Revised Draft November 14, 2002

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Revised Draft November 14, 2002

Transcript Of Revised Draft November 14, 2002

North Carolina Medicaid Special Bulletin
An Information Service of the Division of Medical Assistance
Number VI
Attention:
All Providers

September 2002

Medicare Part B Billing Guidelines
REVISED DRAFT NOVEMBER 14, 2002

Table of Contents
Introduction .............................................................................................................................................1 Medical Policy .............................................................................................................................................1
Copayments ...................................................................................................................................... 1 Carolina ACCESS (CA) Primary Care Providers (PCPs)................................................................1 Prior Approval..................................................................................................................................1 24-Visit Limitation...........................................................................................................................1 Hysterectomy, Sterilization, and Abortion Consents/Statements.....................................................1 Eligibility .............................................................................................................................................2 Blue Medicaid Identification Card...................................................................................................2
Example of Blue MID Card ................................................................................................2 Buff MEDICARE-AID ID Card ......................................................................................................3
Example of Buff MEDICARE-AID ID Card......................................................................3 Billing the Recipient ....................................................................................................................................4 Billing Guidelines ........................................................................................................................................4
CMS-1500 Claim Forms ..................................................................................................................4 Example 1: Medicare/Medicaid Only ................................................................................4 Example 2: Medicare/TPL/Medicaid .................................................................................5 Example 3: Medicare Non-Covered Services ....................................................................5 Example 4: Medicare Non-Covered and TPL Payment .....................................................6 Example 5: Medicare Paid and TPL Non-Covered............................................................6 Example 6: Medicare Applies 100 Percent of Payment Towards the Deductible..............7 CMS-1500 Claim Form Examples......................................................................................8
UB-92 Claim Forms .......................................................................................................................14 Example 1: Medicare/Medicaid Only ..............................................................................14 Example 2: Medicare/TPL/Medicaid ...............................................................................14 Example 3: Medicare Non-Covered Services ..................................................................15 Example 4: Medicare Non-Covered and TPL Payment ...................................................15 Example 5: Medicare Paid and TPL Non-Covered..........................................................16 Example 6: Medicare Applies 100 Percent of Payment Towards the Deductible............16 UB-92 Claim Form Examples...........................................................................................17
ADA Claim Forms .........................................................................................................................23 Example 1: Medicare/Medicaid Only ..............................................................................23 Example 2: Medicare/TPL/Medicaid ...............................................................................23 Example 3: Medicare Non-Covered Services ..................................................................24 Example 4: Medicare Non-Covered and TPL Payment ...................................................24 Example 5: Medicare Paid and TPL Non-Covered..........................................................25 Example 6: Medicare Applies 100 Percent of Payment Towards the Deductible............25 ADA Claim Form Examples .............................................................................................26
Medicaid Claim Resolution Inquiries......................................................................................................32 Instructions for Completing the Medicaid Resolution Inquiry Form.............................................32 Medicaid Resolution Inquiry Form ................................................................................................33
Remittance and Status Reports................................................................................................................34 Example of Paid Claims Section of the RA ...................................................................................35 Example of Denied Claims Section of the RA...............................................................................36
N.C. Medicaid Program Automated Voice Response System................................................. 37

N.C. Medicaid Special Bulletin VI

REVISED DRAFT NOVEMBER 14, 2002

September 2002

Introduction
Effective with dates of service October 1, 2002, billing and payment guidelines have changed for Medicaid claims when Medicare Part B is the recipient’s primary payer. For any recipient with Medicare Part B coverage in addition to Medicaid coverage, providers must file claims directly to Medicare and receive Medicare payment or denial before submitting the claim to Medicaid. Claims filed to Medicare will no longer be crossed over automatically to Medicaid for payment. Once the provider receives the Medicare voucher, the provider is required to submit a claim for those Medicaid covered services directly to Medicaid indicating the Medicare payment as a third party payment on the claim form. These claims are referred to as Medicare TPL claims. Claims can be submitted to Medicaid either electronically or on paper.
The Balanced Budget Act of 1997 permits states to limit payment for dually eligible recipients (Medicare/Medicaid eligible) to no more than Medicaid’s maximum allowable rate. The Division of Medical Assistance (DMA) is implementing this change to ensure that all claims, including claims for Medicaid recipients who have Medicare as the primary payer, are processed based on Medicaid editing, auditing, and pricing, and that services rendered to dually eligible recipients are reimbursed at the same rate as services rendered to straight Medicaid fee-for-service recipients.

This change impacts Medicaid medical policies, procedures and billing guidelines for institutional, professional, and dental claims (UB-92, CMS-1500, and ADA) filed to Medicaid.

Medical Policy
The following medical policies have been affected by this change.
Copayments Services covered by Medicare and Medicaid are not subject to a Medicaid copayment. However, if Medicare denies the service and the provider submits the claim to Medicaid, the recipient may be responsible for the approved Medicaid copayment. Refer to the Basic Medicaid handout for additional information on copayments.
Carolina ACCESS (CA) Primary Care Providers (PCPs) When the recipient is enrolled in Carolina ACCESS – as indicated on the Medicaid identification (MID) card – and the recipient is also eligible for Medicare, the provider is responsible for obtaining a Carolina ACCESS referral. Enter the referral number in block 19 of the CMS-1500 claim form or form locator 83B on the UB-92 claim form as appropriate.
Prior Approval Medicaid does not require prior approval for any service that is covered by Medicare. However, if Medicare denies a service and Medicaid requires prior approval, the provider must obtain prior approval.
24-Visit Limitation Dually eligible recipients are now subject to Medicaid’s 24-visit limit per state fiscal year (July 1 through June 30).
Hysterectomy, Sterilization, and Abortion Consents/Statements Medicaid requires providers to submit hysterectomy and sterilization consent forms, as well as abortion statements in order to receive reimbursement for these services for dually eligible recipients. Forms must be mailed to the address listed on the form.

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N.C. Medicaid Special Bulletin VI

REVISED DRAFT NOVEMBER 14, 2002

September 2002

Eligibility
With the implementation of this change, it is imperative that providers refer to the recipient’s MID card to determine if the recipient is enrolled with Medicare as a primary insurance.

Blue Medicaid Identification (MID) Card The words Medicare A, Medicare B, or Medicare A&B will appear in the insurance data block on the blue MID card. Refer to the example below.
The blue MID card indicates the recipient is eligible for all covered Medicaid services. The card identifies the casehead of the family and all other eligible persons in the family. Each eligible family member has a specific recipient MID number. Family members are only eligible for Medicaid if their name and MID number appear on the card. If the recipient's card is marked “Prepaid Healthplan” or “HMO Enrollee,” contact the provider listed on the card before providing services, except in an emergency.
For Carolina ACCESS (CA) recipients, the blue MID card indicates the name of the CA primary care provider (PCP), the provider's address, and the daytime and after-hours telephone numbers. "Carolina ACCESS Enrollee" appears above the recipient's address. The service provider must contact the CA PCP whose name appears on the MID card to receive a Carolina ACCESS referral prior to providing services. Each CA enrollee in a family receives a separate MID card.
For recipients enrolled in a Medicaid HMO, the blue MID card indicates the name of the HMO, the HMO’s address, member services telephone number, and 24-hour medical advice line telephone number.

Example of Blue MID Card

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N.C. Medicaid Special Bulletin VI

REVISED DRAFT NOVEMBER 14, 2002

September 2002

Buff MEDICARE-AID ID Card The buff-colored MEDICARE-AID ID card, referred to as the Medicare Qualified Beneficiary (MQB-Q class) card, indicates the recipient is eligible for the MEDICARE-AID program. If both Medicare and Medicaid allow the service, Medicaid will pay the difference between the Medicare cost-sharing amounts and the Medicaid maximum allowable for the service. If Medicare denies the service, Medicaid will also deny. Recipients with a buff MEDICARE-AID ID card are not eligible to enroll in Medicaid Managed Care programs.

Example of Buff MEDICARE-AID ID Card

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N.C. Medicaid Special Bulletin VI

REVISED DRAFT NOVEMBER 14, 2002

September 2002

Billing the Recipient

A Medicaid recipient may be billed for services, including the Medicare cost sharing amounts, under the

following conditions:



The recipient does not present a Medicaid identification (MID) card showing eligibility for that

date of service.



The provider does not accept the recipient as a Medicaid patient and informs the recipient prior to

rendering the service. The recipient agrees to be billed as private pay.



The provider may bill a patient accepted as a Medicaid patient for allowable Medicaid

deductibles or copayments.



The service is non-covered by Medicaid and the provider informs the recipient prior to rendering

the service. The recipient agrees to be billed as private pay.



The recipient exceeds the 24-visit limit for provider visits for the state fiscal year (July 1 through

June 30).



The recipient has MEDICARE-AID (MQB-Q) coverage and the service is non-covered by

Medicare. MQB-Q recipients receive a buff MEDICARE-AID card.



The patient is no longer eligible for Medicaid as defined in 10 NCAC 50B.

Billing Guidelines
The list of Medicare noncovered services published in the draft version of this Special Bulletin is not included in the final version. When a claim is denied by Medicare as noncovered, providers may file the claim electronically to Medicaid. If Medicaid denies the claim with an EOB indicating that the claim must be filed to Medicare first, providers must resubmit the claim to Medicaid on paper with the Medicare voucher and a Medicaid Resolution Inquiry form attached (see page 33 for a copy of the form). Refer to the following instructions for how to bill for services provided to dually eligible recipients.

CMS-1500 Claim Forms Refer to pages 8 through 13 for examples of claims filed on the CMS-1500 claim form.

Example 1: Medicare/Medicaid Only When the recipient has both Medicare and Medicaid coverage and no other insurance, the provider must enter the Medicare payment amount including penalties and outpatient psychiatric reduction in block 29. Medicaid deducts the Medicare payment amount from the Medicaid maximum allowable amount and the difference is paid to the provider. These claims can be filed electronically.

Payment Calculation Procedure Code 99214 G0001 Total Medicaid Allowed =

Medicaid Allowable $70.81 $ 4.06 $74.87

Total Medicare Payment (block 29) = $78.81

Total Medicaid allowed - Total Medicare payment = Total Medicaid pays to the provider

$74.87 - $78.81

= less than zero

Therefore, the provider is paid zero by Medicaid.

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N.C. Medicaid Special Bulletin VI

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September 2002

Example 2: Medicare/TPL/Medicaid When the recipient has both Medicare and Medicaid coverage, and another insurance primary to Medicaid, the provider must total both the Medicare payment and the commercial insurance payment and enter the total payment amount including penalties and outpatient psychiatric reduction in block 29. Medicaid deducts the total amount from the Medicaid maximum allowable amount and the difference is paid to the provider. The provider must submit a paper claim with both the Medicare voucher and the commercial insurance voucher attached.

Payment Calculation Procedure Code E0260 Total Medicaid Allowed =

Medicaid Allowable $138.73 $138.73

Total Medicare/TPL Payment (block 29) = $106.53

Total Medicaid allowed - Total Medicare/TPL payment = Total Medicaid pays to the provider

$138.73 - $106.53

= $32.20

Therefore, the provider is paid $32.20 by Medicaid.

Example 3: Medicare Non-Covered Services When a claim is denied by Medicare as noncovered, providers may file the claim electronically to Medicaid. If Medicaid denies the claim with an EOB indicating that the claim must be filed to Medicare first, providers must resubmit the claim to Medicaid on paper with the Medicare voucher and a Medicaid Resolution Inquiry form attached. Medicaid will review the denial to determine if Medicaid will pay the claim.

Payment Calculation Procedure Code 92015 Total Medicaid Allowed =

Medicaid Allowable $61.23 $61.23

Total Medicare Payment (block 29) = $ 0.00

Total Medicaid allowed - Total Medicare payment $61.23 - $0.00

= Total Medicaid pays to the provider = $61.23

Therefore, the provider is paid $61.23 by Medicaid.

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N.C. Medicaid Special Bulletin VI

REVISED DRAFT NOVEMBER 14, 2002

September 2002

Example 4: Medicare Non-Covered and TPL Payment When a recipient has Medicare, commercial insurance, and Medicaid coverage, and the claim is denied by Medicare as noncovered, providers may file the claim electronically to Medicaid. If Medicaid denies the claim with an EOB indicating that the claim must be filed to Medicare first, providers must resubmit the claim to Medicaid on paper with the commercial insurance payment amount entered in block 29, and the Medicare voucher and a Medicaid Resolution Inquiry form attached. Medicaid will review the denial to determine if Medicaid will pay the claim.

Payment Calculation Procedure Code 99396 Total Medicaid Allowed =

Medicaid Allowable $92.72 $92.72

Total TPL Payment (block 29) = $83.21

Total Medicaid allowed - Total TPL payment $92.72 - $83.21

= Total Medicaid pays to the provider = $9.51

Therefore, the provider is paid $9.51 by Medicaid.

Example 5: Medicare Paid and TPL Non-Covered When the recipient has Medicare, commercial insurance, and Medicaid coverage and the commercial insurance denies the service, the provider must submit a paper claim with the Medicare payment amount including penalties and outpatient psychiatric reduction in block 29 with the commercial insurance denial attached to the claim.

Payment Calculation Procedure Code E1390 Total Medicaid Allowed =

Medicaid Allowable $209.50 $209.50

Total Medicare Payment (block 29) = $167.60

Total Medicaid allowed - Total Medicare payment $209.50 - $167.60

= Total Medicaid pays to the provider = $41.90

Therefore, the provider is paid $41.90 by Medicaid.

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N.C. Medicaid Special Bulletin VI

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September 2002

Example 6: Medicare Applies 100 Percent of Payment Towards the Deductible When the recipient has both Medicare and Medicaid coverage and Medicare applies 100 percent of the Medicare allowable toward the Medicare deductible, the provider must submit a paper claim with the Medicare voucher attached to the claim. The claim will then pay up to the Medicaid allowable.

Payment Calculation Procedure Code 99213 Total Medicaid Allowed =

Medicaid Allowable $ 45.05 $ 45.05

Total Medicare Payment (block 29) = $0.00, Medicare voucher must be attached to the claim

Total Medicaid allowed - Total Medicare payment $45.05 - $0.00

= Total Medicaid pays to the provider = $45.05

Therefore, the provider is paid $45.05 by Medicaid.

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N.C. Medicaid Special Bulletin VI

REVISED DRAFT NOVEMBER 14, 2002

September 2002

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