1 Eligibility Verification and Direct Data Entry Billing Requirements February Department of Medical Assistance Services Intellectual Disability Community Waiver

This presentation is to facilitate training of the subject matter in the Virginia Medicaid manuals. This training contains only highlights of the manual and is not meant to substitute for or take the place of the manual. Providers are responsible for reviewing and adhering to all Medicaid manual requirements.

3 Agenda DMAS Web Portal Eligibility Verification Options Patient Pay Information Important Contacts Direct Data Entry Billing Guidelines Timely Filing Department of Medical Assistance Services

4 DMAS Web Portal Department of Medical Assistance Services Current, most up-to-date information on Virginia Medicaid programs: –Provider Memos Available for Review –Access to Medicaid Manuals –Provider Forms –Provider Profile Maintenance –Automated Response System –Direct Data Entry (DDE)

5 DMAS Web Portal Current, most up-to-date information on Virginia Medicaid programs: –Provider Memos Available for Review –Access to Medicaid Manuals –Provider Forms –Provider Profile Maintenance –Automated Response System –Direct Data Entry (DDE) Department of Medical Assistance Services

6 As a participating Provider You Must Determine the patients 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 Department of Medical Assistance Services

7 COMMONWEALTH OF VIRGINIA DEPARTMENT OF MEDICAL ASSISTANCE SERVICES V I RG I N I A J. R E C I P I E N T DOB: 05/09/1994 F CARD# 00001

Department of Medical Assistance Services Medicaid Eligibility Verification Options MediCall/ Automated Response System (ARS)

Department of Medical Assistance Services MediCall/Automated Response System (ARS) Available 24 hours a day, 7 days a week Medicaid Eligibility Verification Claim Status Patient Pay Information Prior Authorization Information Primary Payer Information Managed Care Organization Assignments

Department of Medical Assistance Services MediCall

Department of Medical Assistance Services Automated Response System (ARS) Web based eligibility verification option –Free of Charge –Information received in “real time” –Secure –Fully HIPPA compliant

Department of Medical Assistance Services ARS Registration Process First Time Users –Go to /wps/portal/Webregistration /wps/portal/Webregistration –Establish an user ID and password –By registering you are acknowledging yourself as a staff member with administrative rights for the organization

Department of Medical Assistance Services ARS Web Support Call Center Questions regarding new user registration, temporary password or password resets, call: Available 8 am – 5 pm Monday – Friday (No Holidays)

14 Patient Pay Information The local department of social services (LDSS) will enter data regarding the individual’s patient pay obligation into the Medicaid Management Information System (MMIS) at the time action is taken on a case: –Result of application for long term care services –Time of the annual re-determination of eligibility –Change in the enrollee’s situation is reported Medicaid patient pay information is available via MediCall and ARS. Providers responsible for collecting the patient pay amount should review the information prior to billing each month Department of Medical Assistance Services

Patient Pay Information Begin-End (Date Time Period) Patient PayStatus 06/01/ /30/ A V ARS Patient Pay Information 15

16 Provider Call Center Department of Medical Assistance Services Claims, covered services, billing inquiries: :30am – 4:30pm (Monday-Friday) 11:00am – 4:30pm (Wednesday)

17 Provider Enrollment Department of Medical Assistance Services New provider enrollment, Electronic Fund Transfer (EFT) or change of address: Xerox– PEU P. O. Box Richmond, VA Fax

Department of Medical Assistance Services Direct Data Entry

Department of Medical Assistance Services Accessing DDE Once registered for the Web Portal, the Primary Account Holder (PAH) and Organization Administrator (OrgAdmin) will automatically have access to DDE Other users identified as Authorized Staff, will need to be assigned a new role called Authorized Staff-Claims to have access to DDE

Department of Medical Assistance Services Direct Data Entry (DDE) of Claims DDE allows the submission of professional claims by entering the information at the required locators as detailed in the billing instructions within the User Guide – vhttp:// v –Under Provider Resources tab select Claims Direct Data Entry (DDE) –Provides access to DDE User Guide, Tutorial and FAQs

21 Direct Data Entry (DDE) of Claims Department of Medical Assistance Services Through the DDE process providers will have the ability to –create a new initial claim –create templates –request an adjustment or void

22 Accessing the Claims DDE Department of Medical Assistance Services Upon successful login, you will be directed to the secure Provider Welcome Page Navigational tabs will direct you to Claims DDE and Automated Response System functions

Department of Medical Assistance Services Claims Menu-Access

Department of Medical Assistance Services Claims Main Page DDE functions can be accessed here

25 Create New Professional Claim Department of Medical Assistance Services

26 Void/Replacement Claim 26

Is this a void/replacement (adjustment) of a paid claim:  System defaults to ‘No’ and requires no Claim Resubmission Information fields related to a prior claim  If ‘Yes’ is selected, the system requires Claim Resubmission Information fields be entered as well as the original paid claim except areas changing for adjustment. Claim Resubmission Information section has the following required fields:  Resubmission Type Code (required) Select the 4 digit code identifying the reason for adjusting or voiding an individual claim

Department of Medical Assistance Services Resubmission Type Options- Adjustments Primary carrier has made additional payment Primary carrier denied payment Accommodation charge correction Patient payment amount changed Correcting service periods Correcting procedure/service code Correcting diagnosis code Correcting charges Correcting units/ visits/studies/procedures 1032-IC reconsideration of documented allowance Correcting admitting/referring/ prescribing Provider Identification Number

29 Resubmission Type Options – Voids Department of Medical Assistance Services Original claim has multiple incorrect items Wrong provider identification number Wrong enrollee eligibility number Primary carrier paid DMAS max allowance Duplicate payment was made Primary carrier has paid full charge Enrollee not my patient 1052-Miscellaneous Other insurance available

Submitter Information Submitter ID- this field defaults to the User ID used to login into the portal 30

Patient and Insured Information 31

Patient's Last Name (REQUIRED) – Enter the Last Name of the member receiving the service. First Name (REQUIRED) – Enter the First Name of the member receiving the service. MI (optional) – Enter the member's middle initial. Insured's I.D. Number (REQUIRED) – Enter the 12 digit Virginia Medicaid Identification number for the member receiving the service.

Is Patient's Condition Related To: (REQUIRED) Related Cause 1– Select whether or not the member’s condition is the result of an employment accident. Drop down options: –Not Related To Employment –Related To Employment Related Cause 2– Select whether or not the member’s condition is related to an auto accident. Dropdown options: – Not Related To An Auto Accident – Related To An Auto Accident If ‘Related to an Auto Accident’, the system requires you to enter the state where the auto accident occurred. Related Cause 3– Select whether or not the member’s condition is related to an accident other than auto or employment. Drop down options: –No Accident –Accident

Is there another Health Benefit Plan? (REQUIRED) – This field always defaults to ‘No’ but if other third party coverage exists, select ‘Yes’ and enter Other Coverage Information. If ‘Yes’ is entered and other insurance pays this must be listed as Supplemental Data If ‘Yes’ is entered and other insurance does not pay standard TPL guidelines must be followed –Attachments must be indicated in Service Location section

Physician or Supplier Information This is not required 35 CLIA #

Date of Current (optional/situational) – Select the reason from drop down options and enter the date in the format MM/DD/YYYY –Illness(First Symptom)-Waiver services providers will enter the date care began from the DMAS-93 (PA Letter) Diagnosis or Nature of illness or Injury (REQUIRED) – Enter the appropriate diagnosis code, which describes the nature of the illness or injury for which the service was rendered. You have to enter at least one diagnosis code out of four. Service Authorization # (optional/situational) - Enter the Service Authorization Number for approved services that require a service authorization.

Service Line Item Click on ‘Add Service Line Item’ Button to add additional Line items After entering information You must Save, Reset, or Cancel 37 Note: Taxonomy Code is entered here if applicable

Service Date Begin (REQUIRED) – Enter the date on which the service was first rendered. Format is MM/DD/YYYY Service Date End (REQUIRED) – Enter the date on which the service was last rendered. Format is MM/DD/YYYY. Place of Service (REQUIRED) – Select the two digit code which best describes where the services were rendered. –12 – Home Procedure Code (REQUIRED) – Enter the code that describes the procedure rendered or the service provided. Modifiers (optional/situational) – Enter the appropriate modifiers if applicable.

Diagnosis Pointers (REQUIRED) – Select the diagnosis pointer related to the date of service and the procedure performed for the primary diagnosis. The system requires you to enter at least one diagnosis pointer value out of four. –Drop down options:

Saved Service Line Items After entering information You must Save, Delete, or Cancel Click on Service Line Item to view 40

Save/Reset/Cancel After entering information in identified sections, you will have the following options:  Save- saves the data as part of your DDE claim  Reset- clears the data entered allowing you to start again  Cancel- will exit or close the current data field Data will be required to be saved to be included as part of the DDE claim submission

After saving the data, each line item will be displayed Additional information can be entered by selecting the ‘Add’ link To correct or delete a saved line item, you must first select the line to be amended by clicking on it

After selecting the saved line item, you will have the following options:  Correcting the information and save by clicking the Save link  Remove the entry from the claim by clicking on the Delete link  Keep the original data as listed by clicking on the Cancel link

Service Location and Attachments 44

The Amount Paid field is for Personal Care and Waiver services only –Enter the patient pay amount that is due from the patient. –NOTE: The patient pay amount is taken from services billed. –Providers rendering more than one service will need to send another DDE submission for charges not subject to the Patient Pay. Patient Pay Amount

If the claim has any attachments, you must select ‘Yes’ and enter the following information:  Patient Account Number (required) – Enter up to 20 alphanumeric characters  Date of Service (required) – Enter from date of service the attachment applies to in the MM/DD/YYYY format  Sequence Number (required) – Enter the provider generated sequence number – maximum of 5 digits

A ‘Claim Submitted’ confirmation page will be generated by the system Print the Claim Submitted page Staple documents to a copy of the confirmation page and mail to DMAS Attachment “documentation” must be received by Xerox (DMAS Fiscal Agent) within 21 days of the DDE submission or claim will deny NOTE: Confirmation page must be the first page of the mailed submitted documents

Mailing Address – Claims Submission page and required documents should be mailed within 21 days to: Department of Medical Assistance Services P. O. Box Richmond, VA

Service Facility Location Information 49

Billing Provider Information This section details information about the provider requesting payment for services rendered. Billing Provider Information section has both required and optional/situational fields 50

Claim Submitted Page 51

You will not be able to access the Claim Submitted page anywhere else on the Portal It is strongly recommended you always save a file copy or print this page for your records by clicking on the ‘Print Submission Page’

Claim Information- review the following:  ICN – Displays the ICN number of the submitted claim  Attachment Control Number (ACN) – Displays the ACN number if the ATTACHMENT option has been selected for this claim  Date of Service  Provider #  Member ID  Member Name  Total Charge  Submitted Date/Time (this information will be accepted as Proof of Timely Filing)

Create a Professional Template CMS

Templates are a mechanism for the user to establish a baseline claim that can be reused as needed. They can : –be used to eliminate the need for having to rekey static data with every submission (i.e. billing provider information). –be established for common submissions (i.e. infant well care, immunizations, etc) –be stored for reuse 55

To establish a template for a professional claim, select Create Professional Template from the Claims drop down menu. You will be transferred to the Create New Professional Template page for template creation 56

Template Name 57

All the fields utilized in the Create Professional Template will be the same as the fields in the Create Professional Claim Except for the buttons below From this template page you can –save the template by clicking on ‘Save Template’ button – reset all the entered fields by clicking on the ‘Reset’ button or; – navigate to the ‘Create New Professional Template’ page by clicking on the ‘Cancel’ button. 58

When saving the template, the system only validates the format of the data entered. After clicking 'Save Template' button, the system displays a successful save message by directing you to the ’Save Template‘ portlet. 59

Save Template From this Save Template page you can –navigate to the ’Claims Main Page’ in order to access other claims options by clicking on the 'Claims Main Page’ button or; –create a new professional template by clicking on the 'Create Another Template' button. 60

View/Manage/Delete Templates 61

62

63

64

65

66

DDE Tips Recommend using 6.0 or higher Internet Explorer Web-based cursor must be placed in correct location Templates limited to 100 Be as specific as possible when naming templates-they are to be shared Data entry only-no edits When adjustments and/or voids of claims are required, you must wait until the next business day to submit this information 67

DDE Tips Print or save confirmation-Claim Submitted Page You will not receive prompts to submit required Supplemental Data Don’t worry about capitalization, punctuation, or symbols (except for TPL Supplemental Data) 3 year limit for adjustments and voids Claims for Medallion II members enrolled in Managed Care Organizations will continue to be submitted to the MCO’s according to their guidelines 68

69 TIMELY FILING Department of Medical Assistance Services 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 –Accidents

70 TIMELY FILING Claims documentation can be submitted with DDE Provider must indicate documentation will be submitted during the data entry claims process Documentation should be attached to the claims confirmation page and mailed to the DMAS fiscal agent – Xerox State Health Plans Department of Medical Assistance Services

Thank You