Provider Notice Issued 10/04/2017

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Date:  October 4, 2017

To:      Enrolled Ambulatory Surgical Treatment Centers (ASTC); Hospitals; and Renal Dialysis Facilities

Re:      New Third Party Liability (TPL) Code to Identify Participants in a Medicare Advantage Plan (MAP) Effective with Dates of Service Beginning November 1, 2017

This notice serves to inform providers of a new third party liability (TPL) code that must be used when billing to identify participants who are enrolled in a Medicare Advantage Plan (MAP). Providers must specify this TPL code and any payment received from the MAP on the 837I or UB-04 claim transactions. This notice supersedes the instructions contained in the June 19, 2015 Informational Notice (PDF) to providers.

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 outpatient dates of service and inpatient admissions beginning November 1, 2017. Claims containing this TPL Code will be allowed 24 months from the Through Date of service to be received by the Department for timely filing.

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

Ø  Participants in the Medicare Medicaid Alignment Initiative (MMAI) program: 

◦        Both Medicare and Medicaid covered services must be billed to the MCO. 

Ø  Participants in a Medicaid MCO (e.g., the Managed Long Term Services and Support (MLTSS) program) with a MAP:

◦        Medicare is the primary payer. Medicare covered services must be billed to the MAP first and may be submitted to Medicaid fee-for-service (FFS) after MAP adjudication.

◦        Medicaid MCO only covers long term care, HCBS waiver services, non-Medicare behavioral health, and non-emergency transportation. These services must be billed to the Medicaid MCO.

◦        Medicaid covered services not covered by Medicare or the Medicaid MCO must be billed Medicaid fee-for-service.

◦        The Department soon will be issuing further guidance via provider notice explaining how these participants are identified in the MEDI system.

Crossover claims for dual eligible participants in a Medicaid MCO (e.g., MLTSS) and a MAP should be submitted directly to HFS for Medicare covered service periods only and must show the MAP as the primary payer.

·         For electronic claims, 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.

·         For UB-04 claims, MAP TPL Code 920 must be identified in Form Locator 51 followed by a 2-digit TPL Status Code. The format will continue to be the 3-digit TPL code, one space, and then the 2-digit status code. The amount paid by the MAP should be reported in FL 54.  

Once the MAP benefits are exhausted providers should bill the Medicaid MCO directly for long term care, HCBS waiver services, non-Medicare behavioral health, and non-emergency transportation services 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.

v   Claims for participants who have MAP coverage and are not a participant in a  Medicaid MCO:

Claims for participants who have MAP coverage but are not participating in a Medicaid MCO should be sent to HFS after adjudication by the MAP. These claims must show the MAP as the primary payer on the claim.

·         For electronic claims, 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.

·         For UB-04 claims, MAP TPL Code 920 must be identified in Form Locator 51 followed by a 2-digit TPL Status Code.  The format will continue to be the 3-digit TPL code, one space, and then the 2-digit status code.  The amount paid by the MAP should be reported in FL 54. 

Informational Message

If the Department receives a claim billed with Medicare TPL code 909 or 910 and the Department identifies the participant as having coverage with a MAP, the claim will be paid as a Medicare claim, but informational message L24 – Bill Medicare Advantage Plan will be returned on the Remittance Advice. When this message is received, the provider should verify whether the participant has Original Medicare or a MAP. If the participant has a MAP, the claim should be voided and rebilled with TPL code 920. 

Questions regarding this notice may be directed to the Bureau of Hospital and Provider Services at 1-877-782-5565 (toll-free).

Felicia F. Norwood

Director