Commonwealth of Massachusetts Executive Office of Health and Human Services Office of Medicaid www.mass.gov/masshealth MassHealth Transmittal Letter HHA-47 March 2013 TO: Home Health Agency Providers Participating in MassHealth FROM: Julian J. Harris, M.D., Medicaid Director RE: Home Health Agency 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 Home Health Agency Provider Manual. Appendix D contains specific MassHealth billing instructions that supplement the instructions found in the HIPAA 837I Implementation Guide, in 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) data entry enhancements (DDE) 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.) Home Health Agency Pages vi and D-1 through D-6 OBSOLETE MATERIAL (The pages listed here are no longer in effect.) Home Health Agency Page vi — transmitted by Transmittal Letter HHA-46 Pages D-1 through D-6 — transmitted by Transmittal Letter HHA-45 Commonwealth of Massachusetts MassHealth Provider Manual Series Home Health Agency Manual Subchapter Number and Title Table of Contents Page vi Transmittal Letter HHA-47 Date 12/01/12 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 TPL Exceptions ............................................... D-1 Appendix E. Criteria for Provider Liability............................. E-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 Screening Services Codes............. Z-1 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title Appendix D: Supplemental Instructions for TPL Exceptions Page D-1 Home Health Agency Manual Transmittal Letter HHA-47 Date 12/01/12 Supplemental Instructions for TPL Exceptions Submitting Claims for Members with Medicare or Commercial Insurance This appendix contains supplemental billing instructions for submitting 837I transactions, direct data entry (DDE) claims, or paper claims for members who have Medicare or commercial insurance, and whose services are determined not covered by the primary insurer. This appendix describes TPL exceptions that may apply when members have Medicare or commercial insurance. This appendix contains specific MassHealth billing instructions and supplements the instructions found in the HIPAA 837I Implementation Guide, the MassHealth 837I Companion Guide, and the 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 or health insurance coverage status changes, even if Medicare or a commercial insurer previously denied coverage for the same service. Medicare Exceptions Home-health services for a MassHealth member must be billed to Medicare unless one or more of the following exceptions exists. . The member is not confined to place of residence. . The member is not part-time or intermittent; death is imminent. . The member is not part-time or intermittent; alternative is more costly. . The member is not part-time or intermittent; alternative is being sought. . The member is not part-time; physician documentation of medical necessity exceeds eight hours. . The member is not intermittent; physician documentation of medical necessity exceeds 21 days. . The member is receiving occupational therapy only. Medicare If one of these TPL exceptions exists above, follow the instructions outlined in this appendix for claim submission. Providers must file a claim and seek a new coverage determination any time a member’s medical condition or medical circumstance changes, even if Medicare previously denied coverage for the same service. Providers are required to retain the Medicare advance beneficiary notice (ABN) for auditing purposes. Medicare Denials If a claim for a MassHealth member has been submitted to Medicare and subsequently denied, providers must forward the Medicare remittance advice to MassHealth within 10 days of its receipt. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title Appendix D: Supplemental Instructions for TPL Exceptions Page D-2 Home Health Agency Manual Transmittal Letter HHA-47 Date 12/01/12 Remittance advices must be sent to the following address. UHealth Solutions, Inc. Third-Party Appeals Unit Medicare Appeals Unit 100 Century Drive Worcester, MA 01606 Commercial Insurance Home health services for a member with commercial insurance must generally be billed to the commercial insurer before submitting a claim to MassHealth. Refer to MassHealth regulations at 130 CMR 450.316. Even if an insurer previously denied coverage for the same service, providers must submit a claim and seek a new coverage determination from an insurer whenever there is a new admission or a change in the member’s medical condition or health insurance coverage status, known as a “qualifying event.” A qualifying event is defined as any change in a member’s condition or circumstance that may trigger a change in insurance coverage. The following list includes some examples of qualifying events that would require a coverage determination by a commercial insurer. . new services from a home health agency (HHA); . new HHA services after discharge from an inpatient hospital or skilled facility stay resulting in a change of skilled services in the plan of care; . new commercial insurance coverage or change of insurer; . commencement of annual commercial insurance coverage or other periodic benefit(s); . reinstatement of insurance benefits; or . change in the patient’s medical condition resulting in a change of skilled services in the plan of care. If after review, the commercial carrier has denied the claim due to noncoverage, providers should follow the HIPAA implementation guides and MassHealth companion guides for submission of the initial claim to MassHealth. Implementation and companion guides are available on the MassHealth website at www.mass.gov/masshealth. Providers are required to keep on file for auditing purposes the insurer’s original explanation of benefits (EOB), 835 transaction, or response from the insurer. Providers must continue to submit a copy of the insurer’s denial accompanied by the Home Health Coverage Determination Form within 10 days of its receipt as instructed in Home Health Agency Bulletin 46, dated January 2009. Both the form and the bulletin are available on the MassHealth website at www.mass.gov/masshealth. TPL Exception Criteria Claims for MassHealth members who have Medicare or commercial insurance must be initially billed to Medicare or the commercial insurer, or a Medicare ABN must be issued. There may be instances when the services provided are not covered by the other insurer, including if the MassHealth member does not . have benefits available (benefits have been exhausted); . meet the insurer’s coverage criteria; or . qualify for a new benefit period. Follow the instructions outlined in this appendix for claim submissions when a TPL exception exists. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title Appendix D: Supplemental Instructions for TPL Exceptions Page D-3 Home Health Agency Manual Transmittal Letter HHA-47 Date 12/01/12 Providers are required to keep the following items on file for auditing purposes. . the Medicare ABN; . the Medicare remittance advice: and . the commercial insurer’s original EOB, 835 transaction, or response from the insurer. Billing Instructions for 837I Transactions Providers must follow HIPAA 837I Implementation Guide and MassHealth 837I Companion Guide instructions. Complete the other payer loops in the 837I transactions as described in the following table when submitting claims to MassHealth that have been determined not covered by the other insurer, and that meet the TPL exception criteria. 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 listed in this section. 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) MassHealth-assigned carrier code for the other payer Please Note: MassHealth-assigned carrier codes may be found in Appendix C (ThirdParty- 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 section. 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. 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 TPL Exceptions Page D-4 Home Health Agency Manual Transmittal Letter HHA-47 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 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 TPL Exceptions Page D-5 Home Health Agency Manual Transmittal Letter HHA-47 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. 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. 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. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title Appendix D: Supplemental Instructions for TPL Exceptions Page D-6 Home Health Agency Manual Transmittal Letter HHA-47 Date 12/01/12 This page is reserved.