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Department of Human Services Department of Human Services  
 
Medicare and Other Insurance

Revised: 12-12-2013

Medicare is administered by the Centers for Medicare & Medicaid Services (CMS) and is the federal health insurance program for people age 65 and older, and certain people with disabilities.

Other insurance, or third party liability (TPL), refers to health, long term care, or dental insurance coverage an MHCP recipient may have through private or public funds.

MHCP considers Medicare and TPL primary to MHCP coverage. Verify eligibility through MN–ITS to ensure MHCP and Medicare or other insurance coverage. Providers must bill and receive payment from primary coverage to the fullest extent possible before billing MHCP.


Assignment/Request for Direct Payment
Recipients are responsible to give providers and providers are responsible to obtain TPL/Medicare information and assignment of benefits. Obtain assignment of benefits from the recipient/responsible party.

Request direct payment to you when:

• A dependent child is insured under a group contract pursuant to a court order
• An MHCP recipient is insured by a plan approved in Minnesota

The provider must indicate on the insurance claim that the person is receiving benefits through MHCP.


Authorization Requests and Medicare/TPL Coverage
Review information about authorization requests when a recipient has Medicare/TPL coverage.


Medicare
Medicare is primary to MHCP. Services covered by Medicare must be provided by a Medicare-enrolled provider and billed to Medicare first. Bill any balance after Medicare payment to other TPL payers. If the total amount received from Medicare and other TPL payers is less than the MHCP allowable, submit a claim for the difference to MHCP for payment of the coinsurance/ deductible with appropriate amounts indicated.

• If Medicare pays a claim and the claim does not automatically cross over to MHCP from Medicare, bill MHCP in the same way you billed Medicare
• If Medicare denies a claim, bill MHCP using MHCP guidelines

In both cases, complete the MN–ITS COB and Services line level (PDF) with the all of the adjustments and remarks codes indicated on your Medicare EOMB information. A claim that’s charge and adjustments are out of balance will suspend for review and are considered complex claims that may take up to 90 days to process.

Submit services that are never covered by Medicare directly to MHCP. You do not need a denial from Medicare.

Medicare B Crossover Claim Payment
The Basic Care Service rate reductions do not apply to service lines allowed (covered) by Medicare. Service lines denied by Medicare where MHCP is the sole payer are subject to the basis care rate reductions.

Effective 8/1/12, MHCP began to limit payment on some 837P Professional Medicare B crossover claims with dates of service on or after 1/1/12, only up to the MHCP maximum allowable rate on claim lines where a Medicare coinsurance and/or deductible has been applied. MHCP payment will be the difference between the Medicare payment and the MHCP calculated allowable where the difference is greater than zero. If the difference is less than or equal to zero, the MHCP payment will be zero. MHCP will also retroactively reprocess 837P Professional claims processed prior to 8/1/12, on a two-week cycle beginning in September.

Calculation Example:

Line

Procedure Code

Charge

MHCP Calculated Allowable

Medicare Allowed Rate

Medicare Payment

Medicare Coinsurance or Deductible

MHCP Calculation

1.

98941

$49.00

$21.77

$34.79

$15.30

$19.49

$21.77 - $15.30 = $6.47 payment

Line 1: Our allowable after any add-ons/cutbacks is $21.77. Because this line has a $19.49 coinsurance MHCP will pay the difference between the Medicare payment and the MHCP calculated allowable. MHCP pays the MHCP Calculated Allowable of $21.77 minus the Medicare payment $15.30, which equals $6.47. MHCP no longer pays the $19.49 Medicare determined coinsurance.

Medicare Opt-out Option
Providers may choose to opt-out of Medicare (not enroll as a Medicare provider). However, MHCP will not pay for services covered by, but not billed to, Medicare because the provider has chosen not to enroll in Medicare.

Medicare Replacement (Advantage or Risk Plans)
Many companies have Medicare replacement policies. Providers must verify whether or not a policy is a Medicare replacement policy. Effective 09/26/11, if the policy is a Medicare replacement policy, enter the claim as any other Medicare claim, using Claim Filing Indicator 16. If using MN–ITS Direct Data Entry (DDE) to submit your claim, refer to the COB Field Completion Guide for instructions on which fields must be completed.


Third Party Liability (TPL)
TPL coverage, including Veterans Benefits, private accident insurance, HMO coverage and other health care coverage held by or on behalf of an MHCP recipient is primary to MHCP.

Follow specific plan coverage rules and policies. A recipient with more than one level of private benefits must receive care at the highest level available. MHCP will not pay for services that could have been covered by the TPL payer if the applicable rules of that plan had been followed.

If a recipient fails to complete forms and cooperate in the TPL billing process, contact the financial case worker at the local human service agency (DHS-0005)or a MinnesotaCare representative to request assistance.

Bill TPL payers and receive payment to the fullest extent possible before billing MHCP.

Subrogation
MHCP receives notice that a FFS recipient has other insurance after a provider has billed and received payment from MHCP. MHCP has the right to subrogate the payment by billing the private accident or health care coverage and be reimbursed for MHCP funds that were paid on behalf of a recipient for medical services to an enrolled MHCP provider.

After the private accident or health care coverage reimburses MHCP, the payment responsibility is satisfied. Providers must accept the amount paid by MHCP as payment in full and must not bill the other health insurer or recipient for any additional payment. This includes attempting to replace or void claims with MHCP and then bill the other insurance.

The amount of the MHCP payment substitutes for the TPL payment amount, even if the TPL payment would have been higher.

Unsuccessful TPL Billing
Providers may bill MHCP after three unsuccessful attempts have been made to collect from the TPL payer, except when the TPL payer has already made payment to the recipient. Attach a copy or screen print of the first claim sent to the TPL payer, documentation of two further billing attempts, each attempt up to 30 days after the previous, and any written communication you received from the TPL payer to the MHCP claim. Do not bill MHCP earlier than 90 days after the initial attempt. Bill MHCP correctly within 12 months of the date of service to be considered for payment.

Billing MHCP with TPL
Bill MHCP only if the TPL payer indicates a patient responsibility. If the TPL does not attribute charges to patient responsibility or non-covered service, MHCP will not pay.

Use only HIPAA-compliant codes to indicate reduction, coinsurance, copay, etc. If the codes you receive from the TPL carrier are not HIPAA-compliant, refer to the HIPAA Code Lists on the WPC website.

Effective January 1, 2012, MHCP no longer accepts an AUC Electronic Claim Attachment for TPL explanation of benefits (EOB). Provide TPL adjustment and payment information within the claim transaction.

If you submit TPL information at the header/claim level or at the header/claim and service/line level, MHCP will prorate all submitted lines, which may result in lower payment.

Billing TPL at Header/Claim Level
The following claim transactions and provider types must submit TPL information at the header/claim level using MN–ITS or Batch submission to receive appropriate reimbursement:

• Hospital Inpatient
• Child and Teen Checkups (C&TC)
• Federally Qualified Health Center (FQHC)
• Rural Health Clinic (RHC)
• Indian Health Service (IHS)facilities & tribal social services

Adjustments entered at the Claim level are prorated across all service lines.
Refer to the appropriate MN–ITS User Guide for complete instructions on reporting header/claim level information on the Coordination of Benefits (COB) screen.


Billing TPL at Service/Line Level
Effective on and after 9/9/2013, for MN–ITS direct data entry (DDE): TPL information may be entered at the service/line level, (except for the providers listed in the Billing TPL at Header/Claim Level section above). Prior to this date TPL was entered at the header/claim level and payment calculated on a prorated basis.

Submit TPL information at the line level to report adjustments specific to each line:

• 837P Professional
• 837D Dental
• 837I Outpatient

Refer to the appropriate MN–ITS User Guide for complete instructions on reporting service/line level information on the Services screen, Other Payer section.

Effective 1/1/2012, for batch submissions: Submit line level TPL information for batch claims (except for the provider types listed in the Billing TPL at Header/Claim Level sectionabove) to report adjustments specific to each line.


Out-of-Balance TPL/Medicare Claims
For a claim to balance, the TPL/Medicare payment and adjustment code amounts must equal the U&C:

(TPL/Medicare payment amount) + (adjustment codes and amounts) = U&C

If you do not report all adjustment codes and amounts on the claim/line level to balance the claim/line, MHCP may suspend the claim for up to 90 days or deny the claim/line.

MHCP uses HIPAA-compliant claims adjustment reason code 129 and remittance advice reason code M04.


Billing TPL/Medicare Non-covered Services
Document any services not covered by Medicare/TPL. Keep documentation (such as a denial, information from policy manual, detailed phone contact information, etc.) in the recipient’s file verifying a service is not Medicare/TPL covered. Although a denial is not required for each claim for non-covered services, providers must document the service’s non-coverage on the MHCP claim:

• Complete claim COB information
• Use appropriate claim adjustment reason codes and remark codes
• Enter provider determined number or a series of nines (999) for the ICN (individual claim number); document this ICN

Bill services that are never covered by Medicare directly to MHCP without Medicare COB information. See provider type specific sections for additional information.


Cost Avoidance Requirements
MHCP pursues recovery of benefits when an accident settlement or contested Workers' Compensation benefits are pending, or when legal action may be required.

Providers are not required to bill TPL payers for the following services:

• Prenatal care services. This exclusion does not apply to any inpatient hospital stay related to these services or to coverage provided by an HMO or PPO
• Preventive pediatric care services for recipients under age 21. This exclusion does not apply to coverage provided by an HMO or PPO
• Prescription drugs, when the type of insurance is major medical or no-fault automobile insurance. Cost avoidance requirements do apply to prescription drug services provided to recipients with the following coverage types:
• Private HMO
• Prescription drug plans
• PPOs
• Workers’ Compensation
• Immunosuppressive drugs covered by Medicare

The following government health programs are not considered TPL payers for the purpose of cost avoidance requirements:

• Appalachian Regional Commission (ARC)
• Comprehensive Health Service Projects
• Crime Victims' Compensation Fund
• Head Start
• Health and Child Development Projects
• Health Under-served Rural Areas (HURA)
• Indian Health Services
• Migrant Health Projects

Report Health Insurance Effective and Termination Dates
Notify DHS of health insurance terminations and denials for persons not covered by the policy. Send a copy of the termination notice/denial or document on your office letterhead all of the following information:

• Recipient name
• Recipient MHCP ID number
• Insurance company name
• Termination date
• Whether the termination applies to the policy or individual
• Name and phone number of the person contacted to obtain the termination information

Fax (preferred): (651) 431-7431
Mail: DHS Benefit Recovery Section
PO Box 64994
St Paul MN 55164-0994

Request for Statement
If a recipient requests a billing statement, the statement must clearly state that it is not a bill and payment has been made or could be made by MHCP. Providers must report the request in writing to the Benefit Recovery Section.


Provider Prohibitions Related to TPL
Providers must not:

• Refuse to furnish MHCP-covered services to a recipient because of a TPL's potential liability for payment of the service
• Require MHCP recipients with primary insurance coverage to bill their insurance carrier. However, recipients must cooperate by completing and signing required forms

Liability Not Established or Benefits Not Payable
When probable liability is not established, or benefits are not available at the time a claim is submitted, MHCP will pay the maximum allowable except when Medicare has denied payment on the basis of secondary payer. The provider must accept MHCP payment as payment in full and must not continue to seek payment from TPL payers with pending liability. If MHCP learns of the existence of a TPL, or benefits become available, MHCP may recover payment directly from the TPL payer.


Legal References
MS 62A.045 Payments on Behalf of Enrollees in Government Health Programs

MS 256B.37 Private Insurance Policies, Causes of Action

Minnesota Rules 9505.0070 Third Party Liability
Minnesota Rules 9505.0071
Assignment of Rights
Minnesota Rules 9505.0440
Medicare Billing Required
42 CFR 405.410
and Balanced Budget Act of 1997 Sec. 4507 Conditions for properly opting-out of Medicare


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