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 NF-55 December 2009 TO: Nursing Facilities Participating in MassHealth FROM: Terence G. Dougherty, Interim Medicaid Director RE: Nursing Facility Manual (Revised Appendix G) This letter transmits a revised Appendix G for the Nursing Facility Manual. Appendix G contains a revised set of billing instructions for submitting 837I transactions, paper claims, and direct data entry (DDE) claims for members who have Medicare or commercial insurance, or who were on medical leave of absence (MLOA), and whose services are determined not covered by the primary insurer. The revised Appendix G is effective December 15, 2009. This appendix lists the exceptions that need to be considered when billing MassHealth, Medicare, or commercial insurance. It explains the need for providers to make diligent efforts to obtain payment from other resources and to bill MassHealth as the payer of last resort. 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.) Nursing Facility Manual Pages vi and G-1 through G-6 OBSOLETE MATERIAL (The pages listed here are no longer in effect.) Nursing Facility Manual Pages vi and G-1 through G-4 – transmitted by Transmittal Letter NF-54 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title Table of Contents Page vi Nursing Facility Manual Transmittal Letter NF-55 Date 12/15/09 Appendix A. Directory A-1 Appendix B. Enrollment Centers B-1 Appendix C. Third-Party-Liability Codes C-1 Appendix D. Specifications for Electronic Submission of MMQ D-1 Appendix E. Instructions for Completing MMQ E-1 Appendix F. Unit-Dose-Drugs F-1 Appendix G. Supplemental Instructions for TPL Exceptions G-1 Appendix W. EPSDT Services: Medical Protocol and Dental 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 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title Appendix G: Supplemental Instructions for TPL Exceptions Nursing Facility Manual Transmittal Letter NF-55 Date 12/15/09 Supplemental Instructions for TPL Exceptions Submitting Claims for Members with Medicare and Commercial Insurance This appendix contains supplemental billing instructions for submitting 837I transactions, paper claims, and direct data entry (DDE) claims for members who have Medicare or commercial insurance, and whose services are determined not covered by the primary insurer. Refer to MassHealth regulations at 130 CMR 450.309 through 450.321. This appendix lists certain exceptions that need to be considered when billing MassHealth for members with Medicare or commercial insurance. These are specific MassHealth billing instructions that are not described in the HIPAA Implementation Guide for the 837I transactions, in the 837I Companion Guide, or in the billing guide for the UB-04. Please Note: To bill MassHealth for services provided to members with Medicare or commercial insurance, and whose services are determined not covered by the primary insurer, providers may no longer use the Condition Code field on the claim form. If submitting a claim electronically, the adjustment reason code segment must be populated. If submitting a claim on paper, the TPL Exception Form for Nursing Facilities and All Inpatient Hospitals must be completed and submitted with the claim form. The form is located on the MassHealth Web site at www.mass.gov/masshealth. Click on Provider Forms on the lower right side of the MassHealth home page. 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. Please see MassHealth regulations at 130 CMR 450.316. Accordingly, providers must seek a coverage determination from the insurer any time a member’s medical condition or health insurance coverage status changes. Providers must submit a claim to Medicare or the commercial insurer whenever a new benefit period becomes available. Certain TPL Exceptions If any of the following exceptions exist, follow the instructions outlined in this appendix for the claim submission medium – 837I transactions, paper claims, or DDE. Claim submissions must include codes found in the HIPAA Adjustment Reason Code Crosswalk table on page G-5. There are instances when insurance coverage is no longer available to the MassHealth member. Either the MassHealth member does not have benefits available (benefits exhausted), does not meet the insurer’s coverage criteria, does not qualify for a new benefit period, or the member is on a medical leave of absence (MLOA). These exceptions are explained below. Medicare Denials When submitting a claim for a dually eligible (Medicare/MassHealth) member, providers must indicate to MassHealth the reason the service has been determined to be noncovered by Medicare. This requirement applies to dates of service within 100 days of the date of admission or readmission to the facility where the member has been admitted within 30 days following a hospital stay lasting three days or longer. The nursing facility must keep a copy of the Medicare Advance Beneficiary Notice (ABN) issued to the MassHealth member or the Medicare remittance advice on file at the nursing facility as required for auditing purposes. Commercial Insurance and Medicare Advantage Plan Nursing facility claims for members with commercial insurance and Medicare advantage must be billed to the insurer for payment before billing MassHealth. If the insurer indicates that the member does not have benefits available due to benefits exhausted or the services are not covered, providers may submit the claim to MassHealth for payment. The nursing facility must keep a copy of the insurance denial (EOB), 835 transactions, or response from the insurer on file at the nursing facility as required for auditing purposes. Medical Leave of Absence Providers must follow the general billing instructions when billing for Medical Leave of Absence. If the MassHealth member is on medical leave of absence and has Medicare or commercial insurance, use the appropriate HIPPAA adjustment reason code listed in the HIPAA Adjustment Code Crosswalk table on page G-5. Billing Instructions for 837I Transactions Providers must complete the other payer loops in the 837 transactions as described in the following table when submitting claims that have been initially denied or determined noncovered by the other insurer, and meet the TPL exception criteria listed on the HIPAA Adjustment Reason Code Crosswalk table on page G-5. Loop Segment Value Description 2330B NM109 (Other Payer Name) Enter the MassHealth assigned carrier code for the other payer. 837I: Medicare (institutional) carrier code = 0084000. Note: MassHealth-assigned carrier codes may be found in Appendix C (Third-Party-Liability Code) in your MassHealth provider manual at www.mass.gov/masshealth. 2320 SBR09 (Claim Filing Indicator) Medicare (institutional) carrier code = MA Commercial insurer carrier code = CI 2320 AMT (Amount) 0 2320 CAS01 (Claim Adjustment Group Code) OA (other adjustments) 2320 CAS02 (Claim Adjustment Reason Code) Enter the appropriate HIPAA adjustment reason code. See the HIPAA Adjustment Reason Code Crosswalk table on page G-5. 2320 CAS03 (Monetary Amount) Total charges (amount billed to MassHealth) 2330B DTP03 (Date, Time, or Period) Date of discharge or end date of service for the claim billing period If you are billing claims using the HIPAA remittance remark code enter the following information. Loop Segment Value Description 2320 MIA05 Enter the appropriate HIPAA adjustment reason code. See the HIPAA Adjustment Reason Code Crosswalk table on page G- 5. Billing Instructions for Direct Data Entry (DDE)