Wis. ForwardHealth Online Handbook, Hospice, Topic #8457

Medicare assesses a late fee when providers submit a claim after Medicare's claim submission deadline has passed. Claims that

cross over to ForwardHealth with a Medicare late fee are denied for being out of balance. To identify these claims, providers

(not billing errors), or the member's lifetime benefit, or yearly allotment of available benefits is exhausted.

For Medicare Part A, use M-7 in the following instances (all three criteria must be met):

• The provider is identified in ForwardHealth files as enrolled in Medicare Part A.

• The member is eligible for Medicare Part A.

• The service is covered by Medicare Part A but is denied by Medicare Part A due to frequency limitations,

diagnosis restrictions, or exhausted benefits.

For Medicare Part B, use M-7 in the following instances (all three criteria must be met):

• The provider is identified in ForwardHealth files as enrolled in Medicare Part B.

• The member is eligible for Medicare Part B.

• The service is covered by Medicare Part B but is denied by Medicare Part B due to frequency limitations, diagnosis

restrictions, or exhausted benefits.

M-8 Noncovered Medicare service. This code may be used when Medicare was not billed because the service is not covered

in this circumstance.

For Medicare Part A, use M-8 in the following instances (all three criteria must be met):

• The provider is identified in ForwardHealth files as enrolled in Medicare Part A.

• The member is eligible for Medicare Part A.

• The service is usually covered by Medicare Part A but not in this circumstance (for example, member's diagnosis).

For Medicare Part B, use M-8 in the following instances (all three criteria must be met):

• The provider is identified in ForwardHealth files as enrolled in Medicare Part B.

• The member is eligible for Medicare Part B.

• The service is usually covered by Medicare Part B but not in this circumstance (for example, member's diagnosis).

should reference the Medicare remittance information and check for ANSI (American National Standards Institute) code B4 (late

filing penalty), which indicates a late fee amount deducted by Medicare.

ForwardHealth considers a late fee part of Medicare's paid amount for the claim because Medicare would have paid the

additional amount if the claim had been submitted before the Medicare claim submission deadline. ForwardHealth will not

reimburse providers for late fees assessed by Medicare.

Resubmitting Medicare Crossover Claims with Late Fees

Providers may resubmit to ForwardHealth crossover claims denied because the claim was out of balance due to a Medicare late

fee. The claim may be submitted on paper, submitted electronically using the ForwardHealth Portal, or submitted as an 837 (837

Health Care Claim) transaction.

Paper Claim Submissions

When resubmitting a crossover claim on paper, include a copy of the Medicare remittance information so ForwardHealth can

determine the amount of the late fee and apply the correct reimbursement amount.

Electronic Claim Submissions

When resubmitting a claim via the Portal or an electronic 837 transaction (including PES (Provider Electronic Solutions) software

submissions), providers are required to balance the claim's paid amount to reflect the amount Medicare would have paid before

Medicare subtracted a late fee. This is the amount that ForwardHealth considers when adjudicating the claim. To balance the

claim's paid amount, add the late fee to the paid amount reported by Medicare. Enter this amount in the Medicare paid amount

field.

For example, the Medicare remittance information reports the following amounts for a crossover claim:

• Billed Amount: $110

• Allowed Amount: $100

• Coinsurance: $20

• Late Fee: $5

• Paid Amount: $75

Since ForwardHealth considers the late fee part of the paid amount, providers should add the late fee to the paid amount reported

on the Medicare remittance. In the example above, add the late fee of $5 to the paid amount of $75 for a total of $80. The claim

should report the Medicare paid amount as $80.