Commonwealth of Massachusetts Executive Office of Health and Human Services Office of Medicaid www.mass.gov/masshealth MassHealth Transmittal Letter PIH-21 April 2013 TO: Psychiatric Inpatient Hospital Providers Participating in MassHealth FROM: Julian J. Harris, M.D., Medicaid Director RE: Psychiatric Inpatient Hospital Provider Manual (Revised Appendix D - Coordination of Benefits Direct Data Entry Enhancements for the Provider Online Service Center) This letter transmits a revised Appendix D for the Psychiatric Inpatient Hospital Provider Manual. Appendix D contains specific MassHealth billing instructions that supplement the instructions found in the HIPAA 837I Implementation Guide, the MassHealth 837I Companion Guide, and the MassHealth Billing Guide for the UB-04. These revisions are effective December 1, 2012. MassHealth has implemented Provider Online Service Center (POSC) direct data entry (DDE) enhancements for all coordination of benefits (COB) claim submissions. Certain COB fields in the Coordination of Benefits and Procedure tabs will now be prefilled. The enhancements are described in the “Billing Instructions for Direct Data Entry (DDE)” section of Appendix D. MassHealth Website This transmittal letter and attached pages are available on the MassHealth website at www.mass.gov/masshealth. Questions If you have any questions about the information in 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.) Psychiatric Inpatient Hospital Manual Pages vi and D-1 through D-4 OBSOLETE MATERIAL (The pages listed here are no longer in effect.) Psychiatric Inpatient Hospital Manual Page vi — transmitted by Transmittal Letter PIH-19 Pages D-1 through D4 — transmitted by Transmittal Letter PIH-20 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title Table of Contents Page vi Psychiatric Inpatient Hospital Manual Transmittal Letter PIH-21 Date 12/01/12 Appendix A. Directory ........................ A-1 Appendix B. Enrollment Centers ................... B-1 Appendix C. Third-Party-Liability Codes .............................................. C-1 Appendix D. Supplemental Instructions for TPL Exceptions......................... D-1 Appendix U. DPH-Designated Serious Reportable Events That Are Not Provider Preventable Conditionss for Provider Preventable Conditions .......... V-1 Appendix W. EPSDT Services Medical and Dental Protocols and Periodicity Schedules ........... W-1 Appendix X. Family Assistance Copayments and Deductibles .................................................... X-1 Appendix Y. EVS Codes and Messages ....................................... Y-1 Appendix Z. EPSDT/PPHSD Screening Services Codes................... Z-1 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title Appendix D: Supplemental Instructions for Claims with Other Insurance Page D-1 Psychiatric Inpatient Hospital Manual Transmittal Letter PIH-21 Date 12/01/12 Supplemental Instructions for Submitting Claims with Other Insurance This appendix contains specific MassHealth billing instructions for claims for members who have Medicare or commercial insurance. This appendix 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. Third-Party Liability (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 keep the following items on file for auditing purposes: . Medicare remittance advice; . Medicare or commercial insurer notice of noncoverage; . original explanation of benefits (EOB); . commercial insurer’s original EOB; the 835 transaction, or the response from the insurer. Medicare Crossover Claims When Part A Benefits Have Been Exhausted During the Inpatient Stay Medicare crossover claims (for dually eligible members) that contain both Medicare-covered and noncovered days are automatically transmitted from the coordination of benefits contractor (COBC) to MassHealth for processing. Providers should not bill separately to MassHealth for the Medicare noncovered days, 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 . the claim has not appeared on a MassHealth crossover remittance advice. When billing MassHealth for Medicare inpatient mid-stay claims that contain Medicare-covered and noncovered days for dually eligible members, 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 Exception Criteria 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. Providers must bill psychiatric inpatient services for a MassHealth member who has 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 Subchapter Number and Title Appendix D: Supplemental Instructions for Claims with Other Insurance Page D-2 Psychiatric Inpatient Hospital Manual Transmittal Letter PIH-21 Date 12/01/12 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; . member does not qualify for the new benefit period with the other insurer; . other insurer does not support the patient level of service; or . 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 equal 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 Subchapter Number and Title Appendix D: Supplemental Instructions for Claims with Other Insurance Page D-3 Psychiatric Inpatient Hospital Manual Transmittal Letter PIH-21 Date 12/01/12 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 Date Do not enter a remittance date. Payer Claim Number Enter 99. Payer Responsibility Select the appropriate code from the drop-down list. 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 equal the total billed amount. Remaining Patient Liability Do not enter any values. Claim Filing Indicator Medicare = MA Commercial insurer = CI Release of Information Select the appropriate code from the drop-down list. Assignment of Benefits Select the appropriate code from the drop-down list. Relationship to Subscriber Select the appropriate code from the drop-down list. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title Appendix D: Supplemental Instructions for Claims with Other Insurance Page D-4 Psychiatric Inpatient Hospital Manual Transmittal Letter PIH-21 Date 12/01/12 COB Detail Panel (cont.) Field Name Instructions Subscriber Information Panel If you select “Relationship to Subscriber,” and it is “18 –Self,” then click “Populate Subscriber.” The panel will fill the following data fields that have already been entered on the “Billing and Service” tab. . Subscriber Last Name . Subscriber First Name . Subscriber Address . Subscriber City . Subscriber State . Subscriber Zip Code If you select any other relationship-to-subscriber code, you must enter the following required fields. . Subscriber Last Name . Subscriber First Name Subscriber ID Enter the Other Insurance Subscriber ID number. 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. 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.