Transcript Section 1011 Trailblazer Health Claims Processing Presenter Kathy Whitmire

Section 1011
Trailblazer Health Claims Processing
Presenter
Kathy Whitmire
8-8-2007
Agenda
• Overview
• Georgia Funding – Enrolled Hospitals
• Where to find the resources
• http://www.trailblazerhealth.com/section1011/
• 8 Steps to receiving payments from Trailblazer
• Questions
Overview of Section 1011 Program
• On December 8, 2003, the President signed into law the Medicare
Prescription Drug, Improvement and Modernization Act of 2003
(MMA), Section 1011, Federal Reimbursement of Emergency Health
Services Furnished to Undocumented Aliens.
• Congress has mandated that the Secretary of HHS directly pay
hospitals, physicians, and ambulance providers for their otherwise
un-reimbursed costs of providing services required by section 1867
of the Social Security Act (EMTALA) and related hospital inpatient,
outpatient, and ambulance services furnished to undocumented aliens
• Section 1011 provides $250 million per year for Fiscal Years (FY)
2005-2008 for payments to eligible providers for emergency health
services provided to undocumented aliens and other specified aliens.
2007 State Allocations
2007 Hospitals Enrolled in GA
58 registered Section 1011 hospitals in Georgia
See excel spreadsheet
Provider Enrollment Process
http://www.trailblazerhealth.com/section1011/
•EDI Enrollment Packet • The Section 1011 Final Policy requires all provider types
to submit payment requests electronically. Facilities may
submit payment requests via Direct Data Entry (DDE) or
facility charges only through Electronic Media Claims
(EMC) while any physician or ambulance payment
requests must be submitted through DDE.
Provider Enrollment Process
STEP 1
•Complete the Section 1011 Provider Application
•Submit and mail a hard copy enrollment application,
signed by the authorized representative, to TrailBlazer.
•Note: Only Medicare participating hospitals are eligible to
enroll and receive reimbursement from Section 1011.
Physicians and ambulance companies do not need to
participate in Medicare to be eligible.
http://www.trailblazerhealth.com/section1011/
Provider Enrollment Application – STEP 1
County required in Section 4
Medicare Fiscal Intermediary in Section 7
Provider Enrollment Application
Provide the authorized official’s signature in Section 16
Provider Enrollment Application
STEP 2
EFT Authorization Agreement -Required
STEP 3
ERA Request Form
STEP 4
Attachment 1 -
4 Simple Steps and you are enrolled
To expedite the enrollment process, please ensure all
applications are complete and mailed to the address below:
• TrailBlazer Health Enterprises, LLC
Section 1011
P.O. Box 660529
Dallas, Texas 75266-0529
Enrollment Form Process
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Enrollment Form Process
Upon receipt of the completed hard copy application, TrailBlazer will begin
the application verification process. The verification process will take
approximately two weeks. Applicants will be mailed a written notification
upon completion of the verification process. This written notification will
include the Welcome Letter and the applicable Provider Identification Number
(PIN) Letter for each approved provider.
Welcome Letter
Section 1011 Ambulance PIN Letter
Section 1011 Hospital Only PIN Letter
Section 1011 Hospital Roster PIN Letter
Section 1011 Physician PIN Letter
If during the verification process it is determined that required data elements
are missing, the application will be returned to the provider along with a
Missing Data Elements Letter.
STEP 5 – EDI Enrollment Packet
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From Welcome Letter
STEP 5 – EDI Enrollment Packet
STEP 6 – Provider Payment Determination
Providers must gather the information requested on the
Section 1011 Provider Payment Determination to
determine if a patient is eligible for services under the
Section 1011 program.
This form is not required when the payment request
is submitted; however, the completed form must be
maintained on file and submitted as part of the
necessary paperwork for any records request.
STEP 6 – Provider Payment Determination
STEP 6 – Provider Payment Determination
STEP 6 – Provider Payment Determination
Section 1011 Patient Signature Requirements
All Section 1011 providers must secure and maintain a patient signature for all
Section 1011 payment requests they submit. CMS has adopted the position, as
outlined on pages 31-32 of the Final Policy Notice, that all Section 1011-enrolled
providers are subject to the Electronic Data Interchange (EDI) agreement
submitted with the Section 1011 enrollment application. In Section A(4)(c) of the
EDI agreement, the provider has agreed, "That it will submit claims only on
behalf of those ... beneficiaries who have given their written permission to do so,
and to certify that required beneficiary signatures, or legally authorized
signatures on behalf of beneficiaries, are on file.“
Patients are not required to sign the Section 1011 Provider Payment
Determination form which is the reason no space for the patient’s signature
provided on the form. The patient's signature, however, must be kept on file with
the rest of the documentation that providers are required to keep as part of their
Section 1011 verification information. This signature document does not need to
be submitted with payment requests. Providers should continue to follow their
normal intake process, which should include some type of patient consent for
treatment form that has been signed and dated by the patient or the patient's
representative providing consent. This form will meet the Section 1011 patient
signature requirement.
STEP 7 – FILE CLAIMS
DDE Screens for Hospitals
Providers will access an online payment request system, called
Undocumented Aliens Reimbursement System (UARS). Using Direct Data
Entry (DDE), they will enter information as illustrated in the fields below.
Hospital providers will select transaction 20 from the Payment Request
STEP 7 – DDE Screens for Hospitals
The following three Payment Request entry screens are marked with circled
numbers that correspond to the table following the screen shots.
STEP 7 – DDE Screens for Hospitals
The following three Payment Request entry screens are marked with circled
numbers that correspond to the table following the screen shots.
STEP 8 – GET PAID - Reimbursement
Page 53 of the Section 1011 Final Policy states:
All payment requests would be aggregated (by CMS during claims
processing) at the state level.
Each provider within a state would receive payment equal to the
lesser of its costs, the Medicare reimbursement rate
or, if provider payments exceed the state allotment, a proportional
payment of the Medicare reimbursement rate.
Review the Section 1011 Payment Calculation Example, which can also
be found under Payment Request Resources on this page. Additional
information on Section 1011 payment rules may be found on the Section
1011 Final Policy under Section XIII.
STEP 8 – Payment Calculation Explanation
1. Medicare rules apply to all providers, e.g., hospitals, physicians,
and ambulance services.
2. Calculate Medicare payment.
3. Calculate the cost of providing the emergency services as
follows:
From the Provider Specific File: Multiply the Covered Charges
times the Cost To Charge (CTC)
4. Compare Number 2 to Number 3 above and select the lesser
value. This is Section 1011 payment.
5. For outpatient services only: Multiply value found in Number 4
above times 1.1.
To calculate inpatient services: Use the value arrived at in
Number 4.
6. The value from Number 5 is the final Section 1011 payment.
STEP 8 – Payment Calculation Example
STEP 8 – Payment Request Summary
STEP 8 – Payments
• Payment will not be made on a first come, first served basis.
• Electronic payments will be made directly to providers, not the
involved states, for services provided to undocumented and certain
other aliens on or after May 10, 2005.
• Providers will receive Electronic Remittance Advices (ERA) that
include the provider name, Provider Identification Number (PIN),
calculated Medicare payment amount and amount actually
approved for each payment request submitted.
• Because Section 1011 is a payer of last resort and providers are
required to seek payment from all other payment sources,
TrailBlazer will not be required to coordinate benefits or cross over
payment requests with any other medical insurance plan.
• Review Section 1011 Payment Request Cycles for service dates,
payment request due dates and payment dates.
Patient Identifier Number Methodology
Professional Fees
Billing for Professional Fees
All professional fees must be billed under the physician’s Section 1011 Provider
Identification Number (PIN) as an outpatient payment request. Type of Bill
(TOB) 131 is used for all outpatient payment requests.
Professional fees are keyed using the 096X, 097X and 098X revenue codes. The
Fiscal Intermediary Standard System - Undocumented Alien Reimbursement
System (FISS-UARS) will not accept a payment request if the last six digits of
the Section 1011 provider number are zeros and revenue code(s) 096X - 098X
are present.
If the payment request is entered with the hospital's provider number (TOB 131
or 111), the provider will receive edit 7PFEE, which states:
REVENUE CODES 096X, 097X AND 098X ARE IDENTIFIED AS PROFESSIONAL FEES
AND MUST BE BILLED UNDER THE PHYSICIAN'S NUMBER. PAYMENT REQUESTS
WITH PROFESSIONAL FEES ARE NOT ALLOWED FOR HOSPITALS.
What about protection of privacy?
Some hospitals are cautious about participating in the
program because of privacy issues for the
undocumented patients. What practices are in place to
ensure that patients can access needed healthcare
without any repercussions?
Section 1011 does not require a name or address to be
submitted with the payment request and the provider may
mark out personally-identifiable information (the name,
address, etc) on any medical records requested for Medical
and/or Compliance review purposes.
Summary
• Summarize – Questions
• Email Kathy Whitmire – [email protected]
• Thanks