Information is maintained for third-party policies belonging to or paying for a member's care. The capture and maintenance of these third-party liability (TPL) resources allows the State to pay-and-chase or cost-avoid payments that are the responsibility of other carriers.
The Policy component of the TPL function of Financial allows policies to be related to carriers and members covered by the policies. This information may be captured from various sources that include the current eligibility interface as well as carriers, employers, and online entry by State staff. Claims processing also identifies possible coverage from the claims submitted by the providers. TPL policy information is added either through North Dakota MMIS Web Portal or batch processing.
A single policy can cover individuals from multiple cases. The member's coverage remains associated with the policy even if his or her eligibility in the case changes. When policy information is changed, the new information automatically applies to all included members.
All resources are inactive (pending) until either you verify the information and change the pending status or ND MMIS updates the pending status because the data match file is identified as a trusted source in the parameter file for interfaces. As soon as the TPL policy information is verified and approved, it can be used for claim cost avoidance and post-payment billing.
You have two options to copy a policy and all its information:
Copying a policy does not copy information about individuals that are no longer covered by the policy.
The Policy Period panel on the TPL Policy page allows you to capture effective dates for a specific coverage period for the policy. If the policy already exists and you edit the effective dates, ND MMIS adds the appropriate date range to the Policy table in the database. To view the effective date history for a specific policy, you can search using the policy number and the search results display all policy periods for that policy.
A 270 is an electronic transaction that inquires of an insurance provider in a standard format about an individual's eligibility to be covered by one of its policies.
ND MMIS provides an automated process that runs monthly to re-verify policies that have not been verified or updated in a certain amount of time (as set by a system parameter). It automatically generates these 270 transactions for carriers that have a trading partner agreement on file. In addition, you can request at any time that a 270 transaction be generated for covered individuals using the Generate 270 link on the TPL Policy page.
The re-verification process generates a 270 trigger for the policy or covered individual if the carrier associated to the policy has an active trading partner agreement. The process generates a Policy Verification report that provides you information about which policies have been automatically included for re-verification and which have not because there is no active trading partner agreement. Those policies that were not included for re-verification automatically must be re-verified manually, following your standard procedures.
Medicare is a third-party coverage, but it is handled differently from other third-party policies by the TPL function. Medicare span information is displayed in the TPL Policy area, but the information is received from the Member function. Medicare information is also received through the MMA (Medicare Modernization Act) and COBA (Coordination of Benefits Agreement) interfaces which verify the Medicare span and coverage for members. Medicare span information is normally not entered manually, but it can be with appropriate security permissions. However, a manually-entered span remains pending until the information is validated. ND MMIS changes the status to active after the information is confirmed by the MMA or COBA interface process. You can also manually change the status after validating the information matches the source.
You can also associate a Medicare Part D span and a Benefit plan. This relationship allocates coverage to the Medicare Part D Plan and eligible member. The plan benefit package (PBP) span identifies the Part D plan and contract number in association with the benefit plan ID and the dates surrounding this span(which should match the member’s part D eligibility span). When claims are adjudicated, ND MMIS reviews the benefit plan associated to the member to find out if any coverage is associated based on the Medicare Part D plan and posts the appropriate edits.
You can choose to void the policy or Medicare Part D PBP span so that it is not considered when processing. Normally you do this when the information was entered incorrectly and should not be used to process any claims. However, if the policy period dates are incorrect, you can edit those dates rather than voiding the policy.
After saving a voided policy period, all covered individuals included in the policy are automatically set to void.
Voided policies and spans are frozen in the database, and no further changes are allowed. Once a policy or span is saved as void, it cannot be reactivated.
If you are voiding an active policy that has a beginning date before the current system date (a retroactive policy period), then your changes may cause denied claims with service dates that fall within that period to have adjustment requests generated to reprocess the claims and pay the provider.
If you are voiding a Medicare Part D PBP span, claims are not reprocessed.
You must carefully consider all the processing steps that must be completed if you are making a retroactive change.
If a policy should no longer be used for claims after a certain date, you can close this policy by giving the policy period an ending date. After this date, it is no longer considered for claims whose dates of service fall outside the date range for this policy period. Normally, this ending date should be today's date or a date in the future.
Policies are also closed by ND MMIS when the policy's carrier or group is no longer an active carrier and has been terminated or has been merged with another carrier or group. See What Is a Mass Change Request? and How to Add or Edit a Mass Change Request for more information.
Medicare spans can be closed manually by setting the ending date on or earlier than the current system date. Medicare spans are closed by ND MMIS based on information received from various interfaces. The span's ending date is changed by ND MMIS to end the Medicare coverage. For example, if a Medicare Part D span on the MMA file has an ending date which is different from the Medicare Part D span stored on the ND MMIS database, ND MMIS updates the database with the new ending date. If the Medicare Part D span ending date is on or earlier than the current system date, the Medicare Part D span is considered closed. If a Part D Medicare span is closed, the associated Medicare Part D PBP span is also closed with an ending date matching the ending date of the Medicare Part D span.
How to Search for a TPL Policy or Medicare Span
How to Add or Edit a TPL Policy
How to Request Eligibility Verifications (270 Transactions)
How to View, Add, or Edit a Medicare Span
How to Void or Close a TPL Policy or Medicare Span
Search TPL Policy Page
TPL Policy Page
What Is Financial Accounting Entity?
How to Add or Edit a TPL Mass Change Request
What Is Third Party Liability?
Version as of 5/16/14.
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