Provider Notice issued 09/26/16

New Third Party Liability (TPL) Code to Identify Participants in a Medicare Advantage Plan (MAP) Effective with Dates of Service Beginning October 1, 2016

To: Long Term Care Facilities - Nursing Facilities (NF), Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IID), Supportive Living Program (SLP), Nursing Facilities Eligible to be Licensed Specialized Mental Health Rehabilitation Facilities (SMHRF) and State-Operated Facilities 
Date: September 26, 2016
Re: New Third Party Liability (TPL) Code to Identify Participants in a Medicare Advantage Plan (MAP) Effective with Dates of Service Beginning October 1, 2016

This notice serves to inform long term care providers of a new third party liability code that must be used when billing to identify participants who are enrolled in a Medicare Advantage Plan (MAP).Providers will specify this code and any payment received on the 837I claim transaction. 

Medicare Advantage Plans are an alternative to Original Medicare and claims are not forwarded to Medicaid through the Medicare Administrative Contractor (MAC). HFS will treat MAP coverage like commercial insurance in the Medicaid payment system. The Department has designated TPL Code 920 to identify participant coverage under a MAP for dates of service beginning October 1, 2016. This effective date is linked to the implementation of long term care provider direct billing to HFS. Claims containing this TPL code will be allowed 24 months from the Statement Covers Period Through Date of service to be received by the Department for timely filing.

Claims for participants who have MAP coverage and are also a participant in a Managed Care Program through a Managed Care Organization (MCO): 

• Medicare Medicaid Alignment Initiative (MMAI) program participants: 
• Both Medicare and Medicaid covered services must be billed to the MCO. 
• Managed Long Term Services and Support (MLTSS) program participants:
• Medicaid covered services must be billed to the MCO.
• Medicare covered services must be billed to the MAP first and may be submitted to Medicaid after MAP adjudication.

For participants involved in the MLTSS program, claims submitted directly to HFS should be for Medicare covered service periods only and must show the MAP as the primary payer. The MAP TPL code 920 must be reported in Claim Loop 2330B/REF-Other Payer Secondary Identifier segment using the 2U qualifier followed by a 2-digit TPL Status Code. The amount paid by the MAP should be reported as a claim level payment in Claim Loop 2320 on the AMT – Coordination of Benefits (COB) Payer Paid Amount segment.

Once the MAP benefits are exhausted providers should bill the MLTSS MCO directly for the Medicaid only period. No MAP coverage should be reflected, only Medicaid. The A2 occurrence code and date should be reflected as the first day of Medicaid only benefits.

Claims for participants who have MAP coverage and are not a participant in a Managed Care Program through a MCO: 

Claims for participants who have MAP coverage but are not participating in a Managed Care Program should be sent to HFS after adjudication by the MAP. These claims must show the MAP as the primary payer on the claim. The MAP TPL code 920 must be reported in Claim Loop 2330B/REF-Other Payer Secondary Identifier segment using the 2U qualifier followed by a 2-digit TPL Status Code. The amount paid by the MAP should be reported as a claim level payment in Claim Loop 2320 on the AMT – Coordination of Benefits (COB) Payer Paid Amount segment. 

Error Message

If the Department receives a claim with missing or invalid TPL information for a participant with MAP coverage, the claim will be rejected and identified on the paper Remittance Advice with error code L24 – Bill Medicare Advantage Plan.

Questions regarding this notice may be directed to the Bureau of Long Term Care at

1-844-528-8444 (toll-free).

Felicia F. Norwood
Director