|
Policy and Procedure Name:
|
Medicare and Medicaid Requests for Reimbursement
|
|
Policy #:
|
CP-13-05
|
|
Code/Rule Reference:
|
R.C. 5160.35
through R.C.
5160.43; O.A.C.
5160-1-08; O.A.C.
4123-3-23; 42
U.S.C.§ 1395y(b)(2)
|
|
Effective Date:
|
04/09/2025
|
|
Approved:
|
Shawn Crosby, Chief Operating Officer
|
|
Origin:
|
Operational Policy and Support
|
|
Supersedes:
|
Policy # CP-13-05, effective 03/11/2022
|
|
History:
|
Previous versions of this policy are available upon
request
|
Table of Contents
I. POLICY PURPOSE
II. APPLICABILITY
III. DEFINITIONS
Medicaid
Medicare
Medicare Beneficiary Identifier (MBI)
IV. POLICY
A. Medicare
B. Medicaid
V. PROCEDURE
A. General Claim Note and
Documentation Requirements
B. Medicare Request for
Reimbursement
C. Request for Assistance
for Medicare Coordination of Benefits
D. Medicaid Recovery Request
for Reimbursement
The purpose of this policy is to ensure that BWC responds
appropriately to requests for reimbursement from Medicare and Medicaid.
This policy applies to all BWC staff.
Medicaid:
A joint federal and state funded health insurance program that helps cover
medical costs for low-income individuals and families with limited income and
resources. The federal government sets specific program guidelines, but each
state is given the flexibility to run their Medicaid program within the
federally set parameters.
Medicaid provides benefits for certain services that
Medicare does not normally cover, including nursing home care and personal care
services. Medicaid beneficiaries typically do not pay anything for covered
medical expenses but may owe a small co-payment for some items or
services.
Medicare:
A federal government health insurance program that subsidizes health-care
services for anyone 65 or older, younger people with disabilities, and patients
with end-stage renal disease or amyotrophic lateral sclerosis. Medicare covers
particular health-care services. Some services covered by Medicare require
Medicare enrollees to share the costs.
- Medicare is divided into four components: Medicare Part A,
Part B, Part C (also called Medicare Advantage), and Part D for
prescription drugs.
- Medicare Part A premiums are free for those who have made
Medicare contributions through payroll taxes for at least 10 years.
- Patients are responsible for paying premiums for other
parts of the Medicare program.
Medicare Beneficiary Identifier (MBI):
A personally identifiable number for Medicare recipients. The MBI has replaced
the Social Security number previously used on Medicare cards to identify the
beneficiary.
The MBI number is required on all Medicare transactions
including billing, eligibility status, claims, and appeals. It is assigned to
every Medicare member and should be treated as important and confidential. The
MBI number is an 11-character alpha-numeric identifier that is unique to each beneficiary.
1. BWC processes
Medicare requests for reimbursement.
2. BWC
will assist parties regarding coordination of benefits upon request.
1. BWC
does not process requests from Medicaid and will refer such requests to the managed
care organization (MCO) managing the injured worker’s (IW) medical care.
2. BWC
may refer an inquiry from the IW to the Ohio Department of Medicaid.
1. BWC
staff will refer to the Standard
Claim File Documentation and Altered Documents policy and procedure for
claim note and documentation requirements; and
2. Must
follow any other specific instructions for claim notes and documentation
included in this procedure.
1. Claims
Services staff must email a request for reimbursement to the Medical Billing
and Adjustments (MB&A) BWC
Medicare Medical mailbox upon receipt from any of the following:
a. Centers
for Medicare and Medicaid Services (CMS);
b. A private
collection agency on behalf of CMS;
c. IW
or IW representative; or
d. An MCO.
2. Claims
Services staff may direct Medicare questions to MB&A’s Medicare telephone
number at 614-728-2931.
3. When
MB&A’s Medicare staff receives a request for reimbursement, they will:
a. Ensure
the request has been imaged in the claim file under “confidential;”
b. Research
the request;
c. Send
a response to CMS; and
d. Enter
a claim note describing the response to CMS and any additional action taken.
1. When
the IW, the IW’s representative, or Medicare Benefits Coordination &
Recovery Center (Medicare BCRC) requests assistance
regarding coordination of benefits (e.g., denials of medical equipment requests
or medical services), Claims Services staff must:
a. Complete
the Medicare Referral (C-272) form in its entirety;
b. Email
the completed C-272 form to the BWC
Medicare Inquiries box; and
c. Enter
a claim note with the action taken.
2. A
Medicare request for assistance in a self-insured claim is handled in the same
manner as V.C.1. above.
1. Upon
receipt of a Medicaid recovery request for reimbursement, Claims Services staff will:
a. Ensure
the request has been imaged in the claim file under “confidential;”
b. Rename
the confidential document, “Medicaid Recovery Request;”
c. Email
the request to MB&A;
and
d. Enter
a claim note describing the action taken.
2. Upon
receipt, MB&A staff will:
a. Review
and evaluate the request;
b. Forward
the request via email to the appropriate MCO;
c. Enter
a claim note with action taken; and
d. Oversee
and support the MCO’s subrogation process.