5010 Changes. CHAMPS Changes 01/01/12 4/4/12. Copyright Kearney & Associates, Inc 1. 01/01/2012 Change From 4010 to 5010

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1 Flowing Change Julie Kearney Kearney & Associates, Inc Changes 01/01/2012 Change From 4010 to 5010 Went From Allowing 8 Diagnosis to 12 Diagnosis Postponed fines, and compliance until 04/01/2012 Postponed again until 06/30/2012 Provider address cannot be PO Box CHAMPS Changes 01/01/12 All previous templates not on system Need to create new templates Only can have 5 templates no change Software companies must comply & Associates, Inc 1

2 Medicare/ Medicaid Dual Eligible Policy Change 08/01/11 MSA Policy Change 02/17/2012 MSA Medicaid Is Payer Of Last Resort PPA Offset PPA Voluntary Payments Medicare Primary TPL Medicare 5 6 & Associates, Inc 2

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5 13 Common Rejec3on Codes h7p:// 0,1607, _ ,00.html 14 Medicaid Third Party Liability Third Party Liability Section (option #4) fax MDCH/TPL PO Box Lansing, MI Coordination of benefits issues 15 & Associates, Inc 5

6 LOCD h7p:// 0,1607, _42542_42543_42546_ ,00.html h7ps://sso.state.mi.us 16 LOCD Policy policy requires that the LOCD be conducted online within 14 calendar days from the date of admission of a Medicaid beneficiary. policy requires that the LOCD be conducted online within 14 calendar days from when a private pay resident submits a Medicaid application to DHS, requesting Medicaid as the payer for services (i.e., Medicaid pending resident). Medicaid pending can be verified via medifax, EVS and now CHAMPS & Associates, Inc 6

7 MSA /01/2011 Medicaid claims crossing over from Medicare Must report patient pay, any offset and voluntary payments on the Medicare claim. TCN of co insurance Electronic 2- Crossover 12 - Year day of year Feb 14 MSA Cont... Medicare Part A & Medicare Part B coinsurance crossing over Medicare receives the claims the RA will have MA07 Claim should appear on Medicaid RA in 30 days Not on system 30 days then submit directly to Medicaid MSA Claims are being processed Tuesday thru Saturday If claims are in process for more than 30 days TCN to provider support Provider support phone number providersupport@michigan.gov & Associates, Inc 7

8 MSA Effective Date of Policy 02/17/ Medicare must be reported Primary on Medicaid Dual eligible claims - Value codes (Report the days per Medicare policy) Form Locator COVERED 81 NON-COVERED 82 COINSURANCE Billing Medicare Primary Non-Covered Days Non-Covered Days must be reported using Value Code 81. In Form Locator Non-Covered Days are the days not covered by Medicare due to Medicare being exhausted or the beneficiary no longer requiring skilled care. & Associates, Inc 8

9 Medicare Benefits Exhausted When Medicare non-covered days are reported because Medicare benefits are exhausted, facilities must report Occurrence Code A3 and the date benefits were exhausted Reason Codes (CARC) 96 (Non-Covered Charges), or 119 (Benefit Maximum for the time Period has been Reached). Medicare Active Care Ended When Medicare non-covered days are reported because Medicare active care ended, facilities must report Occurrence Code 22 and the corresponding date Medicare active care ended Claim Adjustment Reason Codes (CARC) 96 (Non- Covered Charges), or 119 (Benefit Maximum for the time Period has been Reached) must be reported & Associates, Inc 9

10 Medicaid Payer Last Resort MEDICAID IS ONLY CONSIDERED THE PRIMARY PAYER WHEN THERE IS NO MEDICARE OR OTHER INSURANCE PRESENT ON THE THIRD PARTY LIABILITY (TPL) You must bill Medicare Primary on all Medicare/ Medicaid dual eligible Medicaid Edits Nursing Facility claim where Room and Board revenue codes reported and no value codes Reason code 16 Claim lacks information which is needed for adjudication. At least one remark code must be provided. Remark code M49 Missing /incomplete invalid value code (s) or amounts(s) Medicaid Edits Nursing Facility Medicare/OI exhausted Reason Code 22 This care may be covered by another payer per COB Remark Code N177 We did not send this claim to patient s other insurer. They have indicated no additional payment can be made. & Associates, Inc 10

11 Medicaid Edit Reason Code B9- Patient is enrolled in a Hospice. This can mean not enrolled in Hospice This can mean no Medicaid This can mean no Medicaid LOC -02 Reason & Remark Codes List of Reason & Remark codes Reason codes are also the CARC (Claim Adjustment Reason Codes) Rejection Code 77 New Medicaid rejection code since the policy MSA implemented on February 17, The reason code is 77 and the claims deny. The reason code 77 is not in the WPC-EDI reason code list the most current list. & Associates, Inc 11

12 CHAMPS DDE Claim Submission So say you have a Medicare/Medicaid dual eligible. You must list the Medicare as Primary. The Payer ID is The filing indicator for Medicare Part A is MA You must put the CAS codes in CHAMPS DDE Claim Submission So say you have a Medicare Advantage that is a Medicaid dual eligible. The payer ID is The filing indicator for this is Medicare Part A it is MA You must put the CAS codes in FD622 on Champs March & April, 2012 both Electronic & Paper 622 Make sure you save these documents April 25, 2012 Letter must be written and submitted in order to get paper still May 3, will only be electronic & Associates, Inc 12

13 Large Computer Network NPI CPE Contract Payment Champs Provider Enrollment LOCD Social Security DHS IRS MSA Effective Date of Policy 03/01/ New Medicaid Fraud Hotline Number MI-FRAUD ( ) - Suspected Medicaid fraud, waste, or abuse can be reported via telephone (1-855-MI-FRAUD), online at Cheer Onward, and Upward she shall prevail. We are here to care for the residents, and provide a wonderful service. & Associates, Inc 13

14 References State of Michigan MSA State of Michigan MSA State of Michigan MSA State of Michigan Web Site Website: & Associates, Inc 14

15 Bulletin Michigan Department of Community Health Bulletin Number: MSA Distribution: Nursing Facilities, County Medical Care Facilities, Hospital Long-Term Care Units, Outpatient County Medical Care Facilities, Hospital Swing Beds, and Ventilator -Dependent Care Units Issued: August 1, 2011 Subject: Medicare Medicaid Nursing Facility Crossover Claims with Group Health Incorporated (GHI) (Coordination of Benefits) Effective: September 1, 2011 Programs Affected: Medicaid Beginning in fall 2011, the Michigan Department of Community Health (MDCH) will be accepting institutional crossover claims from the coordination of benefits contractor, Group Health Incorporated (GHI). The institutional nursing facility crossover claim process will allow nursing facilities to submit a single claim for residents dually eligible for Medicare and Medicaid. After processing the Medicare portion, GHI will forward the claim to Michigan Medicaid for processing and reimbursement. A remittance advice (RA) will be generated from Medicare with the details of the Medicare payment and Remark Code MA07 (the claim information has also been forwarded to Medicaid for review). If this remark code does not appear on the Medicare RA, a separate claim will have to be submitted to MDCH. Once Medicare payment is received by the facility and Remark Code MA07 appears on the Medicare RA, the claim should appear on the Medicaid RA within 30 days. The facility may check claim status online through the Community Health Automated Medicaid Processing System (CHAMPS). If the claim does not appear in CHAMPS within 30 days, a claim should be submitted directly to MDCH showing all of the Medicare payment information. Providers must resolve denied claims with Medicare when there is a denied Medicare service not covered by Medicaid. The excluded Medicare service covered by Medicaid should be billed directly to Medicaid. The following claims are excluded from the crossover process: Original Medicare claims paid in full without deductible or co-insurance remaining; Claims with private and commercial insurance; Adjustment claims fully paid without deductible or co-insurance; Original Medicare claims paid at greater than 100% of submitted charges without deductible or coinsurance remaining; 100% denied original claims; 100% denied adjustment claims, with no additional beneficiary liability; 100% denied original claims, with additional beneficiary liability; 100% denied adjustment claims, with additional beneficiary liability; Adjustment claims;

16 MSA Page 2 of 3 Mass adjustment claims - other (monetary or non-monetary); Medicare secondary payer cost-avoided (fully denied) claims; and Claims reporting Revenue Code 0160 (Medicaid Reimbursement for a Nursing Facility Bed Following a Qualifying Medicare Hospital Stay). Note: For any Medicare Part B services associated with this nursing facility claim, the facility would bill Medicare accordingly. Billing Instructions Nursing facilities must continue to complete their claims as they have been doing for Medicare. Nursing facilities must report the beneficiary s patient-pay, any offset to the patient-pay amount, and voluntary payments on the claim submitted to Medicare. When reporting ancillary services, the facility must indicate the service date on the line level of the claim. Ancillary services are listed in the Medicaid Provider Manual, Billing & Reimbursement for Institutional Providers Chapter, Sections (Revenue Code Oxygen). The manual is posted online at: >> Policy and Forms >> Medicaid Provider Manual. Ventilator - Dependent Care Units Medicaid - enrolled ventilator - dependent care units have a distinct National Provider Identifier (NPI) number for Medicaid billing. That number is separate from their "regular" facility NPI number. The facility would use their "regular" NPI number to bill days 1 to 100 to Medicare. Starting on day 101, the facility would bill Medicaid directly using its ventilator - dependent care unit distinct NPI number. Additional Website Information The following website provides more information and frequently asked crossover questions: >> Billing and Reimbursement >> Medicare Crossover. Public Comment The public comment portion of the policy promulgation process is being conducted concurrently with the implementation of the change noted in this bulletin. Any interested party wishing to comment on the change may do so by submitting comments in writing to: Marion Killingsworth Michigan Department of Community Health Medical Services Administration P.O. Box Lansing, Michigan Or killingsworth@michigan.gov Comments received will be considered for revisions to the bulletin. Manual Maintenance Retain this bulletin until applicable information has been incorporated into the Michigan Medicaid Provider Manual.

17 MSA Page 3 of 3 Questions Any questions regarding this bulletin should be directed to Provider Inquiry, Department of Community Health, P.O. Box 30731, Lansing, Michigan , or at ProviderSupport@michigan.gov. When you submit an , be sure to include your name, affiliation, and phone number so you may be contacted if necessary. Providers may phone toll-free Approved Stephen Fitton, Director Medical Services Administration

18 Bulletin Michigan Department of Community Health Bulletin Number: MSA Distribution: Nursing Facilities, County Medical Care Facilities, Hospital Long Term Care Units, Hospital Swing Beds, and Ventilator Dependent Care Units Issued: January 19, 2012 Subject: Reporting Medicare on the Medicaid Nursing Facility Claim Effective: February 17, 2012 Programs Affected: Medicaid THIS BULLETIN MUST BE SHARED WITH THE FACILITY S ADMINISTRATOR AND BILLING DEPARTMENT. THIS BULLETIN DISCUSSES THE REPORTING OF MEDICARE COVERAGE ON THE MEDICAID NURSING FACILITY CLAIM. When billing Medicaid for beneficiaries who have Medicare, the appropriate Medicare information must be reported on the claim. The Medical Services Administration has improved its claims processing logic by aligning the Community Health Automated Medicaid Processing System (CHAMPS) with the National Uniform Billing Committee (NUBC) and the Michigan Department of Community Health (MDCH) Electronic Submission Manual, including Companion Guides. MEDICAID IS ONLY CONSIDERED THE PRIMARY PAYER WHEN THERE IS NO MEDICARE OR OTHER INSURANCE PRESENT ON THE THIRD PARTY LIABILITY (TPL) COVERAGE FILE LOCATED IN CHAMPS. IF A BENEFICIARY HAS ACTIVE MEDICARE INSURANCE ON CHAMPS, THE NURSING FACILITY MUST ALWAYS REPORT IT, ALONG WITH THE APPROPRIATE VALUE CODES AND CLAIM ADJUSTMENT REASON CODES (CARC). When reporting Medicare, nursing facilities must bill as indicated below. Medicaid Claims Processing will adjudicate claims based on the new logic effective for claims received on and after February 17, Replacement claims will also adjudicate utilizing the new logic effective February 17, Covered Days Covered Days must be reported using Value Code 80. Covered Days are the days in which Medicare approves payment for the beneficiary s skilled care. Covered Days must be reported when the primary insurance makes a payment. Non-Covered Days Non-Covered Days must be reported using Value Code 81.

19 MSA Page 2 of 3 Non-Covered Days are the days not covered by Medicare due to Medicare being exhausted or the beneficiary no longer requiring skilled care. Non-Covered Days must be reported in order to receive the proper Medicaid provider rate payment. SPECIAL NOTE: When Medicare non-covered days are reported because Medicare benefits are exhausted, facilities must report Occurrence Code A3 and the date benefits were exhausted, along with Claim Adjustment Reason Codes (CARC) 96 (Non-Covered Charges), or 119 (Benefit Maximum for the time Period has been Reached). When Medicare non-covered days are reported because Medicare active care ended, facilities must report Occurrence Code 22 and the corresponding date Medicare active care ended, along with Claim Adjustment Reason Codes (CARC) 96 (Non-Covered Charges), or 119 (Benefit Maximum for the time Period has been Reached) must be reported. Coinsurance Days Medicare Coinsurance Days must be reported using Value Code 82. Coinsurance Days are the days in which the primary payer (Medicare or Medicare Advantage Plans) applies a portion of the approved amount to coinsurance. Coinsurance Days must be reported in order to receive the proper coinsurance rate payment. SPECIAL NOTE: When reporting Value Code 82, Occurrence Span Code 70 (Qualifying Stay Dates for SNF) and corresponding From/Through dates (at least a 3-day inpatient hospital stay which qualifies the resident for Medicare payment of SNF services) must also be reported. Facilities billing for beneficiaries in a Medicare Advantage Plan, must report CARC 2 and this must equal the Medicare Advantage Plan Coinsurance rate times the number of Coinsurance days. Facilities using CARC 2 must report it with the amount equal to the Coinsurance rate times the number of Coinsurance days reported. SPECIAL NOTE: The Medicare Advantage Plan Coinsurance rates vary and do not always equal the Medicare Part A Coinsurance rate. Providers must verify the beneficiary s Medicare Advantage Plan Coinsurance rate prior to billing Medicaid. Prior Stay Date If a SNF or nursing home stay ended within 60 days of the SNF admission, Occurrence Span Code 78 and the From/Through dates must be reported along with Occurrence Span Code 70 and the From/Through dates. Claim Examples Nursing facility claim examples on how to report Medicare and Commercial Insurance on the Medicaid Nursing Facility Secondary Claim can be found on the MDCH website at > Provider Tips > Nursing Facility. SPECIAL NOTE TO NURSING FACILITES WITH MEDICAID ONLY CERTIFIED BEDS NOT BILLING MEDICARE Claims submitted directly to Medicaid must be billed as outlined above. For example, for beneficiaries with Medicare coverage based on Medicaid s TPL File, Covered Dates MUST BE LEFT BLANK if Medicare is not covering the service or benefits have exhausted as Medicare is the primary payor. The NON-COVERED DAY MUST BE COMPLETED and it must equal the service units billed for room and board revenue codes and/or leave days revenue codes. The reason Medicare is not covering the service (e.g., benefits exhausted) must also be reported.

20 MSA Page 3 of 3 Manual Maintenance Retain this bulletin until it has been incorporated into the Medicaid Provider Manual. Questions Any questions regarding this bulletin should be directed to Provider Inquiry, Department of Community Health, P.O. Box 30731, Lansing, Michigan , or at ProviderSupport@michigan.gov. When you submit an , be sure to include your name, affiliation, and phone number so you may be contacted if necessary. Providers may phone toll-free Approved Stephen Fitton, Director Medical Services Administration

21 Bulletin Michigan Department of Community Health Bulletin Number: MSA Distribution: All Providers Issued: March 1, 2012 Subject: Effective: Programs Affected: New Medicaid Fraud Hotline Number Immediately Medicaid The Michigan Department of Community Health (MDCH), Office of the Inspector General, has a new Medicaid Fraud Hotline Number. The new toll-free number is MI-FRAUD ( ). The previous Medicaid Fraud Hotline Number appears on several MDCH publications. MDCH will identify these publications and make the appropriate modifications. The older versions will remain in distribution until supplies are exhausted. Therefore, the previous Medicaid Fraud Hotline Number will remain active throughout Suspected Medicaid fraud, waste, or abuse can be reported via telephone (1-855-MI-FRAUD), online at or in writing to: Manual Maintenance Office of Inspector General PO Box Lansing, MI Retain this bulletin until it has been incorporated into the Medicaid Provider Manual. Questions Any questions regarding this bulletin should be directed to Provider Inquiry, Department of Community Health, P.O. Box 30731, Lansing, Michigan , or at ProviderSupport@michigan.gov. When you submit an , be sure to include your name, affiliation, and phone number so you may be contacted if necessary. Providers may phone toll-free Approved Stephen Fitton, Director Medical Services Administration