SDMGMA Third Party Payer Day Lori Lawson, Deputy Medicaid Director 1
Agenda • Medicaid Overview • TPL ARSD • How to report TPL on 1500 form • How to report TPL on UB form • Common TPL Errors • ICD-10 update a. Readiness b. Tips • APC update • Q &A
What is Medicaid? • Medicaid is one of the largest healthcare insurers in South Dakota. • Federal-State partnership governed by Medicaid State Plan (agreement with federal government on who is served and what services are covered). • Each state’s plan is different. • Makes comparisons between states difficult. • Different than Medicare - 100% federal coverage for older and some disabled adults.
Medicaid Claims Processing • South Dakota Medicaid pays for covered health care services that are medically necessary. • Meet or exceed federal timely payment requirements. • South Dakota Medicaid staff process and adjudicate Medicaid claims. • There were approximately 5 million claims processed in SFY15. • Over 83% of the claims are submitted electronically.
Who Uses Medicaid Now? • In SFY15 there were 117,346 average monthly individuals enrolled in South Dakota Medicaid. • Nearly 1 of every 7 persons in any given month will have health coverage through Medicaid or CHIP. • 1 of every 3 persons under the age of 19 in South Dakota has health coverage through Medicaid or CHIP. • 50 percent of the children born in South Dakota will be on Medicaid or CHIP during the first year of their life.
Who We Serve • Low income children, pregnant women, adults and families • Elderly or disabled • Children in foster care • Adult coverage is limited to: – Elderly or disabled – Parent/Caregiver/Relatives of Low Income Children - 53% Federal Poverty level (FPL) • Family of three $10,489 annual income • 68% children and 32% adults
Who We Serve SFY 2015 Average Monthly Eligible South Dakotans • Elderly – 7,057 • Disabled/Blind – 19,126 • Pregnant Women (pregnancy only) 1,188 • Low-income Adults – 13,159 • Children of Low-income Families – 64,690 • Children covered by CHIP – 12,126 • Total Average Monthly – 117,346
Medicaid Participation SFY 2015 Monthly Average = 117,346 8
Health Care Services • Covered Healthcare Services must be medically necessary and physician ordered. Medicaid Mandatory Services South Dakota Optional Services Inpatient hospital services Outpatient hospital services Physician assistants Early and Periodic Screening, Diagnostic, and Psychologists and independent mental health Treatment (EPSDT) services practitioners All Medically Necessary care for eligible children Intermediate Care Facilities for the Mentally under age 21 Challenged (ICF/MR) Nursing facility services Podiatry Home health services Prescription Drugs Physician services Optometry Rural health clinic services Chiropractic services Durable medical equipment Federally qualified health center services Laboratory and X-ray services Dental services Nurse Midwife services Physical, occupational, speech therapy, audiology Certified Pediatric and Family Nurse Practitioner Prosthetic devices and eyeglasses services Hospice care, nursing services Transportation to medical care Personal care services and home health aides Tobacco cessation counseling for pregnant women
THIRD PARTY LIABILITY WHAT IS THIRD PARTY LIABILITY? Third Party Liability (TPL) is the obligation of an entity other than Medicaid to pay for either part or all of the medical cost of an injury, disease or disability. The most common sources of TPL are Medicare and Private Health Insurance plans such as DakotaCare, Blue Cross Blue Shield, etc. TPL can also come from worker’s compensation, disability insurance, or automobile insurance. When a recipient becomes eligible for Medicaid, they assign their right to third party payments to Medicaid. | |
THIRD PARTY LIABILITY WHY DOES SOUTH DAKOTA MEDICAID REQUIRE TPL INFORMATION ON A CLAIM? By federal law, Medicaid is the payer of last resort . This means that when a Medicaid recipient has a third party payment source, such as private health insurance, the insurance company must pay the claim before Medicaid. South Dakota Medicaid requires all providers to submit claims to TPL before billing Medicaid. Claims not submitted to TPL before Medicaid will be denied. Exception: Absent parent insurance and auto insurance. Send these claim to SDMA. South Dakota Medicaid requires proof of third party payment or rejection to be submitted with all paper claims. Electronic claims must provide proof of third party payment or rejection upon request of the Department. | |
Third Party Source ARSD 67:16:26:05 Provider must collect from third-party source before submitting a claim to the department -- Medical assistance program payer of last resort. The provider is eligible to receive the recipient's third party liability responsibility amount or the amount allowed under the department's payment schedule less the third-party liability amount, whichever is less.
THIRD PARTY LIABILITY TERMS Explanation of Benefits (EOB): A statement sent by a health insurance company identifying the patient and services rendered, the amount charged by the provider, the amount of charges covered and not covered by the insurance company including any contractual write- off amounts, and the patient responsibility amount. Alternative Terms: Summary of Benefits, Remittance Advice, Coverage Determination, Beneficiary Notice. Usual and Customary Charge (UCC): The amount charged by the provider for the service. This amount should not contain any deductions. Alternative Terms: Billed Charges Patient Responsibility: The amount of the UCC the patient is responsible for paying, usually the co-payment, co-insurance, and/or deductible amount. | |
THIRD PARTY LIABILITY TERMS Contractual Obligation: The amount of the UCC that neither the insurance company nor the patient is responsible for paying. This amount is usually specified in a contract between the provider and the insurance company or network. Alternative Terms: Network Savings, Not-Allowed Amount, Write-Off, Adjustment, CTR True Payment: The dollar amount that the private health insurance company paid for the service. | |
THIRD PARTY LIABILITY on a 1500 Form WHAT TPL INFORMATION IS REQUIRED TO BE ON THE CLAIM FORM? Block 9: Other Insured’s Name Block 11: Insured’s Policy Group or FECA Number Block 24 A (Shaded): Block 11 Block 9 Enter the contractual obligation/network savings amount with the prefix CTR. Block 24 F (Shaded): Enter the true payment for each service in the shaded portion. The UCC will be entered in the unshaded portion. Block 28 Enter the UCC amount. Block 24 F Block 24 A Block 29 Enter the dollar amount paid by the insurance company. This should equal the sum of the true payments in 24 F. Do not include any network Block 28, 29, 30 savings or contractual obligation amounts. Block 30 Enter the Balance Due. | |
Third Party Liability Example HCFA Claim Submitted to Private Health Insurance • • Usual and Customary Charge SDMA Allowable $588.63 • $1619.00 • • Contractual Obligation SDMA Pays the lesser of : • • $1015.00 $1619.00-$1015.00-$500.00=$104.00 • • Insurance Payment: $500.00 $588.63-$500.00=$88.63
Third Party Liability Example HCFA WELLMARK BCBSSD BLUE PPO X CTR 1015.00 500.00 03 09 15 03 09 15 81 29885 A 1619 00 1 1619 00 500 00 104 00
Third Party Liability Example UB-04 Claim Submitted to Private Health Insurance • • Usual and Customary Charge: Insurance Payment: $155.91 • $262.00 • • Contractual Obligation: SDMA Payment pays the lesser of : • • $62.00 $262.00-$62.00-$155.91=$44.09 • • South Dakota Medicaid Allowable: $219.48-$155.91=$63.57 • $219.48
Third Party Liability Example UB-04 1 262 00 0450 12011 62 00 262 00 62 00 BCBS 141 155 91 44 09 MEDICAID 999
Common TPL Errors • Medicare Crossovers • Adjustments • Billed Charges (Usual and Customary – UCC) • Timely Filing
MEDICARE/MEDICAID CROSSOVERS WHAT IS REQUIRED TO BE ON CLAIMS SUBMITTED TO MEDICARE TO ENSURE SOUTH DAKOTA MEDICAID PAYS THE CLAIM? Ensure that the information on the claim form matches the information that is in South Dakota Medicaid’s SDMEDX Provider Enrollment Record. Zip+4 Servicing and Billing NPI Taxonomy Check the Medicare Box on the claim form. If you do not receive a remittance advice from South Dakota Medicaid within 4 weeks of submitting a crossover claim please contact the Telephone Service Unit at 1-800-452-7691 .
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