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QUEST Integration - Third Party Liability - Coordination of Benefits

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QUEST Integration - Third Party Liability - Coordination of Benefits
Original Effective Date:
08/01/1994
Current Effective Date:
06/01/2015
 

 

Coordination of Benefits (COB) applies when a patient has other healthcare coverage, such as another private health insurance plan or Medicare, in addition to HMSA QUEST Integration. The other insurance must be billed first, and the payment indicated on the HMSA QUEST Integration claim for coordinated processing. If a patient has coverage from more than one insurance plan, both plans are primary to HMSA QUEST Integration and must be billed before submitting a claim to HMSA QUEST Integration.  

 

Other Insurance is a Health Maintenance Organization (HMO)

When a patient's primary insurance is a health maintenance organization (HMO), patients must seek services from their HMO physician, or be referred to another provider by their HMO health center physician. Patients who seek covered services outside their HMO health center without a referral or approval by the HMO are responsible for services rejected by the HMO for no referral. Claims rejected for this reason are not payable by HMSA QUEST. 

If the service to be provided is not a benefit of the HMO but a benefit of HMSA QUEST (i.e., routine vision care or transportation), the patient must obtain services through an HMSA QUEST network provider.  The claim submitted to HMSA QUEST must provide written documentation from the HMO that the service is not a covered benefit.  

The following claim filing information refers to paper claim submissions. If you file claims electronically, refer to Submitting HIPAA EDI Transactions to HMSA for electronic claim submission requirements.
 

 

Claims Filing Information - Other Insurance Payment

File a claim promptly with the primary payer(s), then submit a claim to HMSA QUEST Integration. A copy of the primary payment report is required for any plans other than HMSA. Claims missing this information may result in processing delays and/or claim denial.
 

On the CMS 1500 claim form:

  • Block 11d (Is There Another Health Benefit Plan?)- mark YES
  • Block 9 (Other Insured’s Name)
  • Block 9a (Other Insured’s Policy or Group Number)
  • Block 9d (Insurance Plan Name or Program Name)
  • Block 29 (Amount Paid) by the other insurance plan

 


 

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For Medicare primary claims, the following fields must be completed as indicated below:

  • Block 1a (Insured’s ID Number) - replace the Medicare health insurance number with the QUEST Integration member number.
  • Block 33b (Billing Provider Info) - replace the PIN number to the HMSA QUEST Integration provider number.
 

On the UB-04 claim form:

  • Block 50 (Payer Name)
  • Block 58 (Insured’s Name)
  • Block 60 (Insured’s Unique ID)
  • Block 54 (Prior Payments) – amount of the other insurance plan payment

 


 

For Medicare primary claims, the following fields must be completed as indicated below:

  • Block 60 (Insured’s Unique ID) – replace the Medicare health insurance number with the QUEST Integration member number.
  • Block 57 (Other Provider ID) - replace the PIN number to the HMSA QUEST Integration provider number.


 

Claim Filing Information - Other Insurance Denial

If the other insurance denied the claim, submit a paper claim and indicate $0.00 as the amount of the other insurance payment. Attach a copy of the denial document from the other insurance. 

If the other insurance is an HMSA plan, whether PPO, HMO, or Medicare Advantage, documentation of a denial is not required but HMSA policy information must be provided in the applicable fields of the claim and $0.00 must be indicated as the other insurance payment amount. Claims missing this information will be denied to bill HMSA.


 

Claim Filing Information - Medicare

If the other insurance is Medicare, submit claims as indicated below:

  • Part B claims – submit to Hawaii’s Part B carrier, Blue Cross and Blue Shield of North Dakota. If a patient’s Part B coverage is through one of HMSA’s plans for Medicare beneficiaries, please follow the claims processing directions for the plan.
  • Part A claims – submit to Blue Cross of California.

Medicare claims for Durable Medical Equipment (DME) are processed by the Durable Medical Equipment Regional Carrier (DMERC) for Region D - CIGNA.

Providers may choose to opt-out of Medicare by contacting CMS. A copy of this letter must be attached to each claim submission filed by the opt-out provider to HMSA when HMSA is secondary to Medicare. The letter must include the date range of the opt-out period and it must coincide with the service date filed on the claim form.  

 

Modifier GY

This modifier is used when an item or service is statutorily excluded (non-covered by Medicare Statute) or does not meet the definition of any Medicare benefit. Modifier GY is not a guarantee of payment and a copy of the EOMB may still be required.
  • Modifier code must present for each service line item that is excluded or not covered by Medicare
  • Modifier code can be billed in any position (1-4) on the line-level modifier fields

On the 1500 form, the GY modifier should be billed in field 24D, if applicable.
On the UB04 form, the GY modifier should be billed in field 44, if applicable.


 

Benefit Payment

Primary payer other than Medicare

Payments for services that are QUEST Integration benefits are coordinated up to 100 percent of the eligible QUEST Integration fee, less the amount of the primary insurance payment. If the primary insurance payment is greater than the QUEST Integration fee, there is no balance for QUEST Integration to pay.
 

Examples:
image.png

*Although the actual payment is $234, the payment deduction is limited to the maximum QUEST allowance.
**Even if no QUEST payment is expected, please submit claims/encounter forms for reporting purposes.

 

Primary payer is Medicare

HMSA's Plan for QUEST Integration Members coordinates benefits with Medicare for covered services. For any services not covered under Medicare, but which are benefits under QUEST Integration, are also eligible for reimbursement.  

QUEST Integration will coordinate by paying the Medicare coinsurance/copayment and any unmet annual deductible for the following claim types:
  • Skilled Nursing Facilities (SNFs) – Bill Types 021x, 028x
  • Inpatient Rehabilitation Facilities
  • Hospital Swing Bed – Bill Type 018x
  • Hospice services
  • Home Health Agency
  • Medicare Part B services (ie. Physician, ambulance, DME, etc.)

QUEST Integration will coordinate by paying either the Medicare coinsurance/copayment and any unmet annual deductible, or the QUEST Integration allowed amount minus the Medicare paid amount, whichever is lesser, for the following claim types:
  • Acute Inpatient Hospitalizations (excluding those listed above)
  • Outpatient Hospital services

QUEST Integration will coordinate covered services eligible for PPS reimbursement by paying up to the applicable PPS rate for the following:
  • Rural Health Clinics (RHC) – Bill Type 071x
  • Federally Qualified Health Centers (FQHC) – Bill Type 077x

QUEST Integration payment must be accepted as payment in full. Any difference between the amount billed to QUEST Integration and the QUEST Integration payment must be written off and may not be billed to the patient.

 

HMSA Akamai Advantage® is a PPO plan with a Medicare contract. Enrollment in HMSA Akamai Advantage depends on contract renewal.
Rev#:Date:Nature of Revision:
4.0 (v5)02/08/2024The following disclosure statement has been added: 
HMSA Akamai Advantage® is a PPO plan with a Medicare contract. Enrollment in HMSA Akamai Advantage depends on contract renewal.
3.1 (v4)05/05/2023Minor formatting edit.
3.0 (v3)05/04/2023Content has been updated and is current.
Content from the following PRC articles have been consolidated into this article and archived.
QUEST-Integration-Third-Party-Liability-Coordination-of-Benefits-QUEST-Integration-and-Medicare
QUEST-Third-Party-Liability-Coordination-of-Benefits-QUEST-Integration-and-Other-Private-Insurances-Fee-for-Service-Plans
QUEST-Third-Party-Liability-Coordination-of-Benefits-QUEST-Integration-and-Other-Health-Insurance-Health-Maintenance-Organization
Rev#:Date:Nature of Change:
2.005/09/2016This document replaces the previous version.
2.112/12/2017Naming convention update: Change Akamai Advantage to Medicare Advantage.
2.202/20/2018Updated content in the Claims Filing Information - Other Insurance Payment section.
2.309/17/2018Added the "Note" section to the first paragraph.
First Published:05/09/2016
Latest Revision:09/17/2018
Details
QUEST-Integration-Third-Party-Liability-Coordination-of-Benefits
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