Spend-down HP Provider Relations October 2011
Agenda – Objectives – Spend-down Rule – Spend-down Eligibility – Eligibility Verification System – Enhanced Spend-down Information – Billing a Member – Claims Processing – Examples of Application of Spend -down – Spend-down Quiz – Helpful Tools – Questions & Answers 2 Spend-down October 2011
Objectives – To provide a thorough explanation of spend-down rules and eligibility – To explain when it is appropriate to bill Medicaid members for spend-down – To outline claims processing procedures related to spend-down 3 Spend-down October 2011
Spend-down Rule 405 IAC 1 -1 -3. 1 – Providing services to members enrolled under the Medicaid spend-down provision – Subsection (d) states: • • 4 A provider may not refuse service to a Medicaid member pending verification that the monthly spend-down obligation has been satisfied A provider may not refuse service to a Medicaid member solely on the basis of the member’s spend-down status Spend-down October 2011
Define Spend-down Eligibility
Spend-down Eligibility – 405 IAC 2 -3 -10 – Spend-down eligibility • Certain types of income are counted in determining Medicaid eligibility • Income greater than a certain threshold is considered "excess income” and is referred to as "spend-down obligation" – Spend-down, therefore, is very similar to a "deductible" • The Medicaid member is liable for their initial Medicaid expenses each month, up to their spenddown amount • Spend-down amounts are deducted from the first claim(s) processed each month Ø Pharmacy providers that bill claims on a point of sale (POS) system receive immediate claim adjudication and may collect the amount of spend-down credit at the time of service 6 Spend-down October 2011
Spend-down Eligibility Spend-down may be applied to members in the following aid categories: – Traditional Medicaid fee-for service (FFS) – MEDWORKS – Home and Community-Based Services (HCBS) Waiver Members assigned to Care Select or the risk-based managed care (RBMC) program are not assigned a spend-down 7 Spend-down October 2011
Eligibility Verification System Spend-down information on EVS – Enhanced spend-down information became available on the Eligibility Verification System (EVS) beginning January 1, 2010 – Using EVS, providers can determine the amount of spend-down remaining to be met for a particular month Note: The amount indicated may not be the actual spend-down amount credited to your claim – With the exception of pharmacy claims billed on a POS system, providers may not collect the spend-down amount at the time of service – Reference the IHCP Provider Manual, Chapter 2, Section 4, for additional information 8 Spend-down October 2011
Eligibility Verification System Enhanced spend-down information 9 Spend-down October 2011
Learn Billing a Member
Billing a Member – Providers should always review the Remittance Advice (RA) to see if Adjustment Reason Code (ARC) 178 applies to any claims on the RA • The end of the RA lists the ARC codes that appear within that week’s RA. Review the listing to verify if ARC code 178 is included. – ARC 178 indicates there is a spend-down amount billable to at least one member on that week’s RA – A provider may bill a member for the dollar amount identified beside ARC 178 on the RA statement – This amount will also appear in the "Patient Responsibility" column on the RA 11 Spend-down October 2011
Billing a Member – Once the claim has adjudicated, providers are responsible to bill the member for the spend-down amount credited on the claim – The member is not obligated to pay the provider until the member receives the Medicaid Spend-down Summary Notice listing the amount applied to spend-down • Notices are sent on the second business day following the end of the month • The notices give a detailed itemization of how the spend-down was applied for that month, including provider name, amounts, and dates of service 12 Spend-down October 2011
Billing a Member What if the member doesn’t pay their spend-down? – Providers may discharge a member from their care if a member does not adhere to established payment arrangements of outstanding copayments or spend-down – Providers cannot be more restrictive with spend-down members than with other patients 13 Spend-down October 2011
Error Codes 0387 and 0388 – Providers may have encountered claim denials due to explanation of benefits (EOB) codes 0387 or 0388 – This service is not payable. The recipient has not satisfied spend-down for the month. – Providers should notify their field consultant when claims deny for these error codes. Note: Claims adjudicate to a paid status when spend-down is credited on a claim. Spend-down-related claims should not adjudicate to a denied status. 14 Spend-down October 2011
Quiz Q How can providers determine when a member has a spend-down? Q Why can’t providers collect the spend-down at the time of service? Q How is the provider informed that spend-down has been credited on claims? 15 Spend-down October 2011
Quiz Responses Q How can providers determine when a member has a spend-down? A Providers can verify a member’s eligibility using Web inter. Change, Automated Voice Response (AVR), Omni, or the Health Insurance Portability and Accountability Act (HIPAA) 277/278 transaction Q Why can’t providers collect the spend-down at the time of service? A The amount credited to spend-down is not known until the claim adjudicates Q How is the provider informed that spend-down has been credited on claims? A 16 Providers should review the RA to determine if and how much has been credited to spend-down Spend-down October 2011
Explain Claims Processing
Claims Processing – The first claim processed by the IHCP applies to spend-down, regardless of the date of service within the month – The system uses the billed amount to credit spend-down • Therefore, providers should bill their usual and customary charge – Third Party Liability (TPL) amounts are deducted from billed amount prior to crediting spend-down – State-mandated copayments for pharmacy and transportation claims credit spend-down first 18 Spend-down October 2011
Claims Processing Denied services – Services that are not covered by the Medicaid program do not credit spend-down – Exceptions: • A service that is denied because the member exceeds a benefit limitation, which cannot be overridden with prior authorization (PA), may credit spenddown • Denied services may be split between spend-down months 19 Spend-down October 2011
Claims Processing Benefit limit exhausted – Example 1 Date Billed: September 25, 2011 – $100. 00 Spend-down Remaining for September – $200. 00 Spend-down Remaining for October Billed Amount $200. 00 Claim Status Denied Audit 6122 – Chiropractic Therapeutic Physical Medicine Treatments Limited to 50 20 Spend-down October 2011 Credit to Spend -down $100. 00 – September $100. 00 – October
Claims Processing Voids and replacements – When a claim is paid and credits the member’s spend-down, a provider-initiated void or replacement can cause an increase or decrease in spend-down amount owed to a provider for the claim – In the event a refund is due to the member as a result of a voided claim, the member is notified in the Medicaid Spend-down Summary Notice • The member must have paid the provider to be eligible for a refund – Voids and replacements adjust the spend-down credit immediately 21 Spend-down October 2011
Claims Processing The Division of Family Resources may also credit spend-down for certain “non-claim” expenses, including: – Medical expenses incurred by a recipient’s spouse or other person whose income is considered in determining eligibility – Medical services provided by non. Medicaid providers – Services rendered prior to eligibility 22 Spend-down October 2011
Claims Processing Hierarchy of spend-down credits: – Non-claim items entered by the DFR caseworker – State-mandated transportation and pharmacy copayments – Denied details, when permitted – Paid details 23 Spend-down October 2011
Claims Processing Month-end balancing – Each month, HP performs a month-end balancing process that ensures all “non-claim” items entered by the DFR are credited first – This process ensures that all spend-down items are applied in accordance with the established hierarchy – HP may initiate claim adjustments as a result of month-end balancing • Claims adjusted by the month-end balancing process have an internal control number (ICN) that begins with 64 – These adjusted claims result in additional reimbursement to the provider 24 Spend-down October 2011
Claims Processing Example 1 – Spend-down activity for September – $500 Order of Claims that Credit the Spenddown Date of Service Provider Type Amount Incurred Method of Claim Submission Claim Processing Date Claim Status Spend-down Balance for September 1 9/2/11 Pharmacy $50. 00 (Includes Copay) Point of Sale (POS) 9/2/11 Paid $0. 00 $450. 00 2 9/5/11 Physician $100. 00 Web inter. Change 9/5/11 Paid $0. 00 $350. 00 3 9/8/11 Pharmacy $50. 00 (Includes Copay) Point Of Sale (POS) 9/8/11 Paid $0. 00 $300. 00 4 9/7/11 Non. Claim $50. 00 ICES (County Office) 5 9/8/11 Outpatient Hospital $300. 00 837 I (Electronic) $250. 00 9/15/11 $250. 00 Credit spend-down Paid $0. 00 6 25 Spend-down 9/2/11 Dental October 2011 $100. 00 Paper 9/20/11 Paid IHCP Allowed $0. 00 (Allowed amount is less)
Claims Processing Example 2 – Spend-down activity for October – $300 Order of Claims that Credit the Spenddown Date of Service Provider Type Amount Incurred Method of Claim Submission Claim Processing Date Claim Status Spend-down Balance for October 1 10/2/11 Pharmacy $20. 00 (Includes Copay) Point of Sale (10: 00 a. m. ) 10/2/11 Paid $0. 00 $280. 00 2 10/2/11 Physician $50. 00 Web inter. Change (2: 00 p. m. ) 10/2/11 Paid $0. 00 $230. 00 3 10/8/11 Dental $100. 00 Web inter. Change 10/8/11 Paid $0. 00 $130. 00 4 10/25/11 Physician Void of Claim #2 for $50. 00 Web inter. Change 10/25/11 Void Entire Claim $180. 00 5 10/28/11 Dentist $100. 00 Paper 10/15/11 Paid $0. 00 $80. 00 6 10/29/11 Transport $150. 00 Paper 10/20/11 $80. 00 Credit Spenddown $0. 00 (Allowed amount is less) 26 Spend-down October 2011
Claims Processing Example 3 – Spend-down activity for June – $400 Order of Claims that Credit the Spenddown Date of Service Provider Type Amount Incurred Method of Claim Submission Claim Processing Date Claim Status Spend-down Balance for June 1 6/2/11 Pharmacy $50. 00 (Includes Copay) Point of Sale (POS) 6/2/11 Paid $0. 00 $350. 00 2 6/5/11 Physician $100. 00 Web inter. Change 6/5/11 TPL paid $25. 00 Paid $0. 00 $275. 00 3 6/8/11 Pharmacy $50. 00 (Includes Copay) Point Of Sale (POS) 6/8/11 Paid $0. 00 $225. 00 4 6/8/11 Outpatient Hospital $200. 00 837 I (Electronic) 6/15/11 Paid $0. 00 $25. 00 5 6/2/11 Transport $100. 00 Paper 6/20/11 $25. 00 Credit $2. 00 copay rolls forward) $0. 00 (Allowed amount is less) 27 Spend-down October 2011
Spend-down Quiz (True or False) Q A provider may refuse to provide service to a member if they verify eligibility and determine the member has a spend-down? Q A provider may refuse to provide a service to a member who has a legitimate past-due balance for a spend-down, but refuses to pay it? Q A provider may bill the member for spend-down as soon as they receive a Remittance Advice that includes ARC 178? Q Spend-down is credited based on the provider’s usual and customary charge (UCC)? Q Spend-down is credited to claims in date-of-service order? Q The highest priority transaction to credit spend-down are “nonclaim” items entered by the DFR? 28 Spend-down October 2011
Spend-down Quiz (True or False) Q A provider may refuse to provide service to a member if they verify eligibility and determine the member has a spend-down? FALSE Q A provider may refuse to provide a service to a member who has a legitimate past-due balance for a spend-down, but refuses to pay it? TRUE Q A provider may bill the member for spend-down as soon as they receive a Remittance Advice that includes ARC 178? TRUE Q Spend-down is credited based on the provider’s usual and customary charge (UCC)? TRUE (when the provider bills the UCC) Q Spend-down is credited to claims in date-of-service order? FALSE Q The highest priority transaction to credit spend-down are “nonclaim” items entered by the DFR? TRUE 29 Spend-down October 2011
Find Help Resources Available
Helpful Tools Avenues of resolution – IHCP Provider Manual, Chapter 2, Section 4 (Web, CD, or paper), available at indianamedicaid. com – Customer Assistance • Local • All (317) 655 -3240 others 1 -800 -577 -1278 – Written Correspondence • HP Provider Written Correspondence P. O. Box 7263 Indianapolis, IN 46207 -7263 – Provider field consultant 31 Spend-down October 2011
Q&A
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