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 HHA-42 April 2009 TO: Home Health Agencies Participating in MassHealth FROM: Tom Dehner, Medicaid Director RE: Home Health Agency Manual (New Appendix D) This letter transmits Appendix D for the Home Health Agency Manual. Appendix D is a new set of 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 837I 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 Home Health Agencies 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 Home Health Agencies. 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 this 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 Home Health Agency Bulletin 41, 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 (ARC). The instructions in Appendix D are effective upon implementation of NewMMIS on May 26, 2009. If you have any questions 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.) Home Health Agency Manual Pages vi and D-1 through D-4 OBSOLETE MATERIAL (The pages listed here are no longer in effect.) Home Health Agency Manual Page vi – transmitted by Transmittal Letter HHA-38 Inserted image of the TPL Exception Form for Home Health Agencies with instructions on how to use it. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title Table of Contents Page vi Home Health Agency Manual Transmittal Letter HHA-42 Date 05/26/09 6. Service Codes and Descriptions...................................................................................................... 6-1 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 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. Note: Providers must continue to submit the Home Health Coverage Determination Form and a copy of the insurer’s explanation of benefits (EOB) within 10 days of receipt of the EOB, as described in Home Health Agency Bulletin 46, dated January 2009. Both the form and the bulletin are available on the MassHealth Web site at www.mass.gov/masshealth. Providers must retain the original EOB 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 claim determination. When the initial claim has been adjudicated by the insurer, enter the adjudication details provided by that insurer in loops 2320, 2330, and 2430 for each claim line in the 837I transaction. 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 Code) of your MassHealth provider manual, or at www.mass.gov/masshealth. 2320 SBR09 (Claim Filing Indicator) “MA” when the other payer is Medicare “CI” when other payer is commercial insurer 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 2430 SVD01 (Payer ID Code) 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 Code) of your MassHealth provider manual, or at www.mass.gov/masshealth. 2430 SVD02 (Monetary Amount) Should not be populated with any insurance payment, coinsurance, or deductible. 2430 CAS01 (Service Line Adjustment Group Code) OA (other adjustments) 2430 CAS02 (Service Line 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. 2430 CAS03 (Monetary Amount) Billed amount 2430 DTP03 (Date, Time, or Period) Date of discharge or end date of service Billing Instructions for Paper Claims Providers must submit an initial claim to the other insurer (Medicare or commercial insurance) for claim determination. When the initial claim has been adjudicated by the insurer, the adjudication details provided by that insurer should be documented on the TPL Exception Form for Home Health Agencies to report HIPAA group and adjustment reason codes. This form is available on the MassHealth Web site at www.mass.gov/masshealth. 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 adjustment reason codes (ARCs) given in the following table may be used 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? YO - Valid EOB/Denial on file-Benefits exhausted for the calendar year 119 - Benefit maximum for this time period or occurrence has been reached for the calendar year. Yes Yes Y1 - Benefit maximum has been reached 119 - Benefit maximum for this time period or occurrence has been reached for the calendar year. Yes Yes Y2 - Insurer denied stating custodial in nature 50 -These are noncovered services because this is not deemed a “medical necessity” by the payer. No Yes Y3 - Insurer denied stating not medically necessary. 50 -These are noncovered services because this is not deemed a “medical necessity” by the payer. No Yes Y4 - Services not a covered benefit 150 - Payer deems the information submitted does not support this level of service. Yes Yes Y5 - Insurer denied not stating homebound 150 - Payer deems the information submitted does not support this level of service. Yes Yes Y6 - Insurer denied for other reason as stated on EOB 150 - Payer deems the information submitted does not support this level of service. No Yes Y7 - Service is not parttime or intermittent 152 - Payment adjusted because the payer deems the information submitted does not support this length of service. 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.