introduction why is this needed? federal mandate medicaid is payer of last resort

Introduction Why is this needed?

• Federal Mandate• Medicaid is payer of last resort

• Michigan Document• Was already needed in 4010. Want Medicare and

insurance as non-covered• NY Document

• 0-fill payer specific

The process previously known as “0FILL” is now indicated by usage of this AMT segment. As a result, this indicator is now payer specific.

Entering the Insurance Data • Insurance Master• Put in address w/zip+4

• Insurance Info• Pat 5

• Medicare Info (Michigan)• Pat 10

• code 22 admin date or prior (date not MEDICARE level) (96) • A3 Benefits exhausted (119)

Setting the Billing Parameters • 5010 ONLY!!!!

• NY Basic 57 = D

• Michigan (use non-covered days) Basic 57 = B Basic 23 = X Occur 22 = P and A3 = P

(uses history not “A”)

Resident>System Parameters>Bill Print/Submit Parms>Field Group "B – Occurrence Codes">Click inside cell and make entry>Save.

If A3 does not exist and needs to be added

Resident>System Parameters>Bill Print/Submit Line Edit>Field Group "B – Occurrence Codes”

Effect on the 5010 • Medicaid secondary

• Insurance primary

Note for 5010 CH changed to RP for Michigan

BHT*0019*00*ABCDEF*20111122*114428*RP

Medicaid secondary to Medicare

HL*2*1*22*0SBR*S*18*******MCNM1*IL*1*Aaaaaa*Dddddd*K***MI*0123456789N3*431 Pppp Sppppp N4*CLIO*MI*484200000DMG*D8*19520921*MNM1*PR*2*MEDICAID*****PI*00111N3*201 Tttttttt SssssN4*LANSING*MI*489130000CLM*000802*7750***21:A:3**A*Y*YDTP*434*RD8*20110801-20110831DTP*435*DT*201006230000CL1*1*4*30REF*EA*011111HI*BK:4019HI*BJ:4019HI*BF:3441*BF:V4976*BF:2729*BF:7291*BF:70723*BF:70705*BF:35571HI*BH:A3:D8:20100615HI*BE:81:::31*BE:D3:::863NM1*71*1*WxxxxxN*Jxxxxx*H***XX*1111111111SBR*P*18*******MACAS*PR*119*7750AMT*A8*7750OI***Y***YNM1*IL*1*Aaaaaa*Daaaaa*K***MI*322222222C1NM1*PR*2*MEDICARE*****PI*00450N3*7500 SECURITY BLVDN4*BALTIMORE*MD*212440000DTP*573*D8*20111122REF*F8*311125310215130000LX*1SV2*0120**7750*DA*31**0

270/271 to get information • PT270A

• PT270S (code tables)

• PT270R (code tables)

835 messages

• In some cases no denial file (NY)

• Shows primary payor

• Needs to bill by adjustment after corrections (NY???)