Medicaid Eligibility Verification Options & CMS-1500 (08-05) Billing Guidelines October – December Department of Medical Assistance Services

2 This presentation is to facilitate training of the subject matter in Chapter V of the Virginia Medicaid. This presentation is to facilitate training of the subject matter in Chapter V of the Virginia Medicaid Psychiatric Services Manual. This training contains only highlights of this manual and is not meant to substitute for or take the place of the Psychiatric Services Manual. ************

3 Objectives Upon completion of this training you should be able to :  Correctly utilize Medicaid options to verify eligibility  Understand timely filing guidelines  Properly submit Medicaid claims, adjustments and voids

4 As a Participating Provider You Must-  Determine the patient’s identity.  Verify the patient’s age.  Verify the patient’s eligibility.  Accept, as payment in full, the amount paid by Virginia Medicaid.  Bill any and all other third party carriers.

5 DOB: 05/09/1964 F CARD# DEPARTMENT OF MEDICAL ASSISTANCE SERVICES COMMONWEALTH OF VIRGINIA V I RG I N I A J. R E C I P I E N T

6 Important Contacts  MediCall  ARS- Web-Based Medicaid Eligibility  Provider Call Center  Provider Enrollment

7 MediCall

8 MediCall  Available 24 hours a day, 7 days a week  Medicaid Eligibility Verification  Claims Status  Prior Authorization Information  Primary Payer Information  Medallion Participation  Managed Care Organization Assignment

9 Automated Response System ARS  Web-based eligibility verification option Free of Charge. Information received in “real time”. Secure Fully HIPAA compliant

10 UAC Registration Process Go to Select the ARS tab on FHSC ARS Home Page Choose “User Administration” Follow the on-screen instructions for help with registration, this is a 3-step process to request, register and activate a new account Answer the initial ‘Who are you?’ question by selecting ‘I do not have a User ID and need to be a Delegated Administrator’

11 ARS –Users  Web Support Helpline-  ARS Manual (User Guide)

12 Provider Call Center Claims, covered services, billing inquiries: :30am – 4:30pm (Monday-Friday) 11:00am – 4:30pm (Wednesday)

13 Provider Enrollment New provider numbers or change of address: First Health – PEU P. O. Box Richmond, VA Fax

14 Electronic Billing Electronic Claims Coordinator Mailing Address First Health Services Corporation Virginia Operations Electronic Claims Coordinator 4300 Cox Road Glen Allen, VA Phone: (800) Fax: (804)

15 Billing on the CMS-1500

16 MAIL CMS-1500 FORMS TO: DEPARTMENT OF MEDICAL ASSISTANCE SERVICES PRACTITIONER P. O. Box Richmond, Virginia 23261

17 TIMELY FILING  ALL CLAIMS MUST BE SUBMITTED AND PROCESSED WITHIN ONE YEAR FROM THE DATE OF SERVICE  EXCEPTIONS Retroactive/Delayed Eligibility Denied Claims  NO EXCEPTIONS Other Primary Insurance

18 TIMELY FILING  Submit claims with documentation attached (to the back of claim) explaining the reason for delayed submission

Printing  Must be RED OCR dropout ink or the exact match  Computer generated form must match/line up with National Uniform Claim Committee standard  Print 100% of actual size, set page scaling to “none”  Set page scaling to ‘none’  Margins must be exact  DMAS will not reprocess claims denied for scanning issues as a result of failure to follow the above instructions

CMS-1500 CLAIM FORM: Use ONLY the ORIGINAL WHITE RED & WHITE CMS-1500 (08-05) Invoice Photocopies are not Acceptable Computer generated claims must match NUCC uniform standards

MEDICAID (Medicaid #) Block 1 CHAMPUS (Sponsor's SSN) 1. MEDICARE (Medicare #) TRICARE 21

1a. INSURED'S I.D. NUMBER (FOR PROGRAM IN ITEM 1) Block 1a: Recipient ID Number (Be sure to include all 12 digits)

Block 2: Patient's Name 2. PATIENT'S NAME (Last name, First Name, Middle Initial) Smith, Sam 23

Block 10: Accident-Related 10. IS PATIENT'S CONDITION RELATED TO: a. EMPLOYMENT? (CURRENT OR PREVIOUS) b. AUTO ACCIDENT? c. OTHER ACCIDENT? YESNO PLACE (State) YES NO You MUST check YES or NO for a, b & c 24

Block 11d - Is There Another Health Benefit Plan? d. IS THERE ANOTHER HEALTH BENEFIT PLAN? DMAS does not require providers to complete Blocks 9 a-d YES NO If yes, return to and complete item 9 a-d. 25 Providers must indicate YES for all patients who have any other insurance coverage. Regardless of whether payment is received from the primary carrier for service provided.

21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY Block 21: Diagnosis Codes May enter up to 4 codes Omit decimals

23. PRIOR AUTHORIZATION NUMBER Block 23: Prior Authorization Number - Conditional 27

28 Blocks 24A thru 24J  These blocks have been divided into open areas and a shaded red line area  The shaded area is ONLY for supplemental information  Instructions will be given on when the use of the shaded area is required for claims processing

29 TPL Information Block 24A  Qualifier ‘TPL’ will be used followed by dollars/cents amount whenever an actual payment is made by a third party carrier  No spaces between the qualifier and dollars and no $ symbol used  Decimal between dollars and cents is required to read paid amount correctly  Must be left justified

30 TPL Information Block 24A  DMAS will set COB code based on the information given in locator 11d: No, or nothing indicated-no other carrier on file for the recipient, Medicaid will pay primary No, or nothing indicated and system has other insurance coverage on file - claim will deny bill other insurance No, or nothing indicated and ‘TPL’ qualifier with payment listed in 24a red shaded area – Medicaid will coordinate benefits with other carrier

31 TPL Information Block 24A  DMAS will set COB code based on the information given in locator 11d: Yes, and ‘TPL’ qualifier with payment in 24a red shaded area primary carrier billed and paid, Medicaid will coordinate benefits with the primary carrier Yes, but nothing in 24a red shaded area and other carrier billed and made no payment. Providers must attach current documentation of non-payment from the other carrier. Copy of explanation of benefits denial or information documented on agency/group letterhead is acceptable documentation.

24. A. DATE(S) OF SERVICE FromTo MM DD YY Block 24A : Dates of Service Both FROM and TO dates must be completed Dates must be within same calendar month TPL27.08

B. Place of Service Block 24B: Place of Service Office location 21 – Inpatient Medicaid accepts the same 2 digit CMS Place of Service codes as Medicare. Note: Type of Service is no longer required 33

34 Emergency Indicator-24C  This locator will be used to indicate whether the procedure was an emergency  DMAS will only accept a ‘Y’ for yes in this locator  If there was no emergency leave blank

C. EMG Block 24C: EMG 35

D. Block 24D: Procedure Codes PROCEDURES, SERVICES, OR SUPPLIES (Explain Unusual Circumstances) CPT/HCPCSMODIFIER T

21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY Block 24E: Diagnosis Code E. DIAGNOSI S POINTER ,2 Enter the identifier of the ICD-9- CM diagnosis code listed in Locator 21. To identify more than one diagnosis code, separate the indicators with a comma. 37

F. $ CHARGES Block 24 F: Charges Enter the usual and customary charges 38

G. DAYS OR UNITS Block 24G: Days or Units 1 Enter the number of times or hours the procedure, service, or item was provided during the service period

H. Block 24H: EPSDT/Family Plan 1 EPSDT Family Plan 1-EPSDT 40

41 ID.QUAL Block-24I  Qualifier ‘1D’ is to be used in the red shaded area for claims being submitted using the Atypical Provider Identifier (API).  DMAS requires Treatment Foster Care agencies to bill with an API.  Qualifier ‘ZZ’ is to be used to indicate the taxonomy code-only when the NPI is used and only if necessary to adjudicate the claim.

42 Rendering Provider ID # Block-24J  The shaded red area will contain the API OR  The open area will contain the NPI of the provider rendering the service.

Block 24I: ID. Qualifier & 24J: Rendering Provider ID # I. ID. QUAL J. RENDERING PROVIDER ID. # NPI 1D Atypical Provider Identifier

Block 24I: ID. Qualifier & 24J: Rendering Provider ID # I. ID. QUAL J. RENDERING PROVIDER ID. # NPI ZZTaxonomy (if needed) 44 National Provider Identifier

26. PATIENT ACCOUNT NUMBER Block 26: Patient’s Account Number Can not exceed 14 alphanumeric digits 45

28. TOTAL CHARGE Block 28: Total Charges $ 46

31. SIGNATURE OF PHYSICIAN OR SUPPLIER INCLUDING DEGREES OR CREDENTIALS (I certify that the statements on the reverse apply to this bill and are made a part thereof.) SIGNED DATE Block 31: Signature & Date If there is a signature waiver on file, you may stamp, print, or computer-generate the signature. 47

48 Block 32 Service Facility Location Information  Enter information for the location where services were rendered First line-Name Second line-Address Third line-City, State, 9 digit zip code No punctuation in the address Space between city and state Include hyphen for the 9 digit zip code

49 Block 32 Block 32, cont’d. Service Facility Location Information  Providers with multiple offices/locations - the zip code must reflect the office/ location where services were rendered  Enter the 10 digit NPI number of the service location in 32a. OR  Enter ‘1D’ qualifier with the API in 32b

Block 32: Service Facility Location Information 32. SERVICE FACILITY LOCATION INFORMATION a.b. NPI 50

51 Block 33 Billing Provider Info & PH #-  Enter the information to identify the provider that is requesting to be paid First line-Name Second line-Address Third line-City, State, 9 digit zip code  No punctuation in the address  Space between city and state  Include hyphen for the 9 digit zip  Phone number is to be entered in the area to the right of the field title, no hyphen or space used

52 Billing Provider Info & PH #-Block-33a-b  Enter the 10 digit NPI number of the service location in 33a. OR  Enter ‘1D’ qualifier with the API in 33b.

Block 33: Billing Provider Info & PH # 33. BILLING PROVIDER INFO & PH # a.b. NPI ( ) 53

22. MEDICAID RESUBMISSION CODE ORIGINAL REF. NO. Block 22 : Adjustments and Voids 1032 xxxxxxxxxxxxxxxx Adjustment or Resubmission Code From original remittanc eVoid Chap. V, Psychiatric Services Manual has resubmission code list. 54

REMITTANCE VOUCHER Sections of the Voucher 4 APPROVED for payment. 4 PENDING for review of claims. 4 DENIED no payment allowed. 4 DEBIT (+) Adjusted claims creating a positive balance. 4 CREDIT (-) Adjusted/Voided claims creating a negative balance. 55

REMITTANCE VOUCHER Sections of the Voucher 4 FINANCIAL TRANSACTION 4 EOB DESCRIPTION 4 ADJUSTMENT DESCRIPTION/REMARKS- STATUS DESCRIPTION 4 REMITTANCE SUMMARY- PROGRAM TOTALS 56

THANK YOU Department of Medical Assistance Services