Handling Medicaid and HMO retroactive eligibility?

RETROACTIVE ELIGIBILITY

Providers should be aware that, since bills have to be incurred before the deductible amount is met, there is always a period of retroactive eligibility. This may be several days or up to a period of three months from the current month. In this situation, the local MDHHS office may apply these old bills to the past three months or may prospectively apply them to the next several months, depending on the DOS and the date the bill was presented to the MDHHS worker.


It is the provider's option to bill Medicaid if the beneficiary has paid the provider for services rendered. MDHHS encourages the provider to return the amount the beneficiary paid and bill Medicaid for the service. If the provider decides to bill Medicaid, he must return all money the beneficiary paid over and above the amount identified as the beneficiary's responsibility on the Medicaid deductible letter. If the beneficiary is accepted as a Medicaid beneficiary, he cannot be charged more than indicated on the letter from the local MDHHS office (plus applicable copayment amounts).

Retroactive Medicare Entitlement Involving State Medicaid Agencies

The time for filing a claim will be extended if CMS or one of its contractors determines that failure to meet the filing deadline is caused by all of the following conditions:

(a) At the time the service was furnished the beneficiary was not entitled to Medicare.

(b) The beneficiary subsequently received notification of Medicare entitlement effective retroactively to or before the date of the furnished service.

(c) A State Medicaid Agency recovered the Medicaid payment for the furnished service from a provider or supplier 6 months or more after the date of the furnished service.

In these situations, at the time services were furnished the beneficiary was entitled to Medicaid but not to Medicare. After the date of the furnished services, the beneficiary is then notified that he or she is entitled to Medicare. Finally, sometime after the date of the furnished service, the State Medicaid Agency recoups the money it paid the provider or supplier. If the State Medicaid Agency recoups the money it paid the provider or supplier 6 months or more after the date the service was furnished, the provider or supplier may be given an extension to have those claims filed to Medicare.

In order to qualify for this exception, the provider or supplier will need to provide the claims processing contractor with the following information:

• documentation verifying the date that the State Medicaid Agency recouped money from the provider/supplier;

• documentation verifying that the beneficiary was retroactively entitled to Medicare to or before the date of the furnished service (e.g., an official SSA letter to the beneficiary, or if an official SSA letter is not available, the contractor shall check the CWF database and may interpret the CWF date of accretion and the CWF Medicare entitlement date for a beneficiary in order to verify a beneficiary’s retroactive entitlement; see the example in section 70.7.2 above concerning the CWF for additional details regarding this contractor verification process); and,

• documentation verifying the service/s furnished to the beneficiary and the date of the furnished service/s.

If the contractor determines that all of the conditions described above for meeting this exception are met, the contractor will notify the provider or supplier in writing that a filing extension will be allowed from the end of the 6th calendar month from the month in which the State Medicaid Agency recovered its money.



 Retroactive Disenrollment from a Medicare Advantage plan or Program of All-inclusive Care for the Elderly (PACE) Provider Organization


The time for filing a claim will be extended if CMS or one of its contractors determines that a failure to meet the filing deadline is caused by all of the following conditions:

(a) At the time the service was furnished the beneficiary was enrolled in a Medicare Advantage (MA) plan or Program of All-inclusive Care for the Elderly (PACE) provider organization.

(b) The beneficiary was subsequently disenrolled from the Medicare Advantage plan or Program of All-inclusive Care for the Elderly (PACE) provider organization effective retroactively to or before the date of the furnished service.

(c) The Medicare Advantage plan or Program of All-inclusive Care for the Elderly (PACE) provider organization recovered its payment for the furnished service from a provider or supplier 6 months or more after the service was furnished.

There may be situations where a beneficiary is enrolled in an MA plan or in a PACE provider organization, and later becomes disenrolled from the MA plan or PACE provider organization. And, if the MA plan or the PACE provider organization recoups the money it paid the provider or supplier 6 months or more after the service was furnished, the provider or supplier may be granted an exception to have those claims filed with Medicare.

In order to qualify for this exception, the provider or supplier will need to provide the claims processing contractor with information that verifies:

• prior enrollment of the beneficiary in an MA plan or PACE provider organization;

• the beneficiary, the provider, or supplier was notified that the beneficiary is no longer enrolled in the MA plan or PACE provider organization;

• the effective date of the disenrollment; and,

• the MA plan or PACE provider organization recouped money from the provider or supplier for services furnished to a disenrolled beneficiary.

If the contractor determines that all of the conditions described above are satisfied, the contractor will notify the provider or supplier in writing that a filing extension will be allowed from the end of the 6th calendar month from the month in which the MA plan or PACE provider organization recouped its money from the provider or supplier.


 ELIGIBILITY

There are cases when beneficiaries have the medical need for Medicaid coverage but they have excess income. These beneficiaries are known as Medicaid deductible beneficiaries. Medicaid deductible means that the beneficiary must incur medical expenses each month equal to, or in excess of, an amount determined by the local MDHHS worker to qualify for Medicaid. Once the deductible amount has been incurred, the beneficiary becomes eligible for Medicaid benefits (Benefit Plan ID of MA). Providers must verify Medicaid coverage using the Benefit Plan ID(s) provided in the CHAMPS Eligibility Inquiry.

The process for a Medicaid deductible beneficiary to become Medicaid eligible is as follows:

** The beneficiary presents proof of any medical expenses incurred (e.g., insurance premiums, bills for prescriptions and/or office visits) to the MDHHS worker. Providers may estimate any other insurance or Medicare payment that may be applied to the incurred bill. If the exact charge is not immediately known, providers should estimate the charge on the incurred bill. This expedites the eligibility process.

** The local MDHHS worker reviews the medical bills incurred, and determines if the amount of beneficiary liability is met and the first date of Medicaid eligibility.

** It is fraud to provide beneficiaries with a notice of a bill incurred if no service has been rendered.

** Bills for services rendered prior to the effective date of Medicaid eligibility are the beneficiary's responsibility.

** For the first date of eligibility, the MDHHS worker sends letters to those providers whose services are:

** Entirely the beneficiary's responsibility.

** Partly the beneficiary's responsibility and partly Medicaid's responsibility.

** A letter is also sent to the beneficiary indicating which services are the beneficiary’s responsibilities for that first date of Medicaid eligibility.

** The beneficiary's Benefit Plan ID is changed to MA or MA-ESO to indicate the Medicaid eligibility period. The provider must verify eligibility using the CHAMPS Eligibility Inquiry when the beneficiary becomes eligible. Once the deductible amount is incurred, eligibility is established through the end of the month.

Providers may bill Medicaid for any covered services rendered during that eligible period. Before billing, providers should verify that the Benefit Plan ID of MA or MA-ESO is on file for the DOS. This will assure that the claims will not be rejected for lack of eligibility.

How to handle Retroactive Medicare entitlement

 Retroactive Medicare Entitlement

The time for filing a claim will be extended if CMS or one of its contractors determines that a failure to meet the filing deadline is caused by all of the following conditions:

(a) At the time the service was furnished the beneficiary was not entitled to Medicare.

(b) The beneficiary subsequently received notification of Medicare entitlement effective retroactively to or before the date of the furnished service.

Thus, a provider or supplier may have furnished services to an individual who was not entitled to Medicare. More than a year later, the individual receives notification from SSA that he or she is entitled to Medicare benefits retroactive to or before the date he or she received services from the provider or supplier. In this situation, the provider or supplier may submit a request for a filing extension to the appropriate Medicare claims processing contractor, as long as the provider or supplier submits supporting documentation that verifies that the conditions above are met.

If the beneficiary and the provider or supplier is notified on different days about the beneficiary’s retroactive Medicare entitlement, there will be two extensions of time triggers. One extension of time trigger is when the beneficiary is first notified about the beneficiary’s retroactive Medicare entitlement and the other extension of time trigger is when the provider or supplier is the first party notified of the beneficiary’s retroactive Medicare entitlement. If the beneficiary is submitting the claim, the time to file the claim is based on the day the beneficiary is first notified of the retroactive Medicare entitlement. If the provider or supplier is submitting the claim, the time to file the claim is based on the day the provider or supplier is first notified of the retroactive Medicare entitlement.

Where retroactive Medicare entitlement is alleged, the provider, supplier, or beneficiary will need to provide the contractor with the following information:

• an official Social Security Administration (SSA) letter notifying the beneficiary of Medicare entitlement and the effective date of the entitlement; and,

• documentation describing the service/s furnished to the beneficiary and the date of the furnished service/s.

If the provider, supplier, or beneficiary is unable to provide the contractor with an official SSA letter, the Medicare contractor shall check the Common Working File (CWF) database and may interpret the CWF date of accretion and the CWF Medicare entitlement date for a beneficiary in order to verify a beneficiary’s retroactive entitlement. For example, if the CWF indicates a Medicare entitlement date of March 1, 2008 and a date of accretion of December 14, 2010, then the contractor may interpret the CWF data to mean that the beneficiary was retroactively entitled to Medicare as of March 1, 2008 and that this data was added to the CWF database on December 14, 2010. If the contractor has any problems or concerns with respect to interpreting the CWF data, then the contractor should consult with the appropriate CMS regional office.

If the contractor determines that both of the conditions for meeting this exception described above are met, the time to file a claim will be extended through the last day of the 6th calendar month following the month in which either the beneficiary or the provider or supplier received notification of Medicare entitlement effective retroactively to or before the date of the furnished service.

Does careplus cover diabetes and cardiovascular disorder ?

 Eligibility Requirements for Diabetes SNP – CareDirect (HMO SNP)

* Entitled to Medicare Part A 

* Enrolled in Medicare Part B through age or disability

* Resident within the Plan’s service area

* Diagnosed with diabetes mellitus (ICD-9-CM codes 250.xx)

* Not undergoing treatment  for end-stage renal  disease (ESRD) unless members of CarePlus  since  dialysis began.

* In  addition,  members  enrolled  in  the  Diabetes  SNP  (CareDirect  HMO  SNP)  must  have  their  physician or physician’s office confirm the qualifying condition either verbally or in writing by the  last  day  of the  first  month of enrollment;  written confirmation  can be provided by obtaining the physician’s  signature  on  the  Chronic  Condition  Verification  Form.  This  form  is  intended  to substantiate that the applicant has an appropriate diagnosis for participation in the plan. If CarePlus  does not receive confirmation of the member’s chronic condition by the last day of the first month of enrollment, the patient’s coverage under the Diabetes SNP will be involuntarily terminated.


Eligibility  Requirements  for  Cardiovascular  Disorders/Chronic  Heart  Failure  SNP  –  CareHeart (HMO SNP)
* Entitled to Medicare Part A 

* Enrolled in Medicare Part B through age or disability

* Resident within the Plan’s service area

* Diagnosed with cardiovascular disorder, specifically Cardiac arrhythmias, Coronary artery disease, Peripheral vascular disease, and/or Chronic venous thromboembolic disorder*.

* Diagnosed with chronic heart failure*.

* Not undergoing treatment  for end-stage renal  disease (ESRD) unless members of CarePlus  since  dialysis began.

* In  addition,  members  enrolled  in  the  Cardiovascular  Disorders/Chronic  Heart  Failure  SNP  (CareHeart  HMO  SNP)  must  have  their  physician  or  physician’s  office  confirm  the  qualifying  condition  either  verbally  or  in  writing  by  the  last  day  of  the  first  month  of  enrollment;  written confirmation  can  be  provided  by  obtaining  the  physician’s  signature  on  the  Chronic  Condition  Verification Form. If CarePlus does not receive confirmation of the member’s chronic condition by the  last  day  of  the  first  month  of  enrollment,  the  patient’s  coverage  under  the  Cardiovascular Disorders/Chronic Heart Failure SNP will be involuntarily terminated.

Eligibility verification throught Medicare IVR - Information required

Eligibility Options Available via the Jurisdiction A DME MAC IVR

The DME MAC A Call Center has seen an increase of calls due to eligibility denials
for a Medicare beneficiary.  Some of the common ANSI denials associated with eligibility
include, but aren't limited to:


* ANSI 22: Payment adjusted because this care may be covered by another payer per
coordination of benefits.
* ANSI 13: The date of death precedes the date of service.
* ANSI 24: Payment for charges adjusted.  Charges are covered under a capitation
 agreement/managed care plan.
* ANSI B15 with remark code N70: This service/procedure requires that a qualifying
service/procedure be received and covered.  The qualifying other service/procedure
has not been received/adjudicated.  Consolidated billing and payment applies.
* ANSI 45 with remark code N88: Charge exceeds fee schedule/maximum allowable or
 contracted/legislated fee arrangement.  This payment is being made conditionally.
 A Home Heath Agency episode of care notice has been filed for this patient.  When
a patient is treated under a HHA episode of care, consolidated billing requires
that certain therapy services and supplies, such as this, be included in the HHA's
payment. This payment will need to be recouped from you if we establish that the
 patient is concurrently receiving treatment under a HHA episode of care.
* ANSI B9: Patient is enrolled in a Hospice
* ANSI 109 with remark code M2: Claim not covered by this payer/contractor. You
must send the claim to the correct payer/contractor. Not paid separately when the
patient is an inpatient.
* ANSI 109 with remark code MA101: Claim not covered by this payer/contractor. You
must send the claim to the correct payer/contractor. A Skilled Nursing Facility
(SNF) is responsible for payment of outside providers who furnish these services/supplies
to residents.

Note:The ANSI denials listed above typically have a CO (contractual obligation)
or PR (patient responsibility) reported with the code.

The Centers for Medicare & Medicaid Services (CMS) requires suppliers to utilize
 self-service options, such as the interactive voice response (IVR) system.  When
calling the DME MAC A Call Center and asking for eligibility and/or explanation
of a denial, you will be directed back to the IVR.

The IVR, 866-419-9458, is available for the supplier community Monday -Friday, 6:00
a.m. - 7:00 p.m. EST and Saturday, 6:00 a.m. - 3:00 p.m. EST

In order to obtain eligibility through the IVR, suppliers will need to select option
2.  After selecting option 2, the IVR will request and collect the following elements:


* NPI
* PTAN (ten-digit supplier number)
* Last five digits of the Tax Identification Number (TIN)
* Beneficiary Medicare number
* Beneficiary first and last name (last name and first initial if using touch-tone)
* Beneficiary date of birth
* Date of service

Once the authentication elements have been verified, the IVR will supply the following
information:


* Part A and Part B effective/termination dates
* Current/prior year Part B deductible amounts
* Medicare secondary payer (MSP) type, insurer name, and effective/termination dates
* Medicare advantage plan number, name, address, telephone number, and effective/termination
dates
* Home health name, address, and effective/termination dates
* Hospice name, address, and effective/termination dates
* Date of death
* Corrected Medicare number

Effective January 14, 2011, a new enhancement was added to the Claims option (option
1) on the IVR.  Suppliers are able to select Claim Details (touch tone 4) in order
to obtain admission/discharge dates and patient status date if the claim denied
due to Home Health, Hospice, Inpatient Stay, or Skilled Nursing Facility.  Suppliers
will also be able to obtain the name and address of the facility.

Medicare benefits for Abdominal Aortic Aneurysm (AAA) Screening

Abdominal Aortic Aneurysm (AAA) Screening

Abdominal Aortic Aneurysm (AAA) is a vascular disease with life-threatening implications. If you have a family history of abdominal aortic aneurysm or have smoked at least 100 cigarettes in your lifetime, you are considered at risk.

How often is it covered?

Medicare covers this one-time screening ultrasound if you get a referral for it as a result of your "Welcome to Medicare" physical exam. You must receive the physical exam and the screening ultrasound referral (not the ultrasound exam itself) within the first twelve months you have Medicare Part B.

For whom?

People with Medicare who meet the following criteria are eligible:
     He or she must get a referral for the AAA ultrasound screening from a physician or other qualified non-physician practitioner as a result of their "Welcome to Medicare" physical exam.
He or she has never had an AAA ultrasound screening paid for by Medicare.
The person with Medicare has at least one of the following risk factors a family history of abdominal aortic aneurysm is a man age 65 to 75 who has smoked at least 100 cigarettes in his lifetime
Certain other risk factors may apply. Talk to your doctor to find out more.

Your costs in the Original Medicare Plan?

For the AAA screening ultrasound, you pay 20% of the Medicare-approved amount with no Part B deductible.

How to do Eligibility enquiry - Medicare process

Eligibility Inquiry

This electronic transaction can be used to inquire about the eligibility, coverage, or benefits associated with a health plan, employer, plan sponsor, subscriber, or a dependent under the subscriber's policy. It also can be used to communicate information about, or changes to, eligibility, coverage, or benefits from information sources (such as insurers, sponsors, payers) to information receivers (such as physicians, hospitals, third party administrators, government agencies).

The Centers for Medicare & Medicaid Services (CMS) is making changes to its Information Technology infrastructure to address standards for beneficiary eligibility inquiries to the Medicare Fee-For-Service (FFS) program. The changes will create the necessary national database and infrastructure to provide HIPAA compliant 270/271 health care eligibility inquiries and responses on a real-time basis.

CMS is using a phased approach for providing this eligibility transaction on a real-time basis:

Extranet: Since May of 2005, entities that wish to submit 270s to Medicare on a real-time basis (hereinafter, "Submitter" or "Submitters") have been permitted to submit 270s via the CMS AT&T communication Extranet (the Medicare Data Communication Network, or MDCN). This Extranet is a secure closed private network currently used to transmit data between Medicare FFS contractors and CMS, as well for transmission of electronic transactions in some cases from certain providers and clearinghouses to FFS contractors.

Internet: Internet access to conduct the eligibility transaction on a real-time basis is being developed. Instructions on conducting the eligibility transaction via this method will be provided prior to the time Internet access becomes available.

Regardless of the access method employed, all eligibility inquiries will be processed at the CMS data center. The CMS Data Center will use a single consolidated national eligibility database to respond to the eligibility inquiries.

Access Process : Complete the form linked to below. Once complete, a copy of the completed electronic form will be electronically submitted to the CMS 270/271 Medicare Eligibility Integration Contractor (MEIC) for security authentication. The access process will then continue, and the Submitter will be directed to complete an MDCN connectivity form in order to be connected to the 270/271 eligibility database. Once the MDCN connectivity form is completed, it will automatically be directed to the CMS/MDCN staff and to the MEIC for completion of the connectivity process and authentication. Once these processes have been completed, the MEIC will provide the Submitter with a submitter ID, which must be used on all 270/271 transactions. Please note that in order to access the MDCN, Submitter must obtain the necessary telecommunication software from an AT&T reseller.