What is retrospective billing ?

Q: What is the difference between the effective date and retrospective billing date?

A: The effective date is the later of the following two dates:

• The filing date of an enrollment application that was subsequently approved, or

• The date the provider first began furnishing services at a new practice location.

The provider may bill retrospectively for services when:

• The supplier has met all program requirements, including state licensure requirements, and

• The services were provided at the enrolled practice location for up to

1. 30 days prior to their effective date if circumstances precluded enrollment in advance of providing services to Medicare beneficiaries, or

2. 90 days prior to their effective date if a presidentially-declared disaster precluded enrollment in advance of providing services to Medicare beneficiaries.

Example:

Suppose that a non-Medicare enrolled physician began furnishing services to beneficiaries at her office March 1. She submitted the CMS-855I initial enrollment application May 1, and the application was approved June 1. The physician’s effective date of enrollment would be May 1, which is the later of: (1) the date of filing, and (2) the date she began furnishing services. The retrospective billing date is April 1 (or 30 days prior to the effective date of enrollment).

Q: How do I obtain beneficiary eligibility information and/or claim status?

A: To access the status of a claim or a beneficiary's Medicare eligibility information (including the date of birth, date of death, entitlement dates, benefit dates, deductible, or coinsurance) use these options below.

Prior to providing services, obtain a copy of the beneficiary’s Medicare card and verify the beneficiary’s insurance information with either the beneficiary or his/her legal representative.

Part B providers

• Contact the Part B IVR at 877-847-4992.

Note: Customer service representatives cannot assist you with eligibility information and are required, by the Centers for Medicare & Medicaid Services (CMS), to refer you to the IVR.

Do we need to save verification eligibility screen as a proof

How do I document verification of recipient eligibility?

You can obtain a call reference number through the AVRS. If you use the Web Portal you may choose to save a copy of the screen print or print out a hardcopy. If you use a MEVS vendor you will receive hard copy when you verify eligibility that you can save.

To show proof that we verified eligibility, we use a spreadsheet with recipient name, Medicaid number, date checked and comment box. Is this enough to show or document verification of eligibility? We verify eligibility using the web portal.

Many providers print out or save a screen shot of the page when they look up the eligibility and put it with the recipient’s file. If there is ever a discrepancy at a later time with the recipient’s eligibility it will show what the provider saw at the time the provider checked the eligibility

It is the provider’s responsibility to verify a patient’s Medicaid eligibility prior to providing any Medicaid reimbursable services.” If a recipient is not eligible for the month of September until the 15th of the month (and then eligibility is retroactive for the entire month), but services were provided earlier in September… will those services be billable once the recipient becomes eligible for the month?

Yes, once the recipient has eligibility for the date of service. Keep in mind that if you provide services for a person who is not eligible, you should not expect Medicaid payment. The recipient must be informed and agree to receive services that may not be covered by Medicaid. See Page “1-7” in Chapter 1 of the Florida Medicaid Provider General Handbook. All Medicaid handbooks, fee schedules, forms, provider notices, and other important Medicaid information are available on the Medicaid fiscal agent’s Web Portal at: http://mymedicaid-florida.com/

Will the system’s speed ever be improved? We have 60+ individuals to verify eligibility on. This process currently takes hours and hours to complete because the system response is so slow.

You may want to look into submitting batch transmissions. These can be done on the web portal or with most of the eligibility vendors. You can contact the fiscal agent for assistance with the web portal at www.mymedicaid-florida.com.

Medicaid THIRD PARTY LIABILITY (TPL) - During eligibility

When checking eligibility, sometimes, there is COMMERCIAL INSURANCE listed on the Medicaid website as primary payer. After checking the primary payer websites, I find that the commercial insurance has terminated - sometimes up to 8 months prior. What can I tell parents to do to get the commercial insurance removed, so that we can utilize their Medicaid coverage? Who do they need to contact? Who can they call? If you can please help us with this, it would be very much appreciated.

If a recipient has other insurance coverage through a third party source, such as Medicare, TRICARE, insurance plans, AARP plans, or automobile coverage, we refer to that as Third Party Liability (TPL). As you know, these other sources must be billed prior to billing Medicaid. Florida Medicaid currently contracts with Affiliated Computer Systems (ACS) to manage TPL operations. Providers who have questions or problems concerning third party insurance can contact the Medicaid third party contractor:

*  By telephone at 877-357-3268 (FL-RECOV),

*  By fax at 866- 443- 5559,

*  Through the website at http://www.FLMedicaidTPLRecovery.com,

*  By e-mail at FLMedicaidTPLRecovery@acs-inc.com,

*  Or in writing to:

ACS; Florida TPL Recovery Unit; 230; Killearn Center Blvd., Bldg A1; Tallahassee, Florida 32309

The TPL contractor can make the necessary corrections to the information on the recipients’ files.

Verifiying patient insurance eligibility details - Medical billing - important process

VERIFICATION OF INSURANCE INFORMATION 

During patient registration, it is important for front office staff to identify whether a beneficiary’s expenses should be covered by other insurance before, or in addition to, Medicare. This information helps the office determine who to bill and how to file claims with Medicare. 

This is not an easy task. There are many insurance benefits a patient could have and many combinations of insurance coverage to consider before determining who pays and when. Depending on the type of additional insurance coverage a patient has (if any), Medicare may be the primary payer for a patient’s claims or be considered the secondary payer.

The office staff should:

* Copy the Medicare card and/or other insurance cards.

* Obtain essential patient information through use of completed medical information/history and insurance forms.

* Determine Medicare eligibility.

* Determine “other” insurance coverage, claim submission guidelines and limitations to coverage.

* Determine the proper order of claim submission, who is primary and who is secondary payer. Obtain appropriate information to allow the claim to be submitted to the appropriate insurance payer.

A good practice to incorporate into the patient screening process is to make copies of the patient’s insurance card(s).

COPYING THE MEDICARE CARD

Verification is important since the information from the Medicare card should be obtained during the patient’s initial visit. Medicare also recommends that office personnel periodically verify a beneficiary’s insurance information to determine if any changes have occurred. Rev. 9/2010 3 Patient Registration/Screening

Pay close attention to:

 *Exact patient name.

* Claim number.

* Type of insurance coverage.

* Effective date of coverage.

Claim rejections or denials could occur if complete information is not obtained and supplied on the Medicare claim form submitted. 

The accuracy and verification of the Medicare card information is extremely important because this information will be used on many claim forms and medical documentation materials throughout the patient’s history with the provider’s office. 

verify insurance eligibility

How to verify insurance eligibility - effective dates

Confirming Eligibility

Whenever possible, providers should verify eligibility prior to providing service. To verify eligibility, providers should perform the following:

Step 1  Request to see the recipient’s plastic card, or a copy of the eligibility notification letter.

Step 2  Ask to see a driver’s license or other picture identification for adult recipients.

Step 3  Perform eligibility verification using one of the methods described in Section 3.2, Confirming Eligibility.

Step 4 Review the entire eligibility response, as applicable, to ensure the recipient is eligible for the service(s) in question. Please note that the eligibility response provides lock-in, third party, managed care and dental information. You need all the available information to determine whether the recipient is eligible for Medicaid.

Step 5 Maintain a paper copy of the eligibility response in the patient’s file to reference, should the claim deny for eligibility.

 

Insurance eligibility

Insurance eligibility response - understanding

Understanding the Eligibility Response

When you use Provider Electronic Solutions software, or AVRS to verify eligibility, the system returns a detailed eligibility response. You will receive confirmation of the information displayed on the recipient’s plastic card, along with verification that the recipient is eligible or ineligible for services performed on the requested From Date of Service (FDOS). The eligibility response also returns the following information:

• Recipient’s aid category

• Lock-in information

• Managed Care or Medicare affiliation, if applicable

• Third party information

• Maternity Waiver

• Benefit Limits

• Dental Benefit Limits

Nebraska verifying insurance eligibility

Nebraska verifying insurance eligibility

Verifying Eligibility: Medicaid eligibility, managed care participation, and third party resources may be verified from –

1. The client’s monthly Nebraska Medicaid Card or Nebraska Health Connection ID Document. For explanation and examples, see 471-000-123;

2. The Nebraska Medicaid Eligibility System (NMES) voice response system. For instructions, see 471-000-124; or

3. The standard electronic Health Care Eligibility Benefit Inquiry and Response transaction (ASC X12N 270/271). For electronic transaction submission instructions, see 471-000-50.

List of insurance and IVR phone numbers

This is basically from Florida state.

Telephone Number

1 Medicare 1877-847-4992

2 RR Medicare 1877-288-7600

3 Medicaid 1800-289-7799 and 1800-239-7560

4 AARP 1800-523-5800

5 Aetna 1800-624-0756

6 UMR 1800-826-9781

7 Great West and Cigna baycare 1800-663-8081

8 Amerigroup 1800-454-3730

9 Molina Health 186-472-4585

10 Summit and Coventry 1800-847-3995

11 Sunshine State 166-796-0530

12 Golden Rule 1800-657-8205

13 BCBS 1800-727-2227

What we can do in IVR - What are information need to use IVR . Interactive voice response (IVR) system capabilities

The IVR system provides automated information on claims, benefits and more, 24 hours a day, seven days a week.

Call the number on the back of the member’s Humana identification card to reach the IVR system.

Information available through IVR system

You can obtain a variety of information by using the IVR system.

The system can:

Confirm member coverage and the date the coverage began.

Notify you if referrals are required by the member’s plan.

Give you the status of a referral request.

Provide the member’s deductible, copayment and coinsurance information.

Provide the member’s out-of-pocket and lifetime maximum information.

Retrieve claim status for specific members.

Retrieve claim status for all your claims on one or more days.

Initiate inpatient admission and non-HMO (health maintenance organization) outpatient preauthorization requests.

Provide preauthorization request status*, directing your call to a Humana customer care representative, if needed.

In addition, you can use the system to request that the following information be sent to you by fax:

Member eligibility information.

Claims status: 40 claims per page, organized in a remit format.

Referral documentation.

Preauthorization documentation.

*Available in most areas

The IVR system gives you the option of requesting help from a Humana customer care representative. Assistance is available Monday through Friday on the following topics:

Medical eligibility, benefits and claims status: 8 a.m. to 8 p.m. EST.

Dental eligibility, benefits and claims status: 8 a.m. to 8 p.m. EST.

Preauthorizations: 8 a.m. to 6 p.m. EST.

Financial recovery: 8 a.m. to 5 p.m. EST.

Information you will need to use IVR

Before calling the IVR system, make sure you have the following information handy:

Nine-digit tax ID number.

Nine-digit member ID number (listed on member's ID card).

Member's date of birth (mm/dd/yy).

Date of service in mm/dd/yyyy format (for specific options, such as claims or precertifications).

Your fax number (if a fax-back option is requested). Specific information to initiate a preauthorization, including the following: CPT-4 (five-digit) codes for procedures and surgeries; ICD-9 (three-, four- or five-digit) codes for diagnoses; CPT or HCPCS codes for outpatient procedures. 

Dont call Medicare toll free service line for claim status

Customer service representatives cannot provide claim status via the toll-free service line

Medicare guidelines, specifically, the Internet-only manual (IOM) Publication, 100-09 Chapter 6 Section 50.1 requires that providers call the interactive voice response system (IVR) to obtain claim status.  Service associates responding to calls via our toll-free service line are not allowed to provide claim status.  To do so would be in violation of Medicare service guidelines.

First Coast Service Options’ (First Coast’s) customer service representatives (CSRs) continue to receive a large volume of calls from providers asking for claim status.  In the majority of cases the calls are coming from entities representing Medicare providers.  Because many providers have chosen to outsource their claims monitoring activities, they may not be aware that the entities representing them are calling the toll-free CSR service line for status of claims instead of using the IVR.

When claim status calls are made to the toll-free CSR service line, it slows our response time for other calls coming into our call center because service associates are attempting to explain to customers that status cannot be released via the general inquiry service line.  It is the responsibility of Medicare providers to notify the entities representing them that claim status inquiries must be made via the IVR or our new Internet portal the SPOT. See http://medicare.fcso.com/Landing/256747.asp.