Date: May 4, 2020
To: Enrolled Ambulatory Surgical Treatment Centers (ASTC); Hospitals; and Renal Dialysis Facilities
Re: TPL Code 920 For Medicare Advantage Plan Participants – Payment Methodology
This notice serves to inform providers of a change in fee-for-service claim payment methodology effective April 22, 2020, when billing TPL code 920 for patients enrolled in a Medicare Advantage Plan (MAP). This applies only to claims billed on the institutional claim format.
By informational notice dated October 4, 2017, providers were instructed to use new TPL code 920 on 837I or UB-04 claim transactions to identify participant coverage under a MAP. The notice stated HFS would treat MAP coverage like commercial insurance in the Medicaid payment system. Providers were to specify this TPL code and any payment received from the MAP on the 837I or UB-04 claim transactions. This was effective for outpatient dates of service and inpatient admissions beginning November 1, 2017.
To ensure that the Department’s secondary payments are consistent with agency payment policy, the Department has instituted a payment calculation change to cap payment at the MAP deductible/coinsurance/copayment that providers report on the claim.
Claims processed on or after April 22, 2020, will be processed with HFS capping payment, as is done with traditional Medicare claims. Claims processed on or after April 22, 2020, will be processed with HFS capping payment not to exceed the total MAP deductible/coinsurance/copayment submitted on the claim.
Questions regarding this notice may be directed to the Bureau of Hospital and Provider Services at 877-782-5565.
Interim Medicaid Administrator