On December 19, 2011, the Centers for Medicare & Medicaid Services (CMS) notified providers on the CMS website that Medicare claims that were submitted with dates of service on or after January 1, 2012, would be held for 10 days and not processed by Medicare until after January 17, 2012. On January 1, 2012, the Health Insurance Portability and Accountability Act (HIPAA) 5010 new format was released and Texas Medicaid changed the way Medicare crossover coinsurance and deductible reimbursements were calculated. Once the claims were processed by Medicare and electronically submitted to TMHP by a Coordination of Benefits Contractor (COBC) in the new format, issues with the electronic transmissions were identified. These issues may have caused some Medicare Part B professional and outpatient hospital crossover claims that were submitted with dates of service on or after January 1, 2012, to be rejected or denied incorrectly.
The following issues have been identified:
- Issue #1—Some professional and outpatient hospital Medicare crossover claims may have received an incorrect reimbursement of $0 for the first detail line item listed on the claim.
- Issue #2— Some anesthesia claims were denied incorrectly because of a change in how anesthesia minutes are reported in the HIPAA 5010 format.
- Issue #3—Claims may have been rejected incorrectly because Medicare-only information was transmitted to TMHP or information was not transmitted to TMHP in the appropriate format or location.
- Issue #4—Crossover claims may be denied because of an invalid performing provider.
Issue #1: Incorrect Reimbursement of $0
This is a follow up to the article titled “Claims Processing Issues Impacting Some Professional and Outpatient Hospital Medicare Crossover Claims,” which was published on February 29, 2012, on this website. Effective February 29, 2012, TMHP has resolved the issue that impacts professional and outpatient hospital Medicare crossover claims that were submitted to TMHP with dates of services from January 1, 2012, through March 2, 2012. Medicare crossover claims that were affected by the incorrect reimbursement of $0 for the first detail line item listed on the claim will be reprocessed. After these claims have been reprocessed, providers may receive additional payment, which will be reflected on future Remittance and Status (R&S) Reports. Claim details that received a correct reimbursement of $0 will not be reprocessed.
Issue #2: Crossover Claim Denials for Anesthesia Services
Effective January 1, 2012, some anesthesia claims were denied incorrectly because of a change in how anesthesia minutes are reported in the HIPAA 5010 format. Effected claims can be identified by explanation of benefits (EOB) message 01088 “Quantity billed is missing. Please resubmit.” TMHP is developing a solution to systematically reprocess impacted claims. Providers allow 60 days from the date of Medicare's disposition for a claim to be shown on the Medicaid R&S Report. For crossover claims that are not transferred electronically, providers must submit a paper claim to TMHP. TMHP must receive Medicaid claims within 95 days of the date of Medicare disposition.
Issue #3: Claims Rejections
As reported by CMS on February 24, 2012, some claims submitted under the new EDI format for submission after June 24, 2011 were rejected incorrectly because the claim information was not transmitted to TMHP in the correct format or location. Most of the claims were rejected because they contained a Hospice Employee Indicator on the claim. Although Medicare requires the indicator, HIPAA EDI standards used by TMHP and HHSC do not require it. If providers submitted this value on a claim, the claim was rejected. TMHP is developing a solution to systematically reprocess impacted claims. Providers should review their weekly R&S Reports. Providers allow 60 days from the date of Medicare's disposition for a claim to be shown on the Medicaid R&S Report. For crossover claims that are not transferred electronically, providers must submit a paper claim to TMHP. TMHP must receive Medicaid claims within 95 days of the date of Medicare disposition.
Issue #4: Performing Providers
Effective for dates of service on or after January 1, 2012, crossover claims may be denied for an invalid performing provider. Providers should verify that the performing provider is enrolled with the billing group Texas Provider Identifier (TPI) in Medicaid. Affected claims can be identified by explanation of benefits (EOB) message 01603 “Performing provider NPI/API to TPI combination or NPI/API information is invalid.” Performing providers that are not enrolled in the Medicaid program under the billing group TPI must complete an enrollment application. Once their enrollment is approved, the denied claims can be appealed. In addition, providers identified by Medicare as Sole Proprietors that received the above rejection message should review their weekly R&S reports. Providers allow 60 days from the date of Medicare's disposition for a claim to be shown on the Medicaid R&S Report. For crossover claims that are not transferred electronically, providers must submit a paper claim to TMHP. TMHP must receive Medicaid claims within 95 days of the date of Medicare disposition.
Reminder: Medicare Crossover Coinsurance and Deductible Reimbursement Changes
Effective for dates of service on or after January 1, 2012, if the Medicare payment is less than the Medicaid allowed (e.g., client has not met the yearly deductible), coinsurance and deductible reimbursement for Medicare Part B and Part C (non-contracted MAPs only) professional and outpatient facility crossover claims may be reimbursed the lesser of the following: The coinsurance and deductible payment The amount remaining after the Medicare payment amount is subtracted from the allowed Medicaid fee or encounter rate for the service
- The coinsurance and deductible payment
- The amount remaining after the Medicare payment amount is subtracted from the allowed Medicaid fee or encounter rate for the service
Note: Some portion of the annual deductible for Part B claims will be paid if the service is a benefit of Medicaid, and Medicare does not make payment. If the Medicare payment is equal to or exceeds the Medicaid allowed amount or encounter payment for the service, Texas Medicaid will not make a payment for the coinsurance and deductible.
For more information, providers may refer to the article titled, “Changes to Medicare Crossover Claims Processing and Reimbursement Effective January 1, 2012,” which was published on this website on December 1, 2011.
For more information, call the TMHP Contact Center at 1-800-925-9126.