(Medicare Claims Processing Manual)

Medicare Claims Processing Manual  Chapter 28 - Coordination With Medigap, Medicaid,  and Other Complementary Insurers   Table of Contents   (Rev. 11939, Issued: 04-05-23)  Transmittals for Chapter 28  10 - Medigap - Definition and Scope  20 - Assignment of Claims and Transfer Policy 20.1 - Beneficiary Insurance Assignment Selection  30 - Completion of the Claim Form 30.1 - ASC X12 837 Professional/Form CMS-1500 COB  30.2 - ASC X12 837 Institutional/Form CMS 1450 COB  40 - MSN Messages  50 - Remittance Notice Messages  60 - Returned Medigap Notices  70 - Coordination of Medicare With Medigap and Other Complementary Health Insurance Policies  70.1 - Authorization for Release of Information  70.1.1 - Requests for Additional Information 70.1.2 - Release of Title XVIII Claims Information for Medigap Insurance Purposes by Providers  70.2 - Integration of Title XVIII Claims Processing With Complementary Insurance C laims Processing  70.2.1 - Program Recognition  70.2.2 - Records and Information 70.2.3 - Matching Files Against Medicare Claims Files  70.3 - Standard Medicare Charges for COB Records  70.4 - General Guidelines for A/B MAC (A, B, or HH) or DME MAC Transfer of Claims Information to Medigap Insurers  70.5 - Audits  70.6 - Consolidation of the Claims Crossover Process  70.6.1 - Coordination of Benefits Agreement (COBA) Detailed Error Report Notification Process  70.6.1.1 - Coordination of Benefits Agreement (COBA) ASC X12 837 5010 Coordination of Benefits (COB) Flat File Errors  70.6.2 - Coordination of Benefits Agreement (COBA) Full Claim File Repair Process   70.6.3 -  Coordination of Benefits Agreement (COBA) Eligibility File Claims Recovery Process  70.6.4 -  Coordination of Benefits Agreement (COBA) Medigap Claim -Based Crossover Process  70.6.5 -  Coordination of Benefits Agreement (COBA) ASC X12 837 C oordination of Benefits (COB) Mapping Requirements as of July 2012 70.6.6 -  National Council for Prescription Drug Programs (NCPDP) Version D.0 Coordination of Benefits (COB) Mapping Requirements  80 - Electronic Transmission -  General Requirements  80.1 -  Deleted - Reserved  80.2 -  Deleted - Reserved  80.3 -  Medigap Electroni c Claims Transfer Agreements  80.3.1 -  A/B MAC (A)/A/B MAC (HH) Crossover Claim Requirements  80.3.2 -  A/B MAC/DME MAC Crossover Claim R equirements  90 - Deleted - Reserved  100 -  Medigap Insurers Fraud Referral   110 -  Medigap Criminal Penalties/Types of Complaints Under Section 1882(d)  110.1 -  Outline of Complaint Referral Process   110.2 -  Preliminary Screening and Referral to Regional Office of the Inspector General   110.3 -  CMS Regional Office Quarterly Report on Medicare Supplemental Health Insuran ce Penalty Provision Activity   110.3.1 -  Statistics   110.3.2 -  Narrative   10 - Medigap - Defini tion and Scope  (Rev. 2906, Issued: 03- 14-14, Effective: 04-14-14, Implementation 04-14-14)  The Omnibus Budget Reconciliation Act of 1990 (OBRA 1990, Public Law 101- 508) requires all Medicare supplemental (Medigap) insurance policies to conform to minimum standards including loss ratio requirements, standardized benefit packages and consumer protection requirements.  The procedures described in 20 through 110 apply to all policies meeting the definition of Medicare supplemental insurance policies (Medigap) in 1882(g)(1) of the Social Security Act (the Act.).   A Medigap policy is defined as:  A group or individual policy of accident and sickness insurance, or a subscriber contract of hospital and medical service associations or health maintenance organizations, other than a policy issued pursuant to a contract under 1876 or 1833 of the Act, or a policy issued under a demonstration project.  A Medigap policy is offered by a private company to those entitled to Medicare benefits and provides payment for Medicare charges not payable because of the applicability of deductibles, coinsurance amounts or other Medicare imposed limitations. Typically, a Medigap policy does not include limited benefit coverage areas available to Medicare beneficiaries, such as specified disease or hospital indemnity coverage. By law, the definition explicitly excludes a policy or plan offered by an employer to employees, or former employees, as well as policies offered by a labor organization to members or former members.  The National Association of Insurance Commissioners has developed model regulatory language for State insurance commissions to apply to Medigap insurance offerings.  This model regulatory language is located at: http://www.carfra.com/products/medsupappendixb.pdf.  It recommends the requirements that states should consider for approving proposed Medigap insurance plans.  The following procedures for furnishing information are mandatory for Medigap plans. Medicaid agencies are furnished information in the standard format free of charge. Other commercial payers, including Medigap insurers, must pay a CMS established per claim crossover fee for providing them with Medicare paid claims data.   20 - Assignment of Claims and Transfer Policy  (Rev.  4069, Issued: 06-08  18, Effective: 07 - 09- 18, Implementation: 07- 09-18)  A Medicare beneficiary who has a Medigap policy may  authorize the participating physician/practitioner or supplier of services to file a claim on his or her behalf and to receive payment directly from the insurer instead of through the beneficiary.  In such cases, Medicare must transfer Medicare claims information to the Medigap insurer.  The Medigap insurer pays the physician/provider/supplier directly.  The Medigap insurer, in turn, reimburses CMSs designated COBA contractor for the costs in supplying the information subject to limitations.  Paid claims f rom participating physicians or providers/suppliers for beneficiaries who have assigned their right to payment under a Medigap policy, regardless of whether or not it is in or from a State with an approved Medigap program, are to result in the transfer of claim information to the specified insurers.  The A/B MAC ( Part B) and DME MAC systems must have the capability to distinguish between claims of participating and nonparticipating physicians/practitioners and suppliers. This is because Medigap assignment of claims and transfer policy does not apply to nonparticipating physicians/practitioners or non-participating suppliers.   Effective with the future implementation of CMSs consolidated Medigap claim- based crossover initiative, the process for reporting Medi gap information on incoming claims will change.  Each Part B physician/practitioner and supplier of durable medical equipment, prosthetics, orthotics, and medical supplies (DMEPOS) will only include the CMS -issued Medigap claim -based COBA ID  (ID range 550 00 through 55999), which will be assigned by CMSs Benefits Coordination & Recovery Center (BCRC) , if: (1) the physician/practitioner or supplier participates in the Medicare Program; and ( 2) the beneficiary has assigned his/her rights to payment under a M edigap policy to that provider or supplier.   20.1 - Beneficiary Insurance Assignment Selection  (Rev. 4281, Issued: 04-  19-19, Effective: 05 -20-19, Implementation: 05- 20-19)  The term Medicare beneficiary identifier (Mbi) is a general term describing a beneficiary's Medicare identification number. For purposes of this manual, Medicare beneficiary identifier references both the Health Insurance Claim Number (HICN) and the Medicare Beneficiary Identifier (MBI) during the new Medicare card tran sition period and after for certain business areas that will continue to use the HICN as part of their processes.   Beneficiaries indicate that they have assigned their Medigap benefits to a participating physician/practitioner or supplier by signing block #13 on the Form CMS -1500. This authorization is in addition to their assignment of Medicare benefits as indicated by their signature in block #12.  Form CMS -1450 makes no provision for the provider to indicate that the beneficiary has assigned benefits because the Form CMS -1450 is used only for institutional claims, for which payment is typically assigned to the provider of services. For claims the institutional provider submits to A/B MACs (B) for physician payments for physician employees; hos pitals, SNFs, HHAs, OPTs, CORFs, or ESRD facilities may maintain a beneficiary statement in file instead of submitting a separate statement with each claim. This authorization must be insurer specific.   If the beneficiary has a Medigap policy, the following statement should be signed:    Beneficiarys Medicare beneficiary identifier  NAME OF BENEFICIARY  MEDIGAP POLICY NUMBER   I request that payment of authorized Medigap benefits be made either to me or on my behalf to _______________ for any services furni shed me by that physician/provider/supplier.  I authorize any holder of medical information about me to release to (name of Medigap insurer) any information needed to determine these benefits or the benefits payable for related services.   Since the beneficiary may selectively authorize Medigap assignments, caution providers about routinely stamping item  #13 of the Form CMS -1500 signature on file. The Medigap assignment on file in the participating doctor/suppliers office must be insurer specific. However , it may state that the authorization applies to all occasions of services until it is revoked.  Effective with October 1, 2007, participating Part B physicians/practitioners and DMEPOS suppliers now  will only include the CMS -assigned Medigap claim -based CO BA ID on an incoming claim if confirmation that a beneficiary has authorized Medigap assignment has been obtained.   30 - Completion of the Claim Form  (Rev. 2906, Issued: 03- 14-14, Effective: 04 -14-14, Implementation 04- 14-14)  As part of the national Coordination of Benefits Agreement (COBA) claim -based Medigap crossover process, participating physicians/practitioners and suppliers that are attempting to trigger mandatory  Medigap (claim -based) crossovers must include the CMS -assigned 5- digit Medigap COBA claim- based ID (within range 55000 through 55999) within designated areas on the appropriate claim as follows:    Within field NM109 of the NM1 segment within the 2330B loop of the incoming Health Insurance Portability and Accountability Act (HIPAA) Accredited Standards Committee (ASC) X12 - 837 professional claim (current format). [See 70.6.4 of this chapter for further information.]    Item 9 -D of the incoming paper Form CMS -1500 claim ( NOTE:   the PAYERID or the Medigap company or  plan name within this field will not trigger a Medigap claim -based crossover); and   In addition, unless otherwise specified, retail chain pharmacies that are attempting to trigger crossovers to their clients Medigap insurers should enter the Medigap COBA  claim -based within field 301- C1 of the T04 segment on the incoming National Council for Prescription Drug Programs (NCPDP) batch claims.  For more information regarding the COBA Medigap claim -based crossover process, refer to 70.6.4 of this chapter.   30.1 - ASC X12 837 Professional/Form CMS -1500 COB  (Rev. 2906, Issued: 03- 14-14, Effective: 04 -14-14, Implementation 04- 14-14)  Participating physicians/practitioners and suppliers sign an agreement with Medicare to accept assignment of Medicare benefits for al l Medicare patients. A claim for which a beneficiary elects to assign his/her benefits under a Medigap policy to a participating physician/practitioner and supplier is called a mandated Medigap transfer.   Participating providers and suppliers that must bill electronically shall enter the 5 -digit claim- based Medigap COBA ID in field NM109 of the NM1 segment in loop 2330B of the Health Insurance Portability and Accountability Act (HIPAA) ASC X12 837 professional claim for purposes of triggering Medigap clai m-based crossovers.  If a participating Part B physician/practitioner or DMEPOS supplier fails to include this identifier in the field just described, the claim will not be transferred, as appropriate, to the Medigap insurer via the COBA claim -based Mediga p crossover process.   Under CMSs national COBA claim -based Medigap process, participating Part B physicians/practitioners and suppliers that are exempted under the Administrative Simplification Compliance Act (ASCA) from having to bill electronically are required to enter the CMS -assigned 5- digit claim- based Medigap COBA ID on the paper form.   Medigap information is entered on the CMS Form 1500 as follows:   Version 08/05