Commonwealth of Massachusetts MassHealth Provider Manual Series Psychiatric Inpatient Hospital Manual Subchapter Number and Title Appendix D: Supplemental Instructions for Claims with Other Insurance Page D-1 Transmittal Letter PIH-20 Date 01/01/12 Supplemental Instructions for Submitting Claims with Other Insurance This appendix contains specific MassHealth billing instructions for members who have Medicare or commercial insurance and supplements the instructions found in the HIPAA 837I Implementation Guide, MassHealth 837I Companion Guide, and MassHealth Billing Guide for the UB-04. MassHealth requires all claims to be submitted in an electronic format unless the provider has received an approved electronic claim submission waiver. Please refer to All Provider Bulletin 217. TPL Requirements To ensure that MassHealth is the payer of last resort, generally providers must make diligent efforts to obtain payment from other resources before billing MassHealth. See MassHealth regulations at 130 CMR 450.316. Accordingly, providers must submit a claim and seek a new coverage determination from the insurer any time a member’s condition or health insurance coverage status changes, even if Medicare or a commercial insurer previously denied coverage for the same service. Providers are required to retain the following on file for auditing purposes . the Medicare remittance advice; . the Medicare or commercial insurer notice of noncoverage; . the original explanation of benefits (EOB); . the commercial insurer’s original EOB; the 835 transaction, or the response from the insurer. Medicare Crossover Claims When Part A Benefits Have Exhausted During the Inpatient Stay Medicare crossover claims for dually eligible members that contain both Medicare covered and noncovered days will be automatically transmitted from the coordination of benefits contractor (COBC) to MassHealth for processing. Providers should not bill the Medicare noncovered days separately to MassHealth, since the payment for the Medicare covered and noncovered days is included in the MassHealth mid-stay crossover claim payment. Providers may submit the claim to MassHealth electronically, following the MassHealth COB requirements if 60 days have passed since they received Medicare payment, or the member has other insurance in addition to Medicare and MassHealth, and the claim has not appeared on a MassHealth crossover remittance advice. When billing Medicare inpatient mid-stay claims that contain Medicare covered and noncovered days for dually eligible members to MassHealth, providers should not report the Medicare Part B ancillary payments associated with the inpatient stay on their inpatient claim submission. Providers should follow instructions found in MassHealth billing guides for claims submissions. TPL Exceptions This appendix contains supplemental billing instructions for submitting 837I transactions, direct data entry claims (DDE), and paper claims for members who have Medicare or commercial insurance when services are determined to be not covered by the primary insurer. This appendix lists TPL exceptions that may apply when members have Medicare or commercial insurance. Psychiatric inpatient services for a MassHealth member must be initially billed to Medicare or the commercial insurer unless a notice of noncoverage from the other insurer has been issued for services determined to be not covered. Commonwealth of Massachusetts MassHealth Provider Manual Series Psychiatric Inpatient Hospital Manual Subchapter Number and Title Appendix D: Supplemental Instructions for Claims with Other Insurance Page D-2 Transmittal Letter PIH-20 Date 01/01/12 There may be instances when the services provided are not covered by the other insurer, including . when the benefit maximum for this time period or occurrence has been reached; . when the member does not qualify for the new benefit period with the other insurer; . when the other insurer does not support the patient level of service; and . when the member is on administrative days. Follow the instructions outlined in this appendix for claims submission when one of the above TPL exceptions exists. Billing Instructions for 837I Transactions The table below contains the critical loops and segments required for submitting claims to MassHealth that have been determined to be not covered by the other insurer, and that meet the TPL exception criteria described in this appendix. Providers must complete the loops and segments as described in the table below and follow instructions described in the HIPAA 837I Implementation Guide and MassHealth 837I Companion Guide to complete other required COB and non COB portions of the 837I claim submission. The “Total Noncovered Amount” segment is used to indicate that the insurer has determined the service to be not covered. Do not report HIPAA adjustment reason codes and amounts in the 2320 loop containing the total noncovered amount. Loop Segment Value 2320 SBR09 (Claim Filing Indicator) Medicare = MA 837I: Commercial insurer = CI 2320 AMT01 (Total Noncovered Amount Qualifier) A8 2320 AMT02 (Total Noncovered Amount) The total noncovered amount must = the total billed amount. 2330B NM109 (Other Payer Name) Enter the MassHealth-assigned carrier code for the other payer. Please Note: MassHealth-assigned carrier codes may be found in Appendix C (Third-Party-Liability Codes) of your MassHealth provider manual. Billing Instructions for Direct Data Entry (DDE) Providers must enter the COB information as described in the following table when submitting claims to MassHealth that have been determined to be not covered by the other insurer, and that meet the TPL exception criteria described in this appendix. Providers must follow instructions in the MassHealth billing guides to complete other required COB and non COB data fields of the DDE claim submission that are not specified in the table below. The “Total Noncovered Amount” field is used to indicate that the insurer has determined the service to be not covered. Do not enter HIPAA adjustment reason codes and amounts on the List of COB Reasons panel when reporting a total noncovered amount. Commonwealth of Massachusetts MassHealth Provider Manual Series Psychiatric Inpatient Hospital Manual Subchapter Number and Title Appendix D: Supplemental Instructions for Claims with Other Insurance Page D-3 Transmittal Letter PIH-20 Date 01/01/12 On the “Coordination of Benefits” tab, click “New Item” and complete the fields as described below. COB Detail Panel Field Name Instructions Carrier Code Enter the MassHealth-assigned carrier code for the other payer. Please Note: MassHealth-assigned carrier codes may be found in Appendix C (Third-Party-Liability Codes) of your MassHealth provider manual. Carrier Name Enter the appropriate carrier name. Refer to Appendix C of your MassHealth provider manual. Remittance Advice Do not enter a remittance date. Payer Claim Number Enter 99. COB Payer Paid Amount Do not enter a COB payer paid amount. Total Noncovered Amount Enter the total billed amount. The total noncovered amount must = the total billed amount. Claim Filing Indicator Medicare = MA Commercial insurer = CI Remaining Patient Liability Do not enter a remaining patient liability. Payer Responsibility Select the appropriate code from the drop-down list. Release of Information Select the appropriate code from the drop-down list. Assignment of Benefits Select the appropriate code from the drop-down list. Subscriber Information Panel Enter the appropriate required subscriber information: Subscriber last name First name Subscriber ID The relationship to subscriber code (Select the appropriate code from drop-down list.) Please Note: Click “Add” to save the COB panel. Billing Instructions for Paper Claims MassHealth requires all claims to be submitted in an electronic format unless the provider has received an approved electronic claim submission waiver. Please refer to All Provider Bulletin 217. Commonwealth of Massachusetts MassHealth Provider Manual Series Psychiatric Inpatient Hospital Manual Subchapter Number and Title Appendix D: Supplemental Instructions for Claims with Other Insurance Page D-4 Transmittal Letter PIH-20 Date 01/01/12 Providers must follow the instructions in the MassHealth Billing Guide for the UB-04. Providers must submit the UB-04 claim form with the TPL Exception Form to report total noncovered charges when billing MassHealth for claims that have been determined to be not covered by the other insurer, and that meet the TPL exception criteria described in this appendix. To download the new form, go to www.mass.gov/masshealth. Click on MassHealth Provider Forms in the lower right panel of the home page, then scroll down the list to the TPL Exception Form. MassHealth’s Right to Appeal MassHealth reserves the right to appeal any case that, in its determination, may meet the coverage criteria of an insurance carrier. Providers must, at MassHealth’s request, submit the claim and related clinical or service documentation to an insurance carrier if MassHealth determines that the provider’s submission is necessary in order for MassHealth to exercise its right to appeal. Questions If you have any questions about the information in this appendix, please refer to Appendix A of your MassHealth provider manual for the appropriate contact information.