by Dr. Leila Alter
UPDATE: April 3, 2017
Hewlett Packard has put together more detailed explanation of how to submit secondary claims on the portal for Traditional (FFS) claims. If a service item paid zero, more detailed explanation is required. One way of adding this information is in the Claim Adjustment Detail Box which would require Adjustment Reason Codes (ARC) codes that are listed at the end of this email. Remember, these are not the same reason codes that are on your dental primary insurance’s Explanation of Benefits (EOB). The other option is to bypass the Claim Adjustment Detail Box and attach a copy of the primary EOB.
The first example illustrates the billing of a secondary claim where primary insurance makes a payment greater than zero on all details on the claim . The second example explains the procedures for submitting the appropriate information on a secondary claim when primary insurance pays nothing on one or more details on a claim. In this case, providers are required to provide proof that the primary insurance company was indeed billed.
Example 1: Other insurance primary and all other payer paid amounts > 0
Claim created with two details. Total billed amount on the claim is $325.00. Detail one billed amount = $180.00 and detail two billed amount = $145.00. Other insurance paid $38.00 on detail one and $53.00 on detail two.
- Complete page one of the dental claim form and check the box that says Include Other Insurance.
- Expand the Other Insurance Details section on page 2 and enter (at a minimum) Carrier Name, Carrier ID (which is obtained from the primary insurer), Policy Holder Last Name, First Name, Policy ID, Relationship to Patient, Claim Filing Code, and TPL Paid Amount. TPL paid amount should be the sum of all TPL amounts from each service detail. In this example, the total TPL Amount Paid = $91.00 (38.00+53.00). Click Save.
In this scenario, there is no need to enter Adjustment Reason Codes (ARCs) on the Claim Adjustment Details. ARCs are only used if the TPL payment amount is zero. The use of ARCs on zero paid details will be explained in Example #2.
- Enter the appropriate Service Details on Step 3. In this case, there are two details. After entering service detail information, expand the Service Detail and select the Carrier entered in Step 2 from the Other Carrier dropdown in Other Insurance for Service Detail. Enter the TPL Paid Amount and Paid Date and click Add. In this example, the TPL Paid Amount is $38.00. Since TPL made a payment on the detail, there is no need to enter Claim Adjustment Details. Click Add and Save.
Repeat procedure for the second detail.
Always remember to Save at each detail.
- When complete, click Submit and the Confirm to finish the submission.
Example 2: Other insurance is primary; however, other insurance payment = 0.
If primary insurance is billed and insurance company does not make any payment on a claim/detail, it is the provider’s responsibility to provide proof of the claim submission to the primary payer when submitting the claim to Medicaid. When using the Provider Healthcare Portal, providers can meet this requirement in one of two ways. Each option is illustrated below.
- Option 1: Add Other Insurance for Service Detail and include a TPL Paid amount of zero in the TPL/Medicare Paid Amount field. Using the Attachment feature, upload an image of the primary insurer’s EOB showing the reason for the zero payment. The claim will suspend for review, and a payment determination will be made based on the denial reason posted on the primary insurer’s EOB.
- Option 2: Add Other Insurance for Service Detail and include a TPL Paid amount of zero in the TPL/Medicare Paid Amount field. In the Claim Adjustment Details immediately below the Other Insurance for Service Detail section, include the Claim Adjustment Group Code, Reason Code, and Adjustment Amount reported on the primary payer’s EOB. A list of IHCP approved denial ARCs appears at the bottom of this email.
Claim created with four details. Total billed amount on the claim is $200.00. Detail one billed amount = $80.00, detail two billed amount = $45.00, detail three = $41.00, detail four = $34.00. Other insurance paid $52.00 on detail one, $0 on detail two, $27.00 on detail three, and $20.00 on detail four. The total TPL billed amount is $99.00.
- Complete page one of the dental claim form and check the box that says Include Other Insurance. Click Continue
- Expand the Other Insurance Details section on page 2 and enter (at a minimum) Carrier Name, Carrier ID (which is obtained from the primary insurer), Policy Holder Last Name, First Name, Policy ID, Relationship to Patient, Claim Filing Code, and TPL Paid Amount. TPL paid amount should be the sum of all TPL amounts from each service detail. In this example, the total TPL Amount Paid = $99.00 (52.00+0+27.00+20.00). Click Save.
In this scenario, there is no need to enter Adjustment Reason Codes (ARCs) on the Claim Adjustment Details on page 2. ARCs are only used if the TPL payment amount is zero. In this example, only one detail received a zero payment, so the total amount of TPL on the claim is greater than zero.
- Enter the appropriate Service Details on Step 3. In this case, there are four details, and only detail two has a TPL payment amount of zero. Enter TPL for details 1, 3, and 4 as described in Example 1. Since detail two has a TPL payment amount of zero, providers have two options for including this information on the claim. A provider may submit the primary payer’s EOB as an attachment using the Attachment option. The attachment may be uploaded or submitted by mail. Option two enables the provider to enter valid denial ARCs from the primary payer’s EOB in the Claim Adjustment section. This process is illustrated below. After entering service detail information, expand the Service Detail and select the Carrier entered in Step 2 from the Other Carrier dropdown in Other Insurance for Service Detail. Enter a TPL Paid Amount of zero and the denial date in Paid Date and click Add. In Claim Adjustment Details, enter the Claim Adjustment Group Code, Reason Code, and Adjustment Amount as it appears on the primary payer’s EOB. Adjustment Units are not required. In most cases, the Adjustment Amount will be the billed amount from the service detail.
Always remember to Save at each detail.
- If using the Attachment option to submit proof of zero payment from the primary insurer, there is no need to complete the Claim Adjustment Details section for the detail. Providers must still enter a TPL Paid Amount of zero and the denial date in Paid Date in the Other Insurance for Service Detail section and click Add.
- When complete, click Submit and the Confirm to finish the submission.
Following is a list of valid denial HIPAA Adjustment Reason Codes (ARC). This list was approved by the IHCP as constituting a valid denial from a primary insurance company. Submitting one of these ARCs on a detail that was paid at zero by the primary insurer will bypass the IHCP requirement to manually submit documentation proving the service was billed to the Medicaid member’s primary insurer. Please note that it is still the provider’s responsibility to maintain the denial documents should they ever be required in a back end audit. Also note that some denials will require manual review by an IHCP analyst, and in those cases, an attachment will be required to be submitted with the claim.
|4||The procedure code is inconsistent with the modifier used or a required modifier is missing.|
|5||The procedure code/bill type is inconsistent with the place of service.|
|6||The procedure/revenue code is inconsistent with the patient’s age.|
|7||The procedure/revenue code is inconsistent with the patient’s gender.|
|8||The procedure code is inconsistent with the provider type/specialty (taxonomy).|
|9||The diagnosis is inconsistent with the patient’s age.|
|10||The diagnosis is inconsistent with the patient’s gender.|
|11||The diagnosis is inconsistent with the procedure.|
|12||The diagnosis is inconsistent with the provider type.|
|26||Expenses incurred prior to coverage.|
|27||Expenses incurred after coverage terminated.|
|31||Patient cannot be identified as our insured.|
|32||Our records indicate that this dependent is not an eligible dependent as defined.|
|33||Insured has no dependent coverage.|
|34||Insured has no coverage for newborns.|
|35||Lifetime benefit maximum has been reached.|
|49||This is a non-covered service because it is a routine/preventive exam or a diagnostic/screening procedure done in conjunction with a routine/preventive exam.|
|50||These are non-covered services because this is not deemed a ‘medical necessity’ by the payer.|
|51||These are non-covered services because this is a pre-existing condition.|
|53||Services by an immediate relative or a member of the same household are not covered.|
|54||Multiple physicians/assistants are not covered in this case.|
|55||Procedure/treatment/drug is deemed experimental/investigational by the payer.|
|60||Charges for outpatient services are not covered when performed within a period of time prior to or after inpatient services.|
|97||The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated.|
|109||Claim/service not covered by this payer/contractor. You must send the claim/service to the correct payer/contractor.|
|119||Benefit maximum for this time period or occurrence has been reached.|
|146||Diagnosis was invalid for the date(s) of service reported.|
|149||Lifetime benefit maximum has been reached for this service/benefit category.|
|160||Injury/illness was the result of an activity that is a benefit exclusion.|
|166||These services were submitted after this payers responsibility for processing claims under this plan ended.|
|167||This (these) diagnosis(es) is (are) not covered.|
|168||Service(s) have been considered under the patient’s medical plan. Benefits are not available under this dental plan.|
|181||Procedure code was invalid on the date of service.|
|182||Procedure modifier was invalid on the date of service.|
|185||The rendering provider is not eligible to perform the service billed.|
|188||This product/procedure is only covered when used according to FDA recommendations.|
|193||Original payment decision is being maintained. Upon review, it was determined that this claim was processed properly.|
|200||Expenses incurred during lapse in coverage|
|202||Non-covered personal comfort or convenience services.|
|204||This service/equipment/drug is not covered under the patient’s current benefit plan|
|211||National Drug Codes (NDC) not eligible for rebate, are not covered.|
|212||Administrative surcharges are not covered|
|231||Mutually exclusive procedures cannot be done in the same day/setting.|
|233||Services/charges related to the treatment of a hospital-acquired condition or preventable medical error.|
|234||This procedure is not paid separately.|
|236||This procedure or procedure/modifier combination is not compatible with another procedure or procedure/modifier combination provided on the same day according to the National Correct Coding Initiative or workers compensation state regulations/ fee schedule requirements.|
|246||This non-payable code is for required reporting only.|
|256||Service not payable per managed care contract.|
|258||Claim/service not covered when patient is in custody/incarcerated. Applicable federal, state or local authority may cover the claim/service.|
|B5||Coverage/program guidelines were not met.|
|272||Coverage/program guidelines were not met.|
|273||Coverage/program guidelines were exceeded.|
|B14||Only one visit or consultation per physician per day is covered.|
|W3||The Benefit for this Service is included in the payment/allowance for another service/procedure that has been performed on the same day.|
|P14||The Benefit for this Service is included in the payment/allowance for another service/procedure that has been performed on the same day.|
|W8||Procedure has a relative value of zero in the jurisdiction fee schedule, therefore no payment is due. To be used for Property and Casualty only.|
|P19||Procedure has a relative value of zero in the jurisdiction fee schedule, therefore no payment is due. To be used for Property and Casualty only.|
|W9||Service not paid under jurisdiction allowed outpatient facility fee schedule. To be used for Property and Casualty only.|
|P20||Service not paid under jurisdiction allowed outpatient facility fee schedule. To be used for Property and Casualty only.|
March 29, 2017
With the transition to CoreMMIS, Medicaid is now requiring providers to submit third-party liability (TPL) information at the detail level; many dental software programs refer TPL claims as secondary insurance claims. Offices can submit claims either by paper or on the portal, but it is highly recommend that providers submit secondary claims via paper. The portal will ask for more information than will be asked for paper claim submission.
Below is the “correct” way of submitting paper secondary claims. However, IHCP is allowing dentists the option of not filling out the ARC column on the special TPL form if they submit a copy of the primary insurance EOB with the claim. See attached cheat sheet for guidance and download a blank TPL Special Attachment Form that is required for paper claim submission.
Health Plan ID:
This ID can be obtained by calling the member’s primary insurance carrier or use the Payor ID if you submit claims electronically. It is the same ID.
ARC (Adjustment Reason Codes):
This is optional for dental offices. If you do not submit a copy of the primary EOB with the paper claim, this column will need to be filled out.
An ARC code is only needed if the primary insurance carrier paid zero on a item.
These are not the same “reason” codes that are on the primary insurance explanation of benefits. A complete list of codes can be found at http://www.wpc-edi.com/reference/codelists/healthcare/claim-adjustment-reason-codes/.