Medicare Secondary Payer (MSP) Conditional Claims When Primary Payer Does Not Make Payment August 2009 TMP-EDO-0006 V: 5.0 9/29/08 DISCLAIMER This information release is the property of NHIC, Corp. It may be freely distributed in its entirety but may not be modified, sold for profit or used in commercial documents. The information is provided “as is” without any expressed or implied warranty. While all information in this document is believed to be correct at the time of writing, this document is for educational purposes only and does not purport to provide legal advice. All models, methodologies and guidelines are undergoing continuous improvement and modification by NHIC, Corp. and the Centers for Medicare & Medicaid Services (CMS). The most current edition of the information contained in this release can be found on the NHIC, Corp. Web site at www.medicarenhic.com and the CMS Web site at www.cms.hhs.gov. The identification of an organization or product in this information does not imply any form of endorsement. MSP CONDITIONAL CLAIMS 2 TMP-EDO-0006 v.5.0 9/29/08 Acronyms CC Condition Code CMS Centers for Medicare & Medicaid Services COBC Coordination of Benefits Contractor CWF Common Working File DDE Direct Data Entry DOA Date of Accident DOS Date of Service EGHP Employer Group Health Plan EOB Explanation of Benefits ESRD End-Stage Renal Disease MSP CONDITIONAL CLAIMS 3 TMP-EDO-0006 v.5.0 9/29/08 Acronyms FISS Fiscal Intermediary Standard System GHP Group Health Plan Health Maintenance Organization (through HMO employer) ID Identification IOM Internet-Only Manual IP Inpatient LGHP Large Group Health Plan MSP Medicare Secondary Payer MSPRC Medicare Secondary Payer Recovery Contractor OC Occurrence Code MSP CONDITIONAL CLAIMS 4 TMP-EDO-0006 v.5.0 9/29/08 Acronyms OC Occurrence Code OP Outpatient PIP Personal Injury Protection RTP Return to Provider UB Uniform Billing VC Value Code MSP CONDITIONAL CLAIMS 5 TMP-EDO-0006 v.5.0 9/29/08 Objective Educate providers on why, when, and how to submit MSP conditional claims to Medicare MSP CONDITIONAL CLAIMS 6 TMP-EDO-0006 v.5.0 9/29/08 Agenda General information about conditional claims Conditional claim coding Conditional claim scenarios What you should do now Open question and answer segment MSP CONDITIONAL CLAIMS 7 TMP-EDO-0006 v.5.0 9/29/08 Conditional Claims General Information TMP-EDO-0006 V: 5.0 9/29/08 MSP - Defined Refers to situations in which Medicare does not have primary responsibility for paying health care claims for Medicare beneficiary • Beneficiary has other coverage that should pay primary based on federal law MSP CONDITIONAL CLAIMS 9 TMP-EDO-0006 v.5.0 9/29/08 Provider’s MSP Requirements Any provider that submits claims to Medicare must • Determine whether or not there are payers primary to Medicare for services rendered, and • Submit claims to those primary payers before submission to Medicare MSP CONDITIONAL CLAIMS 10 TMP-EDO-0006 v.5.0 9/29/08 Did You Know… Medicare is prohibited from making payment if payment has been made or can reasonably be expected to be made promptly, by a primary payer MSP CONDITIONAL CLAIMS 11 TMP-EDO-0006 v.5.0 9/29/08 Claim Status with Primary Payer Once proper claims have been filed with primary payers, those payers either • Make payment on claims, or • Do not make payment on claims –For valid reasons, or –Promptly (within 120 days) –Because they are not primary, Medicare is primary MSP CONDITIONAL CLAIMS 12 TMP-EDO-0006 v.5.0 9/29/08 Conditional Claims - Defined Claims submitted to Medicare requesting payment because primary payer • Did not make payment for valid reasons, or –All MSP VCs except 16 and 42 • Did not make payment promptly (within 120 days) –MSP VCs 14, 15, 41 and 47 only Resemble MSP claims except primary payer’s payment amount is zero (0000.00) MSP CONDITIONAL CLAIMS 13 TMP-EDO-0006 v.5.0 9/29/08 Primary Payer Did Not Make Payment for Valid Reason Only certain reasons are considered valid • Examples include, but are not limited to: –Benefits exhausted/maximum benefit reached –Not a covered benefit –Preexisting condition –Applied payment toward plan’s deductible, coinsurance or co- payment MSP CONDITIONAL CLAIMS 14 TMP-EDO-0006 v.5.0 9/29/08 Primary Payer Did Not Make Payment Promptly Only applies to specific MSP Provisions • No-Fault insurance including Med-Pay and PIP (MSP VC 14) • Workers Compensation (MSP VC 15) • Federal Black Lung Program (MSP VC 41) • Liability insurance (MSP VC 47) –Provider must withdraw claim with primary payer before submitting conditional claim to Medicare MSP CONDITIONAL CLAIMS 15 TMP-EDO-0006 v.5.0 9/29/08 Conditional Payment by Medicare Medicare may make conditional payment • Payment amount is equal to amount that would be paid if Medicare were primary MSP CONDITIONAL CLAIMS 16 TMP-EDO-0006 v.5.0 9/29/08 When Medicare Will Not Make a Conditional Payment Conditional payment will not be made if primary payer has not been billed, has not paid, or has not paid promptly, because • Beneficiary refuses to –File a claim with insurer, or –Cooperate with provider in filing claim • Provider/beneficiary failed to file proper claim with insurer –Unless due to beneficiary’s mental or physical incapacity MSP CONDITIONAL CLAIMS 17 TMP-EDO-0006 v.5.0 9/29/08 Did You Know… Providers should not submit conditional claims to Medicare when the reason the primary payer has not made payment is because the plan is not the appropriate primary payer for the beneficiary; Medicare is primary. The following slide contains a list, which is not all- inclusive, of reasons why Medicare is primary and should be billed as such. MSP CONDITIONAL CLAIMS 18 TMP-EDO-0006 v.5.0 9/29/08 When to Submit a Medicare Primary Claim Beneficiary not enrolled in GHP or GHP terminated • Contact COBC Beneficiary has GHP but it is not primary to Medicare • Contact COBC and report any applicable CC Beneficiary and/or spouse retired • Report OC 18 and/or 19 with date(s) of retirement Services not related to prior accident (MSP file on CWF) • Report in Remarks Services related to accident, another insurer was primary, however, Medicare is now primary because case settled • Contact MSPRC Services related to accident but no other insurer is primary • Report OC 05 and DOA; see example on next slide MSP CONDITIONAL CLAIMS 19 TMP-EDO-0006 v.5.0 9/29/08 When to Submit a Medicare Primary Claim Situation: Services related to accident, but no other insurance is primary • Beneficiary is driver in one-car automobile accident • Does not carry optional medical payment coverage • No liability per MSP questionnaire • No MSP file on CWF to contradict this information Provider action • Submit Medicare primary claim –Report OC 05 and DOA MSP CONDITIONAL CLAIMS 20 TMP-EDO-0006 v.5.0 9/29/08 Claim Forms and Coding Conditional Claims TMP-EDO-0006 V: 5.0 9/29/08 Claim Forms CMS-1450/UB-04 Claim entry through FISS/DDE Electronic claim (837) MSP CONDITIONAL CLAIMS 22 TMP-EDO-0006 v.5.0 9/29/08 General Instructions for Conditional Claims Providers must report • Primary payer as first payer • Medicare as second payer • All other applicable MSP billing codes in appropriate claim fields (FLs) to indicate claim is a conditional claim –Use MSP Billing Code Chart (handout), and –List billing code options for certain FLs to complete for conditional claims, MSP claims as well as Medicare primary claims when provider needs to let us know the reason why we are primary –Use MSP information collected from beneficiary and/or his/her representative/family member MSP CONDITIONAL CLAIMS 23 TMP-EDO-0006 v.5.0 9/29/08 Claim Fields to Complete Use MSP Billing Code Chart Code UB-04 FLs FISS/DDE CCs 18 – 28 Page 1 OCs and dates 31 – 34 Page 1 VC and zero payment 39 – 41 Page 1 Primary payer code N/A Page 3 Patient’s relationship to insured 59A Page 5 Reason primary payer did not pay 80 (remarks) Page 4 MSP CONDITIONAL CLAIMS 24 TMP-EDO-0006 v.5.0 9/29/08 CCs Report applicable MSP-related CCs • CC 02 – Condition is employment-related • CC 06 – ESRD beneficiary in first 30 months of entitlement covered by an EGHP • Report, as applicable, any other CC • Do not report a claim change reason code unless claim is an adjustment to a previously submitted claim MSP CONDITIONAL CLAIMS 25 TMP-EDO-0006 v.5.0 9/29/08 OCs and Dates Report OC 33 and first date of ESRD MSP coordination period • If beneficiary is ESRD beneficiary with EGHP Report OC and DOA if claim related to accident for which another plan is primary • 01 with DOA if Med-Pay • 02 with DOA if No-Fault • 03 with DOA if Liability • 04 with DOA if Workers Compensation Report, as applicable, any other OC and date MSP CONDITIONAL CLAIMS 26 TMP-EDO-0006 v.5.0 9/29/08 Did You Know… Automobile No-Fault states include Florida, Hawaii, Kansas, Kentucky, Massachusetts, Michigan, Minnesota, North Dakota, New Jersey, New York, Pennsylvania, and Utah. Puerto Rico, a US commonwealth, is also No-Fault. MSP CONDITIONAL CLAIMS 27 TMP-EDO-0006 v.5.0 9/29/08 OC 24 and Date Report OC 24 and date of primary payer’s denial • Date of primary payer’s EOB statement or letter that explains reason they did not make payment for valid reason Do not report OC 24 and date of primary payer’s denial • When conditional claim is result of not receiving a prompt payment from primary payer –MSP VCs 14, 15, 41 or 47 only MSP CONDITIONAL CLAIMS 28 TMP-EDO-0006 v.5.0 9/29/08 OC 24 Tip Report OC 24 on conditional claims only • Claims that contain OC 24 and date of primary payer’s denial will be RTP with reason code 31409 if there is no MSP VC and zero payment (0000.00) present MSP CONDITIONAL CLAIMS 29 TMP-EDO-0006 v.5.0 9/29/08 Correcting Reason Code 31409 If billing conditionally • Enter appropriate MSP VC and zero payment (0000.00) and all required conditional claim coding If not billing conditionally • Remove OC 24 and date of primary plan’s denial and code claim as intended (Medicare primary or MSP) MSP CONDITIONAL CLAIMS 30 TMP-EDO-0006 v.5.0 9/29/08 VC and Amount Report applicable MSP VC: • 12 = Working Aged with EGHP (age 65 and over) • 13 = ESRD MSP • 14 = Med-Pay (automobile or non-automobile) • 14 = No-Fault (automobile) • 15 = Workers Compensation • 41 = Federal Black Lung Program • 43 = Disabled with LGHP (under age 65) • 47 = Liability (automobile or non-automobile) VC amount must equal zero ($0000.00) Do not report a VC 44 and amount MSP CONDITIONAL CLAIMS 31 TMP-EDO-0006 v.5.0 9/29/08 FISS/DDE Claim Entry Page 01 MAP1711 PAGE 01 NHIC, CORP. XXXX681 07/22/09 XXXXXXX SC INST CLAIM ENTRY HIC TOB 131 S/LOC S B0100 OSCAR SV: UB-FORM NPI TRANS HOSP PROV PROCESS NEW HIC PAT.CNTL#: TAX#/SUB: TAXO.CD: STMT DATES FROM TO DAYS COV N-C CO LTR LAST FIRST MI DOB ADDR 1 2 3 4 CARR: 5 6 LOC: ZIP SEX MS ADMIT DATE HR TYPE SRC D HM STAT COND CODES 01 XX 02 03 04 05 06 07 08 09 10 OCC CDS/DATE 01 XX MM/DD/YY 02 03 04 05 06 07 08 09 10 SPAN CODES/DATES 01 02 03 04 05 06 07 08 09 10 FAC.ZIP DCN V A L U E C O D E S - A M O U N T S - A N S I MSP APP IND 01 XX $0000.00 02 03 04 05 06 07 08 09 PLEASE ENTER DATA PRESS PF3-EXIT PF5-SCROLL BKWD PF6-SCROLL FWD PF7-PREV PF8-NEXT MSP CONDITIONAL CLAIMS 32 TMP-EDO-0006 v.5.0 9/29/08 Primary Payer Code In FISS/DDE, report primary payer as first payer and Medicare as second • Payer code = C (conditional) for primary payer –First payer = Payer A, line A • Payer code = Z (Medicare) for secondary payer –Second payer = Payer B, line B MSP CONDITIONAL CLAIMS 33 TMP-EDO-0006 v.5.0 9/29/08 FISS/DDE Claim Entry Page 03 MAP1713 PAGE 03 NHIC, CORP. XXXXX681 07/22/09 XXXXXXX SC INST CLAIM ENTRY HIC TOB 131 S/LOC S B0100 PROVIDER OFFSITE ZIPCD: CD ID PAYER OSCAR RI AB EST AMT DUE A C B Z C DUE FROM PATIENT MEDICAL RECORD NBR COST RPT DAYS NON COST RPT DAYS DIAGNOSIS CODES 1 2 3 4 5 6 7 8 9 END OF POA IND ADMITTING DIAGNOSIS E CODE HOSPICE TERM ILL IND IDE PROCEDURE CODES AND DATES 1 2 3 4 5 6 NDC CODE ESRD HOURS ADJUSTMENT REASON CODE REJECT CODE NONPAY CODE ATT PHYS NPI LN FN MI OPR PHYS NPI LN FN MI OTH PHYS NPI LN FN MI PROCESS COMPLETED --- PLEASE CONTINUE PRESS PF3-EXIT PF7-PREV PF8-NEXT PF9-UPDT MSP CONDITIONAL CLAIMS 34 TMP-EDO-0006 v.5.0 9/29/08 Patient’s Relationship to Insured When reporting a primary payer as first payer and Medicare as second, report patient’s relationship to insured • 01 through G8 –01 - Spouse –18 - Self –19 - Child –20 - Employee –21 - Unknown –39 - Organ Donor –40 - Cadaver Donor –53 - Life partner –G8 - Other relationship MSP CONDITIONAL CLAIMS 35 TMP-EDO-0006 v.5.0 9/29/08 FISS/DDE Claim Entry Page 05 MAP1715 PAGE 05 NHIC, CORP. XXXXXA681 07/22/09 XXXXXXX SC INST CLAIM ENTRY HIC TOB 131 S/LOC S B0100 PROVIDER INSURED NAME REL CERT-SSN-HIC SEX GROUP NAME DOB INS GROUP NUMBER A XX B C TREAT. AUTH. CODE TREAT. AUTH. CODE TREAT. AUTH. CODE PROCESS COMPLETED --- PLEASE CONTINUE PRESS PF3-EXIT PF7-PREV PF8-NEXT PF9-UPDT MSP CONDITIONAL CLAIMS 36 TMP-EDO-0006 v.5.0 9/29/08 Remarks Report two-position explanation code on all conditional claims to represent reason primary payer has not made payment or has not made payment promptly • Select from list of ten (10) codes –NB, PC, CD, FG –BE, PE –DA –DP, LD, PP MSP CONDITIONAL CLAIMS 37 TMP-EDO-0006 v.5.0 9/29/08 FISS/DDE Claim Entry Page 04 MAP1714 PAGE 04 NHIC, CORP. XXXXX681 07/22/09 XXXXXXX SC INST CLAIM ENTRY REMARK PAGE 01 HIC TOB 131 S/LOC S B0100 PROVIDER REMARKS 2-DIGIT EXPLANATION CODE 47 PACEMAKER 48 AMBULANCE 40 THERAPY 41 HOME HEALTH 58 HBP CLAIMS (MED B) E1 ESRD ATTACH ANSI CODES - GROUP: ADJ REASONS: APPEALS: PROCESS COMPLETED --- PLEASE CONTINUE PRESS PF3-EXIT PF5-SCROLL BKWD PF6-SCROLL FWD PF7-PREV PF8-NEXT PF9-UPDT MSP CONDITIONAL CLAIMS 38 TMP-EDO-0006 v.5.0 9/29/08 NB, PC, CD, and FG Can use with Code Description MSP VCs 12, 13, 14, 15, 41, NB Not a covered benefit 43 PC Pre-existing condition 12, 13, 43 Primary payment applied toward plan CD 12, 13, 43 deductible and/or coinsurance Beneficiary did not follow rules of GHP (VCs 12, 13, 43) or rules of Workers Compensation (VC 15) FG •Untimely filing with primary payer 12, 13, 15, 43 •Out of network (we will pay once) •No prior authorization MSP CONDITIONAL CLAIMS 39 TMP-EDO-0006 v.5.0 9/29/08 Did You Know… All conditional claims submitted with an FG explanation code for GHP rejections due to out of network, untimely filing or no prior authorization will suspend for investigation. There must be remarks explaining which primary health plan guideline the beneficiary failed to follow or the claim will be returned (RTP). MSP CONDITIONAL CLAIMS 40 TMP-EDO-0006 v.5.0 9/29/08 BE and PE (Benefits Exhausted) Can use with Code Description MSP VCs Benefits exhausted 12, 13, 14, 15, BE No-Fault states should use PE; not BE 41, 43 PIP exhausted toward other medical PE 14 expenses Both codes require date benefits exhausted in MM/DD/YY format. If primary payer does not provide exact date, report date of primary payer’s EOB statement or rejection/denial letter. MSP CONDITIONAL CLAIMS 41 TMP-EDO-0006 v.5.0 9/29/08 Did You Know… If No-Fault or Med-Pay benefits have been exhausted, the case is not also a Liability, then Medicare considers itself to be primary following the date on which benefits have exhausted. However, we must process claims conditionally until the COBC or MSPRC terminates the online MSP file on the CWF. MSP CONDITIONAL CLAIMS 42 TMP-EDO-0006 v.5.0 9/29/08 DA (Primary Payer Does Not Pay Promptly) Can use with MSP Code Description VCs 120 days have passed since DA 14, 15, 41, 47 primary payer was billed Code requires date primary payer was billed in MM/DD/YY format. Do not report OC 24 and date when reporting explanation code of DA. MSP CONDITIONAL CLAIMS 43 TMP-EDO-0006 v.5.0 9/29/08 DP, LD, PP Code Description (Report only with MSP VC 47) Response received from liability stating they need more time DP so there will be a delay in their payment Response received from liability insurer stating they feel they LD are not responsible for claim PP Patient paid by liability insurer Code PP used only for claims involving liability insurance payments to patient where provider is not expecting any payment from patient. PP may not be used for medical payment insurance payments to patient. Providers are required to pursue those dollars. MSP CONDITIONAL CLAIMS 44 TMP-EDO-0006 v.5.0 9/29/08 Did You Know… Conditional claims will be RTP if they do not contain a two-position explanation code or if they do not contain an acceptable two-position explanation code. MSP CONDITIONAL CLAIMS 45 TMP-EDO-0006 v.5.0 9/29/08 Claim Fields to Complete Use MSP Information Collected Code UB-04 FLs FISS claim entry Payer Name 50A Page 3 Insured’s name 58A Page 5 Insured’s unique ID 60A Page 5 Insurance group name 61A Page 5 Insurance group number 62A Page 5 Insurance address 80 Page 6 Employer Name 65A N/A MSP CONDITIONAL CLAIMS 46 TMP-EDO-0006 v.5.0 9/29/08 FISS/DDE Claim Entry Page 03 MAP1713 PAGE 03 NHIC, CORP. XXXXX681 07/22/09 XXXXXXX SC INST CLAIM ENTRY HIC TOB 131 S/LOC S B0100 PROVIDER OFFSITE ZIPCD: CD ID PAYER NAME OSCAR RI AB EST AMT DUE A C COMPLETE INSURER NAME B Z MEDICARE C DUE FROM PATIENT 0.00 MEDICAL RECORD NBR COST RPT DAYS NON COST RPT DAYS DIAGNOSIS CODES 1 2 3 4 5 6 7 8 9 END OF POA IND ADMITTING DIAGNOSIS E CODE HOSPICE TERM ILL IND IDE PROCEDURE CODES AND DATES 1 2 3 4 5 6 NDC CODE ESRD HOURS ADJUSTMENT REASON CODE REJECT CODE NONPAY CODE ATT PHYS NPI LN FN MI OPR PHYS NPI LN FN MI OTH PHYS NPI LN FN MI PROCESS COMPLETED --- PLEASE CONTINUE MSP CONDITIONAL CLAIMS 47 TMP-EDO-0006 v.5.0 9/29/08 FISS/DDE Claim Entry Page 05 MAP1715 PAGE 05 NHIC, CORP. XXXXX681 07/22/09 XXXXXXX SC INST CLAIM ENTRY HIC TOB 131 S/LOC S B0100 PROVIDER INSURED NAME REL CERT-SSN-HIC SEX GROUP NAME DOB INS GROUP NUMBER A B C TREAT. AUTH. CODE TREAT. AUTH. CODE TREAT. AUTH. CODE PROCESS COMPLETED --- PLEASE CONTINUE PRESS PF3-EXIT PF7-PREV PF8-NEXT PF9-UPDT MSP CONDITIONAL CLAIMS 48 TMP-EDO-0006 v.5.0 9/29/08 FISS/DDE Claim Entry Page 06 MAP1716 PAGE 06 NHIC, CORP. XXXXX681 07/22/09 XXXXXXX SC INST CLAIM ENTRY HIC TOB 131 S/LOC S B0100 PROVIDER MSP ADDITIONAL INSURER INFORMATION 1ST INSURERS ADDRESS 1 1ST INSURERS ADDRESS 2 CITY ST ZIP 2ND INSURERS ADDRESS 1 2ND INSURERS ADDRESS 2 CITY ST ZIP PAYMENT DATA --- DEDUCTIBLE COIN CROSSOVER IND PARTNER ID PAID DATE PROVIDER PAYMENT PAID BY PATIENT REIMB RATE RECEIPT DATE 072209 PROVIDER INTEREST CHECK/EFT NO CHECK/EFT ISSUE DATE PAYMENT CODE PRICER DATA DRG OUTLIER AMT TTL BLNDED PAYMT FED SPEC GRAMM RUDMAN ORIG REIMBURSEMENT AMT NET INL TECH PROV DAYS TECH PROV CHARGES OTHER INS ID CLINIC CODE PROCESS COMPLETED --- PLEASE CONTINUE PRESS PF3-EXIT PF7-PREV PAGE PF9-UPDT ENTER-CONTINUE MSP CONDITIONAL CLAIMS 49 TMP-EDO-0006 v.5.0 9/29/08 Did You Know… Providers should maintain any documentation on file that supports their request for conditional payment from Medicare, such as the primary payer’s EOB statement, denial/rejection letter, etc.. MSP CONDITIONAL CLAIMS 50 TMP-EDO-0006 v.5.0 9/29/08 Conditional Claim Scenarios TMP-EDO-0006 V: 5.0 9/29/08 Claim Scenario #1 Stewart Stillworks Beneficiary • Is an OP in your facility on 05/10/09 • Over age 65 • Works at Actively Working Co. (over 20 employees) • GHP through XYZ Insurance is primary Provider • Total charges = $500 • Expects to receive $400 XYZ Insurance • Paid zero; per EOB statement dated 6/10/09, entire payment was applied toward plan’s deductible MSP CONDITIONAL CLAIMS 52 TMP-EDO-0006 v.5.0 9/29/08 Claim Scenario #1 Based on information you have, conditional claim should include: CC None OC 24 and 06/10/09 MSP VC 12 MSP VC amount $0000.00 Primary payer name XYZ Insurance Remarks CD MSP CONDITIONAL CLAIMS 53 TMP-EDO-0006 v.5.0 9/29/08 Claim Scenario #2 Carl Crash Beneficiary • Is an IP at your facility 01/01/09-01/04/09 • Services related to automobile accident on 11/24/08 Provider • Total charges = $5000 No-Fault Insurance • Slow Down Insurance Co. • Paid zero; per EOB statement dated 02/01/09, benefits are exhausted as of 12/31/08 MSP CONDITIONAL CLAIMS 54 TMP-EDO-0006 v.5.0 9/29/08 Claim Scenario #2 Based on information you have, conditional claim should include: CC None OCs 02 with 11/24/08 & 24 with 02/01/09 MSP VC 14 MSP VC amount $0000.00 Primary payer name Slow Down Insurance Co. Remarks PE and 12/31/08 MSP CONDITIONAL CLAIMS 55 TMP-EDO-0006 v.5.0 9/29/08 Claim Scenario #3 Pam N. Delayed Beneficiary • Is an OP at your facility on 12/01/08 • Services are related to fall in grocery store on 12/01/08 Provider • Total charges = $500 • Filed proper claim with liability on 12/10/08 • Has not been paid promptly so decides to withdraw claim with liability and request conditional payment from Medicare Liability Insurer • Sorry You Fell Co. MSP CONDITIONAL CLAIMS 56 TMP-EDO-0006 v.5.0 9/29/08 Claim Scenario #3 Based on information you have, conditional claim should include: CC None OCs 03 with 12/01/08 MSP VC 47 MSP VC amount $0000.00 Primary payer name Sorry You Fell Co. Remarks DA with 03/10/09 (date must be equal to 120th day from date primary plan billed) MSP CONDITIONAL CLAIMS 57 TMP-EDO-0006 v.5.0 9/29/08 Did You Know… Providers should always check the online MSP files on CWF to determine if there is a matching MSP file for the claim about to be submitted to Medicare. If there is no online MSP file present on the CWF, contact the COBC before submitting any MSP and/or conditional claim to Medicare. MSP CONDITIONAL CLAIMS 58 TMP-EDO-0006 v.5.0 9/29/08 What You Should Do Now Check internal systems and processes to ensure that your facility submits conditional claims when required and in accordance with Medicare’s instructions • Use this presentation and supporting documentation for assistance Develop, implement and follow internal policies for submitting MSP conditional claims Contact appropriate entity for MSP information when necessary Continue to attend MSP educational sessions Sign up for NHIC list serve on Web site MSP CONDITIONAL CLAIMS 59 TMP-EDO-0006 v.5.0 9/29/08 CMS References IOMs available on CMS’s Web site • Billing codes (including those used for conditional billing) –CMS IOM Publication 100-04, Medicare Claims Processing Manual •Chapter 25, Section 75 • Conditional billing policies –CMS IOM Publication 100-05, Medicare Secondary Payer Manual •Chapter 1, Sections 10.7 and 30 •Chapter 3, Section 40.3.1 •Chapter 5, Section 40.6 http://www.cms.hhs.gov/Manuals/IOM/list.asp MSP CONDITIONAL CLAIMS 60 TMP-EDO-0006 v.5.0 9/29/08 When to Contact COBC Telephone Inquiries 1 (800) 999-1118 Report employment changes, any other insurance coverage information Report liability, automobile/no-fault, workers compensation case General MSP questions/concerns Questions regarding MSP development letters and MSP questionnaires http://www.cms.hhs.gov/COBGeneralInformation/ MSP CONDITIONAL CLAIMS 61 TMP-EDO-0006 v.5.0 9/29/08 When to Contact MSPRC Telephone Inquiries 1 (866) 677-7220 MSP post-payment recovery functions and workloads Obtain conditional payment amount or Medicare’s final recovery claim amount Ask questions regarding MSP recovery demand letters or repayment to Medicare Request waiver of recovery with respect to beneficiary MSP debt • http://www.cms.hhs.gov/MSPRGenInfo/, or • http://www.msprc.info MSP CONDITIONAL CLAIMS 62 TMP-EDO-0006 v.5.0 9/29/08 When to Contact NHIC, Corp. Customer Care Center Part A - (877) 757-7783 RHHI - (866) 289-0423 Ask questions on submitting claims Processing claims for primary or secondary payment Accepting return of inappropriate Medicare payment Regarding Medicare claim/service denials, adjustments MSP CONDITIONAL CLAIMS 63 TMP-EDO-0006 v.5.0 9/29/08 NHIC, Corp. References Conditional billing article on Web site • Part A providers link: –http://www.medicarenhic.com/PA/PartA_msp.shtml • Home Health & Hospice providers link: –http://www.medicarenhic.com/RHHI/RHHI_msp.shtml MSP CONDITIONAL CLAIMS 64 TMP-EDO-0006 v.5.0 9/29/08 Questions? TMP-EDO-0006 V: 5.0 9/29/08 Question #1 Conditional claims are claims submitted to request payment from Medicare after the primary payer has made payment. 1. True 2. False MSP CONDITIONAL CLAIMS 66 TMP-EDO-0006 v.5.0 9/29/08 Question #2 If a provider submits a claim to a beneficiary’s GHP but receives a denial indicating that the GHP is not primary because the beneficiary retired, it should submit a conditional claim to Medicare. 1. True 2. False MSP CONDITIONAL CLAIMS 67 TMP-EDO-0006 v.5.0 9/29/08 Question #3 If a provider submits a claim to a beneficiary’s GHP but receives a an EOB statement indicating that the GHP applied their full payment toward the plan’s deductible, it may submit a conditional claim to Medicare. 1. True 2. False MSP CONDITIONAL CLAIMS 68 TMP-EDO-0006 v.5.0 9/29/08 Question #4 If a provider submits a claim to a beneficiary’s automobile Med-Pay plan but that plan does not make payment within 90 days, it may submit a conditional claim to Medicare. 1. True 2. False MSP CONDITIONAL CLAIMS 69 TMP-EDO-0006 v.5.0 9/29/08 Question #5 Conditional claims resemble MSP claims except that the primary payer’s payment amount is zero. 1. False 2. True MSP CONDITIONAL CLAIMS 70 TMP-EDO-0006 v.5.0 9/29/08 Question #6 If Medicare makes a conditional payment on a claim, the payment amount is equal to the amount that Medicare would pay on the claim if Medicare were primary. 1. True 2. False MSP CONDITIONAL CLAIMS 71 TMP-EDO-0006 v.5.0 9/29/08 Question #7 All claims submitted to Medicare conditionally must have an OC 24 and date. 1. True 2. False MSP CONDITIONAL CLAIMS 72 TMP-EDO-0006 v.5.0 9/29/08 Question #8 FISS DDE requires that the primary payer code be ‘C’ for all conditional claims regardless of the MSP VC that is reported. 1. True 2. False MSP CONDITIONAL CLAIMS 73 TMP-EDO-0006 v.5.0 9/29/08 Question #9 All claims submitted conditionally because primary payer applied their payment toward plan’s deductible should have a two-position explanation code of CD in Remarks. 1. True 2. False MSP CONDITIONAL CLAIMS 74 TMP-EDO-0006 v.5.0 9/29/08 Question #10 Claims submitted conditionally with a two-position explanation codes of BE, PE or DA do not require an associated date in MM/DD/YY format. 1. True 2. False MSP CONDITIONAL CLAIMS 75 TMP-EDO-0006 v.5.0 9/29/08 Thank You for Your Attendance TMP-EDO-0006 V: 5.0 9/29/08 www.medicarenhic.com MEDICARE ADMINISTRATIVE CONTRACTOR JURISDICTION 14 A/B/MAC NHIC, Corp. 75 Sgt William B Terry Dr. Hingham, MA 02043 www.medicarenhic.com TMP-EDO-0006 V: 5.0 9/29/08
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