Commonwealth of Massachusetts Executive Office of Health and Human Services Office of Medicaid www.mass.gov/masshealth MassHealth Transmittal Letter NF-59 April 2013 TO: Nursing Facility Providers Participating in MassHealth FROM: Julian J. Harris, M.D., Medicaid Director RE: Nursing Facility Manual (Revised Appendix G - Coordination of Benefits Direct Data Entry Enhancements for the Provider Online Service Center) This letter transmits a revised Appendix G for the Nursing Facility Provider Manual. Appendix G 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 G. The “TPL Exceptions” section of Appendix G has been revised to include Medical Leave of Absence (MLOA) billing instructions. 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.) Nursing Facility Manual Pages G-1 through G-4 OBSOLETE MATERIAL (The pages listed here are no longer in effect.) Nursing Facility Manual Pages G-1 through G-4— transmitted by Transmittal Letter NF-58 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title Appendix G: Supplemental Instructions for TPL Exceptions Page G-1 Nursing Facility Manual Transmittal Letter NF-59 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, a Medicare Advantage plan, or other insurance. This appendix supplements the instructions found in the 837I HIPAA Implementation Guide, the MassHealth 837I Companion Guide, and MassHealth Billing Guide for the UB-04. 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. Nursing facility services for MassHealth members who have Medicare, a Medicare Advantage plan, or other insurance coverage must initially be billed to the insurance for payment before billing MassHealth, unless a Medicare skilled nursing facility advance beneficiary notice (SNFABN) or a notice of noncoverage has been issued. This requirement applies to dates of service within 100 days of the date of admission or readmission to the facility. Please refer to the date of admission requirements in this appendix. 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, 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 the other insurer previously denied coverage for the same service. Date of Admission Requirements MassHealth Members with Medicare Coverage MassHealth requires providers to change the admit date on the claim from the original date the member was admitted to the nursing facility if the member has returned to the facility following a qualifying hospital stay. The new admit date must be the day the member returns to the nursing facility following a qualifying hospital stay. MassHealth Members with a Medicare Advantage Plan and Other Insurance Coverage MassHealth requires providers to change the admit date on the claim from the original date the member was admitted to the nursing facility if the member’s condition changes and requires skilled care, or if the member has returned from a hospital stay. The new admit date must be the day the member requires skilled care or returns from a hospital stay. TPL Exception Criteria This appendix contains supplemental billing instructions for submitting 837I transactions, direct data entry claims (DDE), and paper claims for MassHealth members who have Medicare, a Medicare Advantage plan, or other insurance when services are determined to be not covered. Nursing facility services for MassHealth members who have Medicare, a Medicare Advantage plan, or other insurance coverage must initially be billed to the insurance for payment prior to billing MassHealth, unless a Medicare SNFABN or a notice of noncoverage has been issued for services determined to be not covered. There may be instances when the services provided are not covered by Medicare, the Medicare Advantage plan, or the other insurer, including if the MassHealth member does not . have benefits available (benefits exhausted); . meet the insurer’s coverage criteria; or . qualify for a new benefit period. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title Appendix G: Supplemental Instructions for TPL Exceptions Page G-2 Nursing Facility Manual Transmittal Letter NF-59 Date 12/01/12 Please Note: When you are billing MassHealth for only Medical Leave of Absence (MLOA) days that are noncovered by the insurer, and the admit date is within 100 days of the date of service, then the “Total Noncovered Amount” segment may be used to indicate that the service is noncovered by the insurer. Follow the instructions outlined in this appendix for claim submissions when one of the above TPL exceptions exists. Providers are required to keep on file for auditing purposes the . Medicare SNFABN; . remittance advice; . insurer’s notice of noncoverage; . insurer’s original explanation of benefits (EOB), the 835 transaction, or the response from the insurer. 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, a Medicare Advantage plan, or the other insurer, and that meet the TPL exception criteria described in this appendix. Providers must complete the loops and segments described in the table below and follow the 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 the 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 Medicare Advantage plan or other 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) 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. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title Appendix G: Supplemental Instructions for TPL Exceptions Page G-3 Nursing Facility Manual Transmittal Letter NF-59 Date 12/01/12 Billing Instructions for Direct Data Entry Providers must complete the coordination of benefits fields as described in the following table when submitting claims to MassHealth that have been determined to be not covered by Medicare, the Medicare Advantage plan, or the other insurer, and that meet the TPL exception criteria described in this appendix. Providers must follow the instructions described in the HIPAA 837I Implementation Guide and MassHealth 837I Companion Guide 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 report the HIPAA adjustment reason codes and amounts on the List of COB Reasons panel when reporting a total noncovered amount. In 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 Enter the total billed amount. The total noncovered amount must equal total billed amount. Remaining Patient Liability Do not enter any values. Claim Filing Indicator Medicare = MA Medicare Advantage plan or other 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 G: Supplemental Instructions for TPL Exceptions Page G-4 Nursing Facility Manual Transmittal Letter NF-59 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. 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, the Medicare Advantage plan, or the other insurer, 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. 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 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.