medicare or

Medicare Replacement Plan?

16

EOB needed

Only when Medicare or

the Medicare

Replacement Plan

denies the service

When is the primary Medicare or Medicare

Replacement Plan EOB required?

A zero-paid claim IS NOT a denied claim.

EOB not needed

The Medicare or Medicare

Replacement Plan COVERS

the service

Actual dollars were

received

Zero-paid claim– Entire or partial amount was

applied to deductible,

coinsurance, or copay

17

How to complete crossover claims

on the IHCP Portal

18

Step 1: Medicare or Medicare Replacement

Plan crossover claim at the header

IMPORTANT – If Medicare does not cover the services

rendered, do not check this box. The claim is not a

crossover claim.

19

Step 2: Medicare or Medicare

Replacement Plan crossover claim header

If Medicare or the Medicare Replacement Plan is not listed, click on the “+”

sign to add the insurance payment to be reported

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Traditional Medicare = MB

Medicare Replacement Plan = 16

• When the Other Insurance Details window opens, complete all

items marked with asterisks. “*”

NOTE: The TPL/Medicare Paid Amount does not have an

asterisk but is still a required field.

21



After you save and see the information in the Other Insurance Details

window, click on the insurance line number again to add the coinsurance and

deductible information in the Claim Adjustment Details window.

22



Reason codes

1 = Deductible 2 = Coinsurance 3 = Copayment

23



After the Claim Adjustment Details window is completed, click Save

and Continue.

24


Replacement Plan crossover claim at detail

• Click on the Service Detail line

• The Service Detail line will expand

• Enter the Service Detail information and Click Add

25



• Use the drop-down menu to choose the insurance that was added at the

header level.

• Add the payment received for that detail line and date of primary EOB.

• Click Add.

26



• Click on the line item with the insurance that you added to open it

again.

27



• Use the drop-down menu to choose PR - Patient Responsibility.

• Choose the appropriate reason code.

• Add amount of coinsurance/deductible/copayment.

• Click Add and Save.

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Click Save.

29


Replacement Plan ‒ additional details

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Replacement Plan ‒ additional details

Repeat these steps for EACH detail line to report the payment for

each detail individually.

31

How to add attachments on the

IHCP Portal

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Adding claim attachments

When the primary EOB is required, use the “Attachments” feature

• 5 MB total allowed

• Document types allowed: PDF, BMP, GIF,

JPG/JPEG, PNG, and TIFF/TIF

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Submit the claim

34

Claim Status and Claim ID

35

IHCP updates

36

Enhanced coverage of

substance use disorder treatment

• Effective February 1, 2018, the IHCP expanded coverage for inpatient stays for treatment of opioid use disorder (OUD) and other substance use disorders (SUDs) in facilities that qualify as institutions of mental disease (IMD)

• Providers enrolled as psychiatric hospitals (provider type 01 and provider specialty 011) that have 17 or more beds are currently the only providers recognized by the IHCP as qualified IMDs

– Members age 21 through 64 are authorized for up to 15 days in a calendar month

– Inpatient stays are reimbursed on diagnosis-related group (DRG) payment methodology

• Coverage applies to Healthy Indiana

Plan (HIP), Hoosier Care Connect,

Hoosier Healthwise, and Traditional

Medicaid

37

Residential substance use disorder

treatment facilities

• Effective March 1, 2018, the IHCP provides coverage for short-term low-

intensity and high-intensity residential treatment for OUD and other SUD

treatment in settings of all sizes, including facilities that qualify as IMDs

• Providers have been able to enroll under a new provider type (35) and

specialty (836), Addiction Services/SUD Residential Addiction Treatment

Facility, as of March 1, 2018

– The CMS is allowing short-term residential stays with a statewide average

length of 30 calendar days

– PA is required for all residential stays

– Reimbursement is per diem

38

Residential substance use disorder

treatment facilities

• Admission criteria will be based on the American

Society of Addiction Medicine (ASAM) Patient

Placement Criteria Level 3.1 (Clinically Managed

Low-Intensity Residential Services) and Level 3.5

(Clinically Managed High-Intensity Residential

Services)

• Facilities can be reimbursed for residential stays for

SUD treatment on a per diem basis for an interim

period of time – only through dates of service

(DOS) on or before June 30, 2018. Please see

bulletin BT201801 for intensity level specifics.

http://provider.indianamedicaid.com/ihcp/Bulletins/BT201801.pdf

39

Enrollment for provider type 35

• Effective July 1, 2018, reimbursement for SUD residential

treatment will be made only to facilities that are enrolled under

the provider type 35/specialty 836

• A facility must meet the following requirements and submit proof

of both:

– DMHA certification as a residential (sub-acute stabilization)

facility or Department of Child Services (DCS) licensing as a

child care institution or private secure care institution

– DMHA designation indicating approval to offer ASAM Level

3.1 or Level 3.5 residential services (Facilities that have

designations to offer both ASAM Level 3.1 and Level 3.5

services within the facility must include proof of both

with their enrollment application.)

Visit the DMHA website for more information

about the ASAM designation process

https://www.in.gov/fssa/dmha/3105.htm

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Enrollment for provider type 35

A provider enrolled as a residential SUD addiction treatment facility (provider

type 35/specialty 836) is limited to billing only the following procedure codes

under that enrollment:

• H2034 U1 or U2 – Low-Intensity Residential Treatment

• H0010 U1 or U2 – High-Intensity Residential Treatment

41

More information about SUD

treatment services

For more information about residential SUD treatment services, see:

• IHCP Bulletin BT201801, which includes additional information about:

– Enhanced coverage of residential SUD treatment, including intensity

level specifics

– Enrollment of residential SUD treatment facilities

o Provider type 35 – Addiction Services

o Provider specialty 836 – SUD Residential Addiction Treatment

Facility

– Billing guidance

• IHCP Bulletin BT201821, which contains responses to provider FAQs about

residential SUD treatment benefits

http://provider.indianamedicaid.com/ihcp/Bulletins/BT201801.pdfhttp://provider.indianamedicaid.com/ihcp/Bulletins/BT201821.pdf

42

Hospice services for

Hoosier Care Connect members

• Effective January 1, 2019, all covered hospice benefits for members enrolled in Hoosier Care Connect will be the responsibility of the enrolling health plan:

– Hoosier Care Connect MCEs = Anthem and MHS

• Members will remain enrolled with their managed care entity (MCE) for the duration of the hospice period

• As the professional manager of the member’s hospice care, the hospice provider is responsible for obtaining contracts with all IHCP providers for arranged services

• See IHCP Bulletin BT201809 for additional details


43

Electronic visit verification (EVV)

• The 21st Century Cures Act directs

state Medicaid programs to require

providers of personal care services

(waiver) and home health services to

use an electronic visit verification

(EVV) system to document services

rendered

• Use of an EVV system to document

personal care services will be effective

and in place January 1, 2019

• Future use of an EVV system to

document home health services will be

implemented by January 1, 2023; see

BT201820 for details


44

Electronic visit verification (EVV)

• Federal law requires that providers use the

EVV system to document the following

information:

– Type of service performed

– Individual receiving the service

– Date of the service

– Location of service delivery

– Individual providing the service

– Time the service begins and ends

• More information on EVV is available in

IHCP Bulletin BT201820


45

Claim filing limit

• The IHCP will mandate a 180-day filing limit for fee-for-service (FFS) claims,

effective January 1, 2019 (tentative date)

• The 180-day filing limit will be effective based on date of service:

– Any services rendered on or after January 1, 2019, will be subject to the

180-day filing limit

– Dates of service before January 1, 2019, will be subject to the

365-day filing limit

Watch for future communications!

46

Claim filing limit

The following remain unchanged by the revised claim timely filing limit:

• Circumstances for exclusions, extensions, and waivers

• Claim submission, corrections/resubmissions, and adjustment guidance

• Processes and timeframes for requests for claim administrative review

and appeals

47

IHCP vendors and stakeholders

48

IHCP vendors

• Posted on the Quick Reference Guide (QRG) on the Contact Us page at

indianamedicaid.com

http://provider.indianamedicaid.com/about-indiana-medicaid/contact-us.aspx

49

IHCP stakeholders

*Not all IHCP programs/contractors are listed.

Fee-for-Service HIPHoosier

Healthwise

Hoosier Care

Connect

Anthem

CareSource

MDwise

MHS

CMCS

Prior Authorization

DXCAnthem

CareSource

MDwise

MHS

Myers & Stauffer

OptumRx

Anthem

MHS

FSSA

OMPP

50

APR-DRG update

• Fee-for-service traditional Medicaid

• Targeted for change January 1, 2019

• All-Patient Refined (APR) Diagnosis-Related Group

(DRG) grouper, version 35

• See IHCP Bulletin BT201819 for more information

• Monitor future IHCP publications for more detailed

information on implementation


51

Helpful tools

52

Other helpful tools

• IHCP website at indianamedicaid.com

– IHCP Provider Reference Modules

– Medical Policy Manual

• Customer Assistance:

– 8 a.m.-6 p.m. EST

– Monday – Friday

– 1-800-457-4584

• IHCP Provider Relations field consultants

– See the Provider Relations Field Consultants page at

indianamedicaid.com

• Secure correspondence via the Provider Healthcare Portal

• Written Correspondence:

DXC Technology Provider Written Correspondence

P.O. Box 7263

Indianapolis, In 46207-7263

http://provider.indianamedicaid.com/general-provider-services/provider-reference-materials.aspxhttp://provider.indianamedicaid.com/media/219191/medical policy manual.pdfhttp://provider.indianamedicaid.com/about-indiana-medicaid/contact-us/provider-relations-field-consultants.aspx

53

Questions

Documents

FSSA OMPP PPT Template - IN.gov secondary... · 2019. 5. 31. · • When TPL has applied the entire amount to the copay, coinsurance, or deductible, and no ... 38 Residential substance