Commonwealth of Massachusetts Executive Office of Health and Human Services Office of Medicaid www.mass.gov/masshealth MassHealth Transmittal Letter AIH-48 April 2013 TO: Acute Inpatient Hospital Providers Participating in MassHealth FROM: Julian J. Harris, M.D., Medicaid Director RE: Acute Inpatient Hospital 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 Acute Inpatient Hospital 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.) Acute Inpatient Hospital Manual Pages vi and D-1 through D-8 OBSOLETE MATERIAL (The pages listed here are no longer in effect.) Acute Inpatient Hospital Manual Pages vi and D-1 through D-8 — transmitted by Transmittal Letter AIH-47 Commonwealth of Massachusetts MassHealth Provider Manual Series Acute Inpatient Hospital Manual Subchapter Number and Title Table of Contents Page vi Transmittal Letter AIH-48 Date 12/01/13 Appendix A. Directory.... A-1 Appendix B. Enrollment Centers......... B-1 Appendix C. Third-Party-Liability Codes ............. C-1 Appendix D. Supplemental Instructions for Submitting Claims with Other Insurance................. D-1 Appendix E. Information Required for the Utilization Management Program ........... E-1 Appendix F. Admission Guidelines .......................... F-1 Appendix U. DPH-Designated Serious Reportable Events That Are Not Provider Preventable Conditions............................................ U-1 Appendix V. MassHealth Billing Instructions 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 Services Screening 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 Acute Inpatient Hospital Manual Transmittal Letter AIH-48 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. Providers must submit a claim and seek a new coverage determination from the insurer any time a member’s condition changes and the member is determined to be at a hospital level of care, or if a member’s 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 notice of noncoverage; . Medicare remittance advice; and . original explanation of benefits (EOB) and 835 transaction. 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. These crossover claims are suspended with error code 1803 (Recycle Medicare Part A Claim). MMIS systematically collects the Medicare Part B ancillary payments associated with the inpatient stay that have adjudicated in MMIS, and deducts the Medicare Part A and Part B payments from the final mid-stay crossover claim payment. 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 coordination of benefits (COB) requirements if . 60 days have passed since they 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 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. Medicare Part B ancillary payments are systematically deducted from the MassHealth mid-stay crossover claim payment. Providers should follow instructions found in MassHealth billing guides for claims submissions. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title Appendix D: Supplemental Instructions for Claims with Other Insurance Page D-2 Acute Inpatient Hospital Manual Transmittal Letter AIH-48 Date 12/01/12 TPL Exception Criteria This appendix contains supplemental billing instructions for submitting 837I transactions, direct data entry claims (DDE), and paper claims for dually eligible members (Medicare and MassHealth) when services are determined to be not covered by Medicare. Providers must continue to bill Medicare for all Part B ancillary and physician services associated with the inpatient stay before billing MassHealth for the noncovered Part A services. This section describes the TPL exceptions that may apply when members have Medicare. Providers must bill acute inpatient hospital services for a MassHealth member who has to Medicare before billing MassHealth, unless a Medicare notice of noncoverage has been issued. There may be instances when the services provided are not covered by Medicare including when . the benefit maximum for this time period or occurrence has been reached; . the member does not qualify for the new Medicare benefit period; . Medicare does not support the patient level of service; and . the member is on administrative days. Follow the instructions outlined in this appendix for claim submissions 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 Medicare, 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 Description 2320 SBR09 (Claim Filing Indicator) MA 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) 0084000 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title Appendix D: Supplemental Instructions for Claims with Other Insurance Page D-3 Acute Inpatient Hospital Manual Transmittal Letter AIH-48 Date 12/01/12 Medicare Part B The table below contains the critical loops and segments required to report Medicare Part B ancillary payments associated with the inpatient stay when a member’s Medicare Part A benefit has been exhausted. Providers must complete 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. Please Note: For COB balancing, the sum of the claim level Medicare Part B payer paid amount and HIPAA adjustment amounts must balance to the claim billed amount. Providers should report a claim adjustment segment (CAS) with the appropriate reason code and amount on their Medicare Part B payer loop. Medicare Part B Ancillary Payments Loop Segment Value Description 2320 SBR09 (Claim Filing Indicator) MB 2320 AMT01 (Paid Amount Qualifier) D 2320 AMT02 (Medicare/Other Insurance Prior Payment Amount) Payer paid amount 2330B NM109 (Medicare Part B) 0085000 2330B DTP01 (Date Claim Paid Qualifier) 573 2330B DTP03 (Check or Remittance Date) Medicare’s payment date Billing Instructions for Direct Data Entry (DDE) Medicare Part A 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 Medicare, and that meet the TPL exception criteria described in this appendix. Providers must follow the 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 following table. 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-4 Acute Inpatient Hospital Manual Transmittal Letter AIH-48 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 0084000. Carrier Name Enter Medicare Part A. 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 no 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. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title Appendix D: Supplemental Instructions for Claims with Other Insurance Page D-5 Acute Inpatient Hospital Manual Transmittal Letter AIH-48 Date 12/01/12 COB Detail Panel (cont.) Field Name Instructions Relationship to Subscriber Select the appropriate code from the drop-down list. 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. Medicare Part B Providers must enter information in the fields given below to report Medicare Part B ancillary payments associated with the inpatient stay when a member’s Medicare Part A benefit has been exhausted. 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 following table. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title Appendix D: Supplemental Instructions for Claims with Other Insurance Page D-6 Acute Inpatient Hospital Manual Transmittal Letter AIH-48 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 0085000. Carrier Name Enter Medicare Part B. Remittance Date Enter the other payer‘s EOB date. Please Note: This is a required field. Payer Claim Number Enter the other insurer claim number on the EOB. Payer Responsibility Select the appropriate code from the drop-down list. COB Payer Paid Amount Enter the Medicare B prior paid amount. Total Noncovered Amount Do not enter a total noncovered amount. Remaining Patient Liability Do not enter any values. Claim Filing Indicator Select “MB” from the drop-down list. 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-7 Acute Inpatient Hospital Manual Transmittal Letter AIH-48 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 Enter Subscriber ID number Enter the Subscriber ID number for the Other Insurance number. Please Note: For COB balancing, the sum of the Medicare Part B payer paid amount entered on the COB detail panel and the HIPAA adjustment amounts entered on the List of COB reasons panel should balance to the total charges entered on the Billing and Services tab. To submit a HIPAA adjustment reason code and amount for the Medicare Part B payer, from the list of COB reasons panel, click on “New Item” and complete the fields as described below. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title Appendix D: Supplemental Instructions for Claims with Other Insurance Page D-8 Acute Inpatient Hospital Manual Transmittal Letter AIH-48 Date 12/01/12 List of COB Reasons Panel Field Name Instructions Group Code Select the appropriate code from the drop-down list. Amount Enter the adjustment amount associated with the group/reason code. Units of Service Enter the units of service. Reason Enter the reason code identifying the detailed reason the adjustment was made. Click “Add” to save COB reasons. Click “Add” to save the COB detail 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 Medicare, 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. To report Medicare Part B ancillary payments associated with the inpatient stay when a member’s Medicare Part A benefit has been exhausted, providers should attach the Medicare Part B explanation of benefits (EOB) to the UB-04 claim form and follow these instructions. . Circle the applicable EOB information that corresponds to the claim. . Write the carrier code 0085000 on the EOB. 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.