Web Portal Tutorial – TPL and Medicare Secondary Claims (Institutional, Professional and

Dental) 1/9/2012

Institutional Claim – Medicare Secondary/X-Over

Complete the claim as normal, and then complete these additional fields:

• Select the red + before Other Insurance Information • Select the red + before Other Payer Information

o Payer/Insurance Organization Name – Enter the name of the other payer (Medicare)

• Select the red + before Additional Other Payer Information o Adjudication Date - Enter the paid date from the Medicare EOMB

• Select the red + before COB Monetary Amounts o COB Payer Paid Amount - Enter the amount paid by Medicare

• Select the red + before Other Subscriber Information • Select the red + before Additional Other Subscriber Information

o Claim Filing Code – Select Medicare from the drop down o Payer Responsibility Sequence Number Code – Select Primary from the drop

down • Select the red + before Other Insurance Coverage

o Benefits Assignment Certification – Select Yes o Release of Information Code – Select Provider Has Signed Release

• From the top of the claim, select the tab that says Other Claim Info

• Select the red + before Claim Level Adjustments o Claim Adjustment Group Code – Select Patient Responsibility o Reason Code – Enter the appropriate code

1 – Deductible 2 – Coinsurance 122 – Psych Deductible

o Amount – Enter the amount assigned to this code

• From the top of the claim, select the tab that says Basic Claim Info • Complete the rest of your claim as normal

Institutional Claim - TPL (other than Medicare)

Complete the claim as normal, then enter these additional fields.

• Select the red + before Other Payer Information o Payer/Insurance Organization Name – Enter the name of the other insurance

• Select the red + before COB Monetary Amounts o COB Payer Paid Amounts – Enter the amount paid by the other insurance

• Select the red + before Other Subscriber Information • Select the red + before Additional Other Subscriber Information

o Claim Filing Code – Select the appropriate choice from the drop down o Payer Responsibility Sequence Number Code – Select Primary

• Select the red + before Other Insurance Coverage o Benefits Assignment Certification – Select Yes o Release of Information Code – Select Provider Has Signed Release

Professional Claim – Medicare Secondary/X-Over

Complete the claim as normal, then enter these additional fields.

• Does the subscriber have insurance other than Medicaid – Select yes • Select the red + before Other Subscriber Information • Select the red + before Additional Other Subscriber Information

o Claim Filing Code – Select Medicare from the drop down list o Payer Responsibility Sequence Number Code – Select Primary from the drop

down list

• Other Payer Information o Payer/Insurance Organization Name – Enter the name of the insurance

(Medicare) • Additional Other Payer Information

o Other Payer Primary ID – Enter an ID to identify the insurance by – this can be letters, numbers or a combination. You will need to use this again later.

o ID Type – Select Payor Identification from the drop down list o Adjudication Date – Enter the paid date from the Medicare EOMB

• COB Monetary Amounts o COB Payer Paid Amount – Enter the amount Medicare paid

On each line item, after you have entered your line items and added them, complete the following.

• Select the Other Svc Info link at the end of the line item data line

• Select the red + before Service Line Adjudication o Other Payer Primary ID – Enter the same thing entered previously as Other Payer

Primary ID on the first screen o Service Line Paid Amount – Enter the amount paid by Medicare for this line item o Adjudicated or Pay Date – Enter the paid date from the Medicare EOMB o Paid Service Unit(s) – Enter the number of units Medicare paid o Procedure Qualifier – Select HCPCS from the drop down list o Procedure Code – Enter the procedure code on this line item

• Select the red + before Service Adjustment o Adjustment Group Code – Select Patient Responsibility from the drop down list o Adjustment Amount – Enter the amount for the adjustment o Adjustment Reason – Enter the appropriate reason code:

1 – Deductible 2 – Coinsurance 122 – Psych Deductible

o Enter up to 5 items as necessary for this line item o Select Add Line Item

• To edit entered adjustment codes, select the Group Code link, moving the items back up to the entry area. When done, select update Line Item

• To delete a whole group code, select the Delete link at the end of the line • When done entering information for this line item, select the Basic Claim Form button

and repeat for each line item on the claim

Professional Claim – TPL (other than Medicare)

Enter the claim as normal, then enter these additional fields.

• Does the subscriber have insurance other than Medicaid – Select yes • Select the red + before Other Subscriber Information • Select the red + before Additional Other Subscriber Information

o Claim Filing Code – Select the appropriate type of other insurance from the drop down list

o Payer Responsibility Sequence Number Code – Select Primary from the drop down list

• Other Payer Information o Payer/Insurance Organization Name – Enter the name of the insurance

• Additional Other Payer Information o Other Payer Primary ID – Enter an ID to identify the insurance by – this can be

letters, numbers or a combination. You will need to use this again later. o ID Type – Select Payor Identification from the drop down list

• COB Monetary Amounts o COB Payer Paid Amount – Enter the amount Medicare paid

On each line item, after you have entered your line items and added them, complete the following.

• Select the Other Svc Info link at the end of the line item data line

• Select the red + before Service Line Adjudication o Other Payer Primary ID – Enter the same thing entered previously as Other Payer

Primary ID on the first screen o Service Line Paid Amount – Enter the amount paid by the other insurance for this

line item o Adjudicated or Pay Date – Enter the paid date from the other insurance’s EOB o Paid Service Unit(s) – Enter the number of units Medicare paid o Procedure Qualifier – Select HCPCS from the drop down list

o Procedure Code – Enter the procedure code on this line item

• Select the Basic Claim Form to return to the 1st screen of your claim, and repeat these steps for each line item.

Dental Claim – TPL

Enter the claim as normal, then complete these additional fields.

• Does the subscriber have insurance other than Medicaid – Select yes • Payer/Insurance Organization Name – Enter the name of the other insurance • Additional Other Payer Information

o Other Payer Primary ID – Enter an ID to identify the insurance by – this can be letters, numbers or a combination. You will need to use this again later.

o ID Type – Select Payor Identification from the drop down list

On each line item, after you have entered your line items and added them, complete the following.

• Select the Other Svc Info link

• Select the red + before Service Line Adjudication Information o Other Payer Primary ID – Enter the same thing entered previously as Other Payer

Primary ID on the first screen o Service Line Paid Amount – Enter the amount paid by the other insurance for this

line item o Adjudicated or Pay Date – Enter the paid date from the other insurance’s EOB o Paid Service Unit(s) – Enter the number of units the other insurance paid o Procedure Qualifier – Select ADA Codes from the drop down list o Procedure Code – Enter the procedure code on this line item

o Select the Basic Claim Form button to return to the 1st page of the claim, repeat these steps for each line item on the claim.