Secondary Billing Updates

September 30, 2013

Effective August 28, 2013, we have changed the way Third Party Liability (TPL) and crossover claims process in MIHMS. This will align with MaineCare policy to reimburse based on ‘lesser than’ logic.

System Changes: CR 17483 & CR 28367

These CRs were created to add “lesser than” reimbursement logic to MIHMS. When MaineCare pays after a primary commercial insurance carrier and/or Medicare, reimbursement should be the lowest of the following: - MaineCare rate - Medicare allowed amount - Third Party Liability (TPL) allowed amount - Or the provider’s usual, customary, and reasonable (UCR) charges (the charges billed on the claim)

If the primary allowed amount is greater than the MaineCare allowed amount, the claim will pay the difference between the primary payment and the MaineCare allowed amount.

Example:

Billed Amount $25.00 Primary Carrier Allowed Amount $25.00 Primary Carrier Paid Amount $10.00 MaineCare Allowed Amount $20.00 MaineCare Secondary Payment $10.00

If the MaineCare allowed amount is greater than the primary allowed amount, MaineCare will pay the difference between the primary allowed amount and the primary paid amount.

Example:

Billed Amount $25.00 Primary Carrier Allowed Amount $15.00 Primary Carrier Paid Amount $10.00 MaineCare Allowed Amount $20.00 MaineCare Secondary Payment $ 5.00

If the primary paid amount is greater than the MaineCare allowed amount, the claim will be adjudicated without payment.

Example:

Billed Amount $25.00 Primary Carrier Allowed Amount $25.00 Primary Carrier Paid Amount $22.00 MaineCare Allowed Amount $20.00 MaineCare Secondary Payment $ 0.00

When submitting the EOB for Medicare Part C, you must write “Medicare” on top of the Explanation of Benefits (EOB). This is necessary for accurate processing of these claims.

Claim Submissions Updates

Direct Data Entry (DDE) - Entering claims in MyHealth PAS Portal: - Allowed amounts for both Medicare and TPL must equal the sum of paid, deductible, and coinsurance amounts (coinsurance amount will include copays). - Enter primary payer information at the line level whenever possible. - Choose the Medicare or TPL option as appropriate. If entering claims when Medicare C is primary, choose the Medicare option.

Paper Claim Submission: - UB-04: +Box 54 - Enter the primary payment information (do not include the discount or contractual adjustment). - CMS-1500: +Box 24F – Enter the provider charge (usual & customary). It is no longer necessary for you to enter the primary payers allowed amount. +Box 29 – Enter the primary payment information (do not include the discount or contractual adjustment). - No changes for ADA Dental

Electronic Claim Submission (837I, 837P, & 837D): - No changes for electronic claims