Commonwealth of Massachusetts Executive Office of Health and Human Services Office of Medicaid 600 Washington Street Boston, MA 02111 www.mass.gov/masshealth MassHealth Transmittal Letter AIH-44 April 2009 TO: Acute Inpatient Hospitals Participating in MassHealth FROM: Tom Dehner, Medicaid Director RE: Acute Inpatient Hospital Manual (New Appendix D) This letter transmits a new Appendix D for the Acute Inpatient Hospital Manual. Appendix D contains instructions for submitting 837I transactions and paper claims (after the implementation of NewMMIS) for members who have Medicare or other insurance benefits where services were deemed to be noncovered because the patient does not have benefits available (benefits exhausted), or does not qualify for a new benefit period. Appendix D contains specific MassHealth instructions for billing claims for these situations, which are not described in the HIPAA implementation guide for the 837I transaction. It also provides instructions for using the TPL Exception Form for Nursing Facilities and All Inpatient Hospitals to submit paper claims using the new instructions. When the initial claim has been adjudicated by Medicare, the adjudication details provided by Medicare must be documented on the TPL Exception Form for Nursing Facilities and All Inpatient Hospitals. This form must be attached to the claim to report HIPAA group and adjustment reason codes (ARCs). This form is available on the MassHealth Web site at www.mass.gov/masshealth, and is fillable online. A copy of the form is attached to this transmittal letter. Requests for paper copies of this form must be submitted in writing and faxed to 617-988-8973 or mailed to the following address. MassHealth ATTN: Forms Distribution P.O. Box 9118 Hingham, MA 02043 This transmittal letter supersedes the billing instructions in Acute Inpatient Hospital Bulletin 126, dated November 2003, which is available on the MassHealth Web site at www.mass.gov/masshealth. Previously, providers were instructed to use condition codes to indicate the reason the insurer did not cover the service. After the implementation of NewMMIS, condition codes will no longer be used, but will be replaced by HIPAA adjustment reason codes (ARCs). The instructions in Appendix D are effective upon implementation of NewMMIS on May 26, 2009. If you have any questions about this transmittal letter, please contact MassHealth Customer Service at 1-800-841-2900, e-mail your inquiry to providersupport@mahealth.net, or fax your inquiry to 617-988-8974. NEW MATERIAL (The pages listed here contain new or revised language.) Acute Inpatient Hospital Manual Pages vi and D-1 through D-4 OBSOLETE MATERIAL (The pages listed here are no longer in effect.) Acute Inpatient Hospital Manual Page vi – transmitted by Transmittal Letter AIH-41 Inserted image of the TPL Exception Form for Nursing Facilities and All Inpatient Hospitals with instructions on how to use it. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title Table of Contents Page vi Acute Inpatient Hospital Manual Transmittal Letter AIH-44 Date 05/26/09 Appendix A. Directory................................................................................................................... A-1 Appendix B. Enrollment Centers................................................................................................... B-1 Appendix C. Third-Party-Liability Codes..................................................................................... C-1 Appendix D. Supplemental Instructions for Claims with Other Insurance.................................... D-1 Appendix E. Utilization Management Program............................................................................ E-1 Appendix F. Admission Guidelines.............................................................................................. F-1 Appendix W. EPSDT Services: Medical Protocol and Periodicity Schedule................................. W-1 Appendix X. Family Assistance Copayments and Deductibles..................................................... X-1 Appendix Y. EVS Codes/Messages............................................................................................... Y-1 Appendix Z. EPSDT/PPHSD Screening Services Codes.............................................................. Z-1 Supplemental Instructions for Claims with Other Insurance This appendix contains billing instructions for submitting 837I transactions and paper claims for members who have Medicare and/or commercial insurance, and whose services were deemed by the payer to be noncovered because the patient does not have benefits available (benefits exhausted), or does not qualify for a new benefit period. This appendix contains specific MassHealth billing instructions that are not described in the HIPAA Implementation Guide for the 837I transaction, in the 837I Companion Guide, or in the billing guides for the UB-04. Providers must continue to bill Medicare for all Part B ancillary services and physician services associated with the inpatient stay before billing MassHealth for the noncovered Part A services. MassHealth will continue to process Medicare Part B crossovers sent by Medicare. Note: Providers must retain the original EOB (EOB, notice of the noncoverage, or the remittance advice) in their records for auditing purposes. Billing Instructions for 837I Transactions Providers must submit an initial claim to the other insurer (Medicare or commercial insurance) for a claim determination. When the initial claim has been adjudicated by the insurer, enter the adjudication details provided by that insurer on the other payer loops (2320 and 2330) in the 837I transaction. The provider must fill in the other payer loops in the 837I transaction as described in the following table. Loop Segment Value Description 2330B NM109 (Other Payer Name) MassHealth-assigned carrier code. For Medicare, the carrier code is 0084000 (Part A). Note: MassHealth-assigned carrier codes may be found in Appendix C (Third-Party-Liability Codes) of your MassHealth provider manual, or at www.mass.gov/masshealth. 2320 SBR09 (Claim Filing Indicator) “MA” when the other payer is Medicare 2320 AMT (Amount) Should not be populated with any insurance payment, coinsurance, or deductible. 2320 CAS01 (Claim Adjustment Group Code) OA (other adjustments) 2320 CAS02 (Claim Adjustment Reason Code) See Claim Adjustment Reason Code Crosswalk Table on page D-3. The table cross walks the previously used condition codes to the current HIPAA adjustment reason codes. Providers must bill using the correct HIPAA ARC to ensure that claims process correctly. 2320 CAS03 (Monetary Amount) Billed amount 2330B DTP03 (Date, Time, or Period) Date of discharge or end date of service Providers must fill in the other payer loops in the 837I transaction as described in the following table to report Medicare Part B prior payments. Loop Segment Value Description 2320 SBR09 (Claim Filing Indicator) MB 2320 AMT01 (Allowed Amount Qualifier) B6 2320 AMT02 (Allowed Amt = 0) 0 2320 AMT01 (Paid Amount Qualifier) C4 2320 AMT02 (Medicare Prior Payment Amount) Medicare prior payment amount 2330B NM109 (Medicare Part B) 0085000 Billing Instructions for Paper Claims Providers must submit an initial claim to Medicare for a claim determination. When the initial claim has been adjudicated by Medicare, the adjudication details provided by Medicare should be documented on the TPL Exception Form for Nursing Facilities and All Inpatient Hospitals. This form must be attached to the claim to report HIPAA group and adjustment reason codes (ARCs). This form is available on the MassHealth Web site at www.mass.gov/masshealth. Note: Providers submitting paper claims must refer to the Billing Guide for the UB-04. Otherwise, claims may be processed incorrectly. Billing Instructions for Both Paper and 837I Transactions The ARCs given in the following table may be used for both paper and 837I transactions to indicate the reason that the insurer is not covering the service. MassHealth allows providers to use ARCs to report noncovered or benefits-exhausted services only in the circumstances described in the table. Claim Adjustment Reason Code Crosswalk Table Prior Condition Code Replace with HIPAA Adjustment Reason Code Applies to Medicare? Applies to Commercial Insurers? Y9 - Valid EOB / Utilization review notice. Patient does not have benefits available or does not qualify for a new benefit period. 119 - Benefit maximum for this time period or occurrence has been reached for the calendar year. Yes No 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. This page is reserved.