Commonwealth of Massachusetts Executive Office of Health and Human Services Office of Medicaid www.mass.gov/masshealth MassHealth Transmittal Letter ALL-190 January 2012 TO: All Providers Participating in MassHealth FROM: Julian J. Harris, M.D., Medicaid Director RE: All Provider Manuals (Revised Administrative and Billing Instructions) The Centers for Medicare & Medicaid Services (CMS) requires all trading partners who submit electronic transactions to convert from Health Insurance Portability and Accountability Act (HIPAA) Accredited Standards Committee (ASC) X12 Version 4010A1 to HIPAA ASC X12 Version 5010. All covered entities (health care providers, health plans, and health care clearinghouses) must be HIPAA 5010 compliant by January 1, 2012. This letter transmits a revised Subchapter 5, Part 7 of the administrative and billing instructions for all provider manuals to reflect changes related to 5010 implementation. Please Note: The TPL Exception Form has been revised to reflect the 5010 mandate. Effective January 1, 2012, providers who have received an approved electronic claim submission waiver must submit their claim form with the updated TPL Exception Form to report noncovered charges when a dependent has insurance through an absent parent as described in Subchapter 5, Part 7. To download the 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. The revised Subchapter 5, Part 7 is effective January 1, 2012. Parts 1 through 7 of Subchapter 5 are available in your MassHealth provider manual. You can access the provider manuals from the MassHealth Web site at www.mass.gov/masshealthpubs. Click on Provider Library, then on MassHealth Provider Manuals. It is important for providers to understand that while all parts of Subchapter 5 provide general instructions on various administrative functions within MassHealth, detailed billing information is provided in the MassHealth Billing Guide for the UB-04 and the MassHealth Billing Guide for the CMS-1500. Detailed technical specifications for electronic claims submission are available in the MassHealth companion guides. Both the billing guides and the companion guides are available on the MassHealth Web site at www.mass.gov/masshealth. For billing guides, click on MassHealth Regulations and Other Publications, and then on MassHealth Billing Guides for Paper Claim Submitters. For companion guides, click on MassHealth Regulations and Other Publications, and then on MassHealth Companion Guides. MassHealth Web Site This transmittal letter and attached pages are available on the MassHealth Web site 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.) All Provider Manuals Pages 5.7-1 through 5.7-4 OBSOLETE MATERIAL (The pages listed here are no longer in effect.) Commonwealth of Massachusetts MassHealth Provider Manual Series All Provider Manuals Subchapter Number and Title 5. Administrative and Billing Instructions Transmittal Letter ALL-190 Page 5.7-1 Date 01/01/12 Part 7. Other Insurance This part contains instructions for submitting claims for services provided to members who have other health insurance or Medicare, in addition to MassHealth. MassHealth regulation at130 CMR 450.316 requires providers to make “diligent efforts” to identify and obtain payment from all other liable parties, including insurers. “Diligent efforts” is defined as making every effort to identify and obtain payment from all other liable parties, and include, but are not limited to * determining the existence of health insurance by asking the member if he or she has other insurance and by using insurance databases available to the provider; and * verifying the member’s other health insurance coverage, currently known to MassHealth through EVS, on each date of service and at the time of billing following instructions found in Part 1 of these administrative and billing instructions For additional information about third-party-liability requirements, see MassHealth regulations at 130 CMR 450.316 through 450.321. Updating Other Insurance Information If you have evidence that a member’s other health insurance information differs from what appears on EVS, you must fax or mail a Third Party Liability Indicator (TPLI) form to the TPL Unit. To download this form, go to www.mass.gov/masshealth. Click on MassHealth Provider Forms and scroll down the list. In addition to the TPLI form, please submit acceptable documentation verifying the coverage change to ensure that the member’s file is updated to reflect current information. Acceptable documentation for updating member’s insurance information includes an explanation of benefits (EOB), a letter from an employer or health insurance carrier, or a copy of the health insurance card for any new insurance. Contact information for the TPL Unit is at the bottom of the TPLI form. This information can also be found in Appendix A of your MassHealth provider manual. Member Has Other Health Insurance If the member has other insurance, submit the claim to the other insurance carrier, following the other insurer’s billing instructions. If the claim is denied for reasons other than a correctable error, or is partially paid by the other insurance carrier, you may submit the claim to MassHealth. You may not submit the claim to MassHealth if the claim is denied for noncompliance with any one of the insurer’s billing and authorization requirements. For general information about submitting the claim to MassHealth, see Part 3 of these administrative and billing instructions. Coordination of Benefits Claim Submission 837 Transaction Providers may submit coordination of benefits (COB) claims to MassHealth following instructions found in the HIPAA 837 implementation guides and MassHealth companion guides. Include the other insurer’s adjudication information in the transaction as outlined in the guides. Commonwealth of Massachusetts MassHealth Provider Manual Series All Provider Manuals Subchapter Number and Title 5. Administrative and Billing Instructions Transmittal Letter ALL-190 Page 5.7-2 Date 01/01/12 The MassHealth companion guides are available at www.mass.gov/masshealth. To start submitting claims electronically, 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. Provider Online Service Center Direct Data Entry Claim You can use the Provider Online Service Center (POSC) at www.mass.gov/masshealth/providerservicecenter to submit COB claims to MassHealth using direct data entry (DDE). Job aids are available on the Web to assist providers with COB claim submissions. To download job aids, go to www.mass.gov/masshealth. Click on Information for MassHealth Providers, then on MassHealth Provider Training. Click on NewMMIS Provider Training and choose a job aid from the list. If you have more questions about DDE claim submission, contact MassHealth Customer Service. Medicare Crossover Claims After Medicare has made a payment or applied the charge to the deductible, the coordination of benefits contractor (COBC) automatically transmits claims to MassHealth for processing. A claim must contain at least one Medicare-approved service line in order for the entire claim to be automatically crossed over to MassHealth. For Medicare crossover payment methodology, please refer to 130 CMR 450.318. Providers may submit the claim to MassHealth electronically, following the MassHealth COB requirements if 60 days have passed since you 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 Medicare Denies Your Entire Claim When there are no Medicare-approved services on your claim, you may submit a MassHealth claim after you have received an explanation of Medicare benefits (EOMB) indicating that the claim was denied for reasons other than a correctable error. A valid HIPAA adjustment reason code (ARC) from Medicare must be provided with the COB information on your claim. Adjusting a COB Claim When the primary insurer (other insurer or Medicare) voids or adjusts a claim that has been previously paid by MassHealth, providers should submit an adjustment claim to MassHealth including the revised COB information on the claim. Refer to MassHealth billing guides for instructions to submit an adjustment claim to MassHealth. Preventive Pediatric Care and Prenatal Care Services Preventive pediatric care services may be billed by the provider to MassHealth as primary when the patient has additional insurance (as described in the EPSDT and PPHSD Billing Guidelines for MassHealth Physicians and Mid-level Providers, for members under the age of 21, and prenatal care services including routine prenatal office visits and tests, for members of any age). Commonwealth of Massachusetts MassHealth Provider Manual Series All Provider Manuals Subchapter Number and Title 5. Administrative and Billing Instructions Transmittal Letter ALL-190 Page 5.7-3 Date 01/01/12 Dependent has Insurance through an Absent Parent Providers may bill services to MassHealth as the primary insurer if both the following conditions are true. * The dependent has insurance through an absent parent against whom child support enforcement is being carried out by the State Title IV-D agency (Department of Revenue). * The provider has billed the other insurer and has not received payment or a response for 30 days after billing. Providers should include the correct carrier code and noncovered amount on their claim submission. Supplemental Instructions Please refer to the appendix in your MassHealth provider manual (as listed in the table below) for supplemental instructions that may be applicable to your provider type. Provider Type Location Acute Inpatient Hospitals Appendix D of the Acute Inpatient Hospital Manual Chronic Disease and Rehabilitation Appendix D of the Chronic Disease and Rehabilitation Inpatient Hospitals Inpatient Hospital Manual Community Health Centers Appendix D of the Community Health Center Manual Home Health Agencies Appendix D of the Home Health Agency Manual Mental Health Centers Appendix D of the Mental Health Center Manual Nursing Facilities Appendix G of the Nursing Facility Manual Psychiatric Inpatient Hospitals Appendix D of the Psychiatric Inpatient Hospital Manual Commonwealth of Massachusetts MassHealth Provider Manual Series All Provider Manuals Subchapter Number and Title 5. Administrative and Billing Instructions Transmittal Letter ALL-190 Page 5.7-4 Date 01/01/12 This page is reserved.