Primary and Secondary Insurance Claims Filing. A Step by Step Guide.

Filing Insurance Claims for Medicare Primary & Secondary Mental Health Care

Navigating the complexities of insurance claims can be challenging, especially when dealing with Medicare as the primary payer and a commercial insurer as secondary. This guide gives mental health facility providers a clear path for filing claims effectively in such scenarios.

Understanding Primary and Secondary Insurance

It’s important to understand the order of payment when a patient has multiple insurance plans. Medicare generally acts as the primary payer for individuals aged 65 or older, or those with certain disabilities. A secondary insurance, such as Empire, BCBS, Aetna, Cigna, UHC, or Humana, covers costs that Medicare doesn’t.

According to Medicare.gov, “If you have other health insurance, like from an employer, union, or spouse’s employer, it’s called ‘other coverage.’ In most cases, when you have other coverage, Medicare is the ‘secondary payer.'”

Step-by-Step Filing Process

Verify Patient Insurance Information: Always start by verifying the patient’s Medicare and secondary insurance details. Ensure all information is current and accurate. With the increase of managed care organizations, there are so many variables of both in network and out of network benefits.
Submit the Claim to Medicare First: Since Medicare is the primary payer, submit the claim to Medicare first. Wait for Medicare to process the claim and issue a Medicare Summary Notice (MSN).
Submit the Claim to Secondary Insurance: After Medicare processes the claim, submit a copy of the Medicare MSN and the original claim to the secondary insurance provider (Empire, BCBS, Aetna, Cigna, UHC, or Humana).

Key Considerations

Coordination of Benefits (COB): According to the Centers for Medicare & Medicaid Services (CMS), “Coordination of Benefits (COB) is when a person has more than one health insurance coverage.” Do your homework up-front so you understand how COB works to avoid claim denials.
Accurate Coding: Proper coding is essential for claim processing. Use the correct ICD-10 and CPT codes for mental health services. Any coding errors may result in claims rejection.
Documentation: Maintain thorough records of each session. Detailed documentation can support your claims and help resolve any disputes.

Tips for Successful Claim Submission

Electronic Filing: Electronic filing can speed up the process and reduce errors. Many insurers prefer electronic submissions.
Stay Updated: Insurance policies and procedures can change frequently. Regularly check with Medicare and the secondary insurers for any updates.
Provider Portals: Utilize online provider portals. These portals often provide valuable information and tools for claim submission and tracking.

Resources

Referencing research from the Kaiser Family Foundation, “Understanding Medicare can be complex, with various parts covering different services.” For mental health providers, it’s important to focus on Medicare Part B, which covers outpatient services.

According to the American Psychological Association, “Mental health claims processing requires careful attention to detail and accurate documentation.” They emphasize the importance of staying current with billing and coding regulations.

To Recap:

Let’s look at a specific example of Medicare as a primary payer and Empire as a secondary payer.

We are dealing with two payers: Medicare (primary) and Empire (secondary). The process involves submitting the claim first to Medicare, then Medicare will automatically forward the claim to Empire if set up correctly. However, it’s crucial to ensure that both insurances are on file and that the patient is eligible for both. Here is a step-by-step process:

Step 1: Verify Patient Insurance Eligibility and Benefits

– Confirm the patient’s eligibility with Medicare (Part A and/or Part B) and with Empire (secondary).

– Check the effective dates, coverage details, and any limitations for behavioral health services for both insurances.

– Ensure that the mental health facility is enrolled in Medicare and accepts assignment, and is also in-network with Empire if required.

Step 2: Obtain Necessary Authorizations (if applicable)

– Determine if pre-authorization or pre-certification is required by either Medicare or Empire for the services provided. If so, obtain the necessary authorizations and document the approval numbers.

Step 3: Collect Patient Information and Documentation

– Collect the patient’s demographic information, Medicare ID, and Empire insurance information (policy number, group number, etc.).

– Have the patient complete and sign the necessary forms, including:

– CMS-1500 or UB-04 (CMS-1450) claim form (depending on facility type) but note: for institutional claims, use UB-04.

– Medicare Secondary Payer (MSP) questionnaire to establish that Empire is secondary.

– Assignment of Benefits (AOB) form for Medicare and Empire if required.

– HIPAA authorization for release of information.

Step 4: Provide Services and Document

– Deliver the mental health services to the patient.

– Ensure thorough and accurate documentation of the services provided, including dates, types of service, diagnosis (ICD-10 codes), and procedure codes (CPT/HCPCS codes). For mental health facilities, the documentation must support medical necessity.

Step 5: Prepare the Claim for Medicare (Primary)

– For a mental health facility, institutional claims (UB-04) are typically used. However, if the facility is billing as an institutional provider, they will use the UB-04 form. If the provider is an individual practitioner (like a psychologist or clinical social worker) in the facility, they might bill using the CMS-1500 form. Confirm the appropriate form.

– Complete the UB-04 form with the following key information:

– Patient information (name, date of birth, Medicare number, address, etc.)

– Provider information (name, NPI, address, etc.)

– Dates of service

– Diagnosis codes (ICD-10)

– Procedure codes (CPT/HCPCS) and modifiers if applicable

– Units of service

– Charges for each service

– Type of Bill (TOB) and the appropriate revenue codes for the level of care. The institutional UB-04 (CMS-1450) describes where and how services were rendered through the Type of Bill and revenue codes – it does not carry a place-of-service (POS) code. POS codes such as 55 (Residential Substance Abuse Treatment Facility) or 56 (Psychiatric Residential Treatment Center) belong on the professional CMS-1500, not on the UB-04.

– Note: Traditional (fee-for-service) Medicare generally does not reimburse residential or RTC levels of care, so the POS 55/56 examples are illustrative of professional-claim coding only and would not typically apply to a Medicare-primary residential claim. Confirm coverage and the correct level-of-care coding for your specific payer scenario.

– In the UB-04, specify the primary insurance as Medicare and include the secondary insurance information (Empire) in the appropriate fields (usually in the “Other Insurance” section). This is crucial for Medicare to forward the claim to Empire.

Step 6: Submit the Claim to Medicare

– Submit the claim electronically (preferred) via a Medicare Administrative Contractor (MAC) or via paper if electronic submission is not possible. For electronic submission, use the HIPAA 837I transaction for institutional claims.

– If submitting electronically, ensure that the secondary payer information (Empire) is included in the electronic claim. This will trigger Medicare to automatically forward the claim to Empire after processing (this is known as the Medicare Crossover process).

Step 7: Medicare Processing and Crossover to Empire

– Medicare will process the claim and determine the amount they cover and the patient’s responsibility (co-pay, deductible, coinsurance).

– If the claim is set up correctly with the secondary insurance information, Medicare will automatically forward the claim (via the Crossover process) to Empire for secondary payment. This usually happens within a few days of Medicare’s adjudication.

– Note: To ensure the crossover happens, the patient’s Medicare record must have the secondary insurance (Empire) information on file. This can be confirmed with the Medicare Coordination of Benefits (COB) contractor.

Step 8: Monitor Claim Status and Follow Up

– Track the status of the Medicare claim through the MAC portal or by using the Medicare Administrative Contractor’s online tools.

– Once Medicare processes the claim, they will send a Medicare Summary Notice (MSN) to the patient and an Electronic Remittance Advice (ERA) or a Paper Remittance Advice (RA) to the provider.

– Verify that the claim was crossed over to Empire. If not, you may need to submit the claim to Empire manually.

Step 9: If Crossover Doesn’t Occur, Submit to Empire Manually

– If the claim does not automatically cross over to Empire (for example, if the secondary information was not on file at Medicare), then the facility must submit a claim to Empire.

– Use the same UB-04 form (or CMS-1500 if applicable) but adjust for secondary submission:

– Indicate that it is a secondary claim.

– Attach the Medicare EOB (Explanation of Benefits) or RA (Remittance Advice) that shows what Medicare paid and what the patient owes.

– Submit the claim to Empire electronically (using the 837I transaction) or by paper, according to Empire’s requirements.

Step 10: Empire Processing

– Empire will process the secondary claim and make payment according to the coordination of benefits rules (typically covering some or all of the patient’s cost-sharing amounts from Medicare, up to the limits of the policy).

– Empire will send an EOB/ERA to the provider and the patient.

Step 11: Patient Billing for Any Remaining Balance

– After both insurances have paid, if there is any remaining balance (for example, if there are non-covered services or patient cost-sharing amounts not covered by Empire), bill the patient.

Step 12: Record Keeping and Appeals (if necessary)

– Keep copies of all submitted claims, EOBs/ERAs, and any correspondence.

– If a claim is denied by either Medicare or Empire, review the reason and, if appropriate, file an appeal with the respective insurer.

Important Considerations of Primary and Secondary Insurance Claims Filing

– Timely Filing: Be aware of the timely filing limits for both Medicare (within 12 months from the date of service) and Empire (check their policy, typically 90-180 days from the primary EOB). For crossover claims, the timely filing is usually extended, but if submitting manually, adhere to Empire’s deadline.

– Coordination of Benefits (COB): Ensure that the patient’s insurance information is accurate and that the order of primary and secondary is correct (Medicare is primary, Empire is secondary).

By following these steps, the mental health facility can maximize reimbursement and minimize denials and delays.

Now let’s walk through the process again for submitting behavioral health claims to Medicare for a mental health facility, with coordination to Empire (Empire BlueCross BlueShield) as the secondary payer. This ensures Medicare automatically “crosses over” the claim to Empire after processing.

Step 1: Verify Patient Eligibility & Benefits

• Confirm Medicare Primary Coverage:

◦ Check patient’s Medicare Part A/B eligibility (e.g., via MAC portal like National Government Services (NGS), Jurisdiction K for NY).

◦ Ensure services are covered by Medicare (e.g., outpatient therapy, inpatient mental health care).

• Verify Empire Secondary Coverage:

◦ Confirm Empire plan details (group/policy number) and secondary coverage rules.

◦ Check if the facility is in-network with Empire (if required).

• Obtain Authorizations:

◦ Secure pre-authorization from Medicare and Empire if needed (e.g., for intensive outpatient programs).

Step 2: Collect Required Information

• Patient Details: Name, DOB, Medicare ID, Empire member ID, group number.

• Service Documentation:

◦ Diagnosis (ICD-10 codes, e.g., F33.1 for major depression).

◦ Procedure codes (CPT/HCPCS, e.g., 90837 for psychotherapy).

◦ Dates of service, provider NPI, and facility tax ID.

• Secondary Payer Data: Empire’s claim Payer ID and group number (for electronic claims).

Step 3: Submit the Claim to Medicare (Primary)

• Use the Correct Form:

◦ Institutional Claims (e.g., inpatient): Submit UB-04/CMS-1450 form.

◦ Professional/Outpatient Claims: Use CMS-1500 form.

• Include Empire as Secondary Payer:

◦ Electronic Claims (837I/837P): Populate the “Other Payer” field with Empire’s details:

▪ Claim Payer ID: Empire’s payer ID (verify the current value with Empire or your clearinghouse).

▪ Group/policy number, and patient’s Empire ID.

◦ Paper Claims: Complete Box 9 (CMS-1500) or Box 50 (UB-04) with Empire’s information.

• Submit via:

◦ Medicare Administrative Contractor (MAC) portal (e.g., NGS for NY).

◦ Directly through your EHR/billing software.

Step 4: Medicare Adjudication & Crossover

• Medicare Processes Claim:

◦ Allow 14–30 days for processing.

◦ Medicare pays its portion (e.g., 80% for outpatient services).

• Automatic Crossover to Empire:

◦ Medicare forwards the claim to Empire electronically via the Medicare COBA crossover process, administered by the Benefits Coordination & Recovery Center (BCRC).

◦ Key Requirement: Ensure patient’s Empire details are correctly listed in Medicare’s Coordination of Benefits (COB) database. Verify via:

▪ Medicare’s COB Contractor: 1-855-798-2627.

▪ HIPAA Eligibility Transaction System (HETS).

Step 5: Track & Confirm Crossover

• Check Medicare Remittance Advice (RA):

◦ Look for Remark Code MA18: “Forwarded to secondary payer.”

• Monitor Empire’s Receipt:

◦ Use Empire’s provider portal (e.g., Availity or Empire’s Provider Hub) to track crossover status.

◦ If crossover fails within 5 business days:

▪ Correct COB in Medicare’s system via the COB Contractor.

▪ Manually submit to Empire with Medicare’s RA.

Step 6: Empire Adjudication (Secondary)

• Empire Processes Claim:

◦ Reviews Medicare’s payment and applies secondary coverage.

◦ Pays remaining coinsurance/deductible per plan rules (e.g., covers the 20% Medicare didn’t pay).

• Receive Empire’s EOB:

◦ Check for payment or denials via Empire’s portal/ERA.

Step 7: Handle Denials/Discrepancies

• Common Issues:

◦ COB Mismatch: Empire denies due to incorrect Medicare payment info. Fix: Submit a corrected claim to Medicare first.

◦ Timely Filing: Empire requires claims within 90–180 days of Medicare RA. Fix: Appeal with proof of crossover attempt.

• Appeals:

◦ Medicare: File redetermination with your MAC.

◦ Empire: Use Empire’s provider appeal process.

Step 8: Patient Billing

• Bill the patient only for:

◦ Medicare deductibles/copays not covered by Empire.

◦ Non-covered services (with ABN on file).

Key Tips for Success

Enrollment: Ensure your facility is enrolled with Medicare and Empire.
Crossover Setup: Confirm Empire’s electronic crossover agreement with Medicare using Empire’s claim Payer ID (verify the current value with Empire or your clearinghouse).
Software: Use Medicare-certified billing software with Empire’s secondary fields pre-configured.
Timely Filing:
Medicare: 1 year from service date.
Empire: Typically 180 days from Medicare RA.

Where to find more information:

Medicare Claims: National Government Services (NGS), Jurisdiction K
Medicare COB: 1-855-798-2627 (COB Contractor)
Empire Provider Support: 1-800-676-BLUE (2583) or Empire Provider Hub
CMS Manual: Pub 100-04 (Claims Processing Manual), Chapter 28 (COBA crossover rules).

In Summary

Filing insurance claims with Medicare as the primary payer and a commercial insurer as secondary requires meticulous attention to detail and a clear understanding of the process. By following these guidelines and staying updated on insurance policies, mental health facility providers can streamline the process and ensure timely reimbursement. Remember, consistency and accuracy in filing claims will contribute to a smoother process and better financial management for your mental health facility.