Medicaid Eligibility Verification Options & Residential Treatment Facility CMS-1450 (UB-04) Billing Requirements September – October Department of Medical Assistance Services

This presentation is to facilitate training of the subject matter in the Virginia Medicaid Psychiatric Services manual. This training contains only highlights of the manuals 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.

Agenda 1. Medicaid Eligibility Verification Options 2. Service Authorizations 3. Timely Filing 4. CMS-1450 (UB-04) Billing Requirements

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.

DOB: 05/09/1994 F CARD# DEPARTMENT OF MEDICAL ASSISTANCE SERVICES COMMONWEALTH OF VIRGINIA V I RG I N I A J. MEMBER

Important Contacts MediCall ARS- Web-Based Medicaid Eligibility Provider Call Center Provider Enrollment Electronic Claims Coordinator

MediCall/ Automated Response System (ARS) Available 24 hours a day, 7 days a week Medicaid Eligibility Verification Claims Status Service Limits Service Authorization Information Primary Payer Information Medallion Participation Managed Care Organization Assignment

MediCall

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

Registration Process  First Time Users  To establish an user ID and password go to:  By registering you are acknowledging yourself as a staff member with administrative rights for the organization

Registration Process  Established Users- Delegated Administrators  Received a letter containing their NPI and instructions on accessing the Web Portal  Must have accessed the Web Portal and changed their temporary password  Capable of adding or deleting ARS users

ACS Web Registration Support Call Center  Questions regarding new user registration, existing user access letter, or temporary passwords   8 am – 5 pm Monday thru Friday  No holidays 

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

Provider Enrollment NPI enrollment, EFT sign-up, update provider phone contact or change of address: Provider Enrollment Unit P. O. Box Richmond, VA Fax

ARS Prior Authorization Status Codes/Descriptions Status Code Description AAccepted AJApproved and rejected AMApproved and modified ARApproved/Received (New Data Received) CCancelled DDenied DRDenied/Received (Supporting Document Received) 15

ARS Prior Authorization Status Codes/Descriptions Status CodeDescription JRejected PPend PRPend/Received (Supporting Document Received) RReceived RJReceived/Rejected 16

Service Authorization Log Service Authorization ID Header Status Rejected Service Line Item Information Procedure Code Begin Date End Date Authorized Units Authorized Amount Units Used Remaining Units Used Amount /12/ /12/ Please review the status of your service authorization. Just because an authorization number was assigned to your request, that does not mean it was approved. All requests are assigned a Service Authorization ID. 17

Electronic Billing Electronic Claims Coordinator Phone: (866) Fax: (888)

MAIL CMS-1450 (UB-04) FORMS TO: Virginia Medical Assistance Program P. O. Box Richmond, Virginia 23261

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

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-1450 CLAIM FORM: Use ONLY the ORIGINAL WHITE RED & WHITE UB-04 Invoice Photocopies are not Acceptable Computer generated claims must match NUBC uniform standards

Locator 1: Provider’s Name, Address and Phone Number Enter the provider’s name, complete mailing address and telephone number of the provider that is submitting the bill and which payment is to be sent. NOTE: DMAS will need to have the 9 digit zip code on line four, left justified for adjudicating the claim.

Locator 1: Provider Name, Address and Phone Number 25 1 Our Place Facility 121 Friendly Street Any TownVA

Locators 3a and 3b 3a Patient Control Number - Enter the patient’s unique financial account number which does not exceed 20 alphanumeric characters. 3b Medical/Health Record - Enter the number assigned to the patient’s medical/health record by the provider. This number cannot exceed 24 alphanumeric characters. 26

Locators 3a- Patient Control Number & 3b- Medical/Health Record Number 3a PAT. CNTL # b. MED REC. # ABCDEFGH HGFEDCBA Patient Control Number and Medical/Health Record Number are required for all UB-04 claim submissions.

Locator 4 :Type of Bill Enter the code as appropriate. The Type of Bill field is four digits with a leading zero. Claims submitted without the required four digit bill type will be denied.

Locator 4: Type of Bill 0161 Original Residential Treatment Invoice 0162 First Interim Residential Treatment Invoice 0163 Subsequent Residential Treatment Invoice (s) 0164 Final Residential Treatment Invoice 0167 Adjustment Residential Treatment Invoice 0168 Void Residential Treatment Invoice Only approved claims can be adjusted or voided. 29

Locator 4: Type of Bill –Use this bill type for patients who are admitted and discharged within the same month. For established patients who leave your facility for admission to an acute care hospital, and return within the same month, two separate claims must be submitted.

Example: Same Month Admit/Discharge/Re-Admit First claim will be a Bill Type 0164, as the patient was discharged to be admitted to the acute care facility. The second claim, billed for the patient being readmitted to your facility, will be a Bill Type 0162.

Admit/Discharge/Re-Admit Patient admitted to residential facility 08/13/10. Patient developed pneumonia and was admitted to a hospital on 09/12/10. Patient returned to the residential facility on 09/20/10. Bill Type 0164 for dates 09/01/10 – 09/12/10, with a status of 02. Bill Type 0162 for dates 09/20/10 – 09/30/10, with a status code of 30.

4 TYPE OF BILL Locator 4: Type of Bill 0162 Interim Bill Residential Treatment Facility 33

Locator 6: Statement Covers Period 6 STATEMENT COVERS PERIOD FROM THROUGH Enter the beginning and ending service dates reflected by this invoice (include both covered non-covered days). Use both “from” and “to” for a single day. Invoice billing periods cannot overlap months

Locator 8: Patient Name/Identifier b 8 PATIENT NAMEa Enter the last name, first name and middle initial of the patient. Last First M 35

Locator 10: Patient Birthdate 10 BIRTHDATE Enter the date of birth of the patient using the following format - MMDDYYYY

Locator 11: Sex 11 SEX Enter the sex of the patient as recorded at admission, outpatient or start of care. M = Male; F = Female; U = Unknown F 37

Locator 12: Admission/Start of Care The start date for this episode of care. For inpatient services this is the date of admission. For all other services, the date the episode of care began: Residential Treatment Facility – Original admission date or new date the patient is re-admitted to the facility.

Locator 12: Admission/Start of Care ADMISSION 12 DATE 39

Locator 13: Admission Hour ADMISSION 13 HR 14 Enter the hour during which the patient was admitted to the facility. Medicaid will allow a default time for Residential Facility patients. NOTE: Military time is used as defined by NUBC. 40

Locator 14: Priority Type of Visit Appropriate PRIORITY TYPE codes accepted by DMAS are: CODEDESCRIPTION 1Emergency 2Urgent 3Elective 5Trauma 9Information not available 41

Locator 14: Priority (Type) of Visit ADMISSION 14 TYPE 3 Enter the code indicating the priority of this admission /visit. 42

Locator 15: Source of Referral/Admission CodeDescription 1Physician Referral 2Clinic Referral 4Transfer From Another Acute Care Facility 6Transfer From Another Healthcare Facility 7Emergency Room 8Court Law Enforcement 9Information Not Available

Locator 15: Source of Referral for Admission Visit 6 15 SRC Enter the code indicating the source of the Referral for this admission or visit. 44

Locator 17:Patient Discharge Status Appropriate codes accepted by DMAS in claims processing: CodeDescription 01Discharge to Home 02Discharged/transferred to Short Term General Hospital for Inpatient Care 03Discharged/transferred to SNF 04Discharged/transferred to ICF 05Discharged/transferred to Another Facility not Defined Elsewhere 45

Locator 17: Patient Discharge Status CodeDescription 07 Left Against Medical Advice/Discontinued Care 20 Expired 30 Still a Patient 46 Appropriate codes accepted by DMAS in claims processing:

Locator 17: Patient Discharge Status 17 STAT 30 Enter the code indicating the disposition or Discharge status of the patient at the end for the Service period covered on this bill (Statement Covered Period, Locator 6). 47

Locators 18-28: Condition Codes These codes are used by DMAS in the adjudication of claims: CodeDescription 39Private Room Necessary A1EPSDT 48 NOTE: Condition Code A1 is a required for all Residential Facility Claims submitted to DMAS.

Locators 18-28: Condition Codes (Required if Applicable) Condition Codes Enter the code (s) in alphanumeric sequence Used to identify conditions or events related to this bill that may affect adjudication. A1 49

Note: DMAS will be capturing the number of covered or non-covered day (s) or units for outpatient services with these required value codes: Locators 39-41:Value Codes and Amount 80Enter the number of covered days for inpatient facility. 81Enter the number of non-covered days for facility.

Locators 39-41: Value Codes and Amount Enter the appropriate code (s) to relate amounts or values to identify data elements necessary to process this claim. One of the following codes must be used to indicate coordination of third party insurance carrier benefits: 82 No Other Coverage 83 Billed and Paid (enter amount paid by primary carrier) 85 Billed Not Covered/No Payment

a b c d VALUE CODES CODE AMOUNT 40 VALUE CODES CODE AMOUNT 41 VALUE CODES CODE AMOUNT 83 Value Codes and Amount LOCATORS 39-41:

Locator 42: Revenue Code Enter the appropriate revenue code (s) for the service provided. Note: Multiple services for the same item, providers should aggregate the service under the assigned revenue code and then total the number of units that represent those services DMAS has a limit of five pages for one claim The Total Charge revenue code (0001) should be the last line of the last page of the claim

Locator 42: Revenue Code REV. CD Revenue codes are four digits, leading zero, left justified and should be reported in ascending numeric order. 54

Locator 43: Revenue Description R&B-Semi-Pvt-2 Bed-General Total Charge 43 DESCRIPTION Enter the standard abbreviated description of the related revenue code categories included on this bill. 55

Locator 44: HCPCS/Rates/HIPPS Rates Codes 44 HCPCS / RATE / HIPPS CODE Inpatient: Enter the accommodation rate. 56

Locator 45: Service Date (Required if Applicable) 45 SERV. DATE

Locator 46: Service Units 46 SERV. UNITS 30 Inpatient : Enter total number of covered accommodation days or ancillary units of service where appropriate. 58

Locator 47: Total Charges 47 TOTAL CHARGES Enter the total charge(s) for the primary payer during the ‘statement covers period’ including both covered and non-covered charges. Note: Use code “0001” for TOTAL. TOTALS 46 SERV. UNITS

Locator 50: Payer Name A-C Enter the payer from which the provider may expect some payment for the bill. When Medicaid is the only payer, enter “Medicaid” on line A. If Medicaid is the secondary or tertiary payer, enter on lines B or C.

Locator 50: Payer Name A-C 50 PAYER NAME A Primary Payer B Enter the secondary payer identification, if applicable. C Enter the tertiary payer if applicable. MEDICAID 61

Locator 56: National Provider Identification (NPI) Providers must share their NPI with the DMAS Provider Enrollment Unit (PEU). Once your NPI is on file with the PEU, providers will bill their NPI in this field.

Locator 56: NPI 56 NPI digit NPI should be listed in this field.

Locator 58: Insured’s Name ABCABC 58 INSURED’S NAME Enter the name of the insured person covered by the payer in locator 50. The name on the Medicaid line must correspond with the member name when eligibility is verified. Virginia J. Member 64

Locator 59: Patient’s Relationship to Insured Note: appropriate codes accepted by DMAS are: CodeDescription 01Spouse 18Self 19Child 21Unknown 39Organ Donor 40Cadaver Donor 53Life Partner G8Other Relationship

Locator 59: Patient’s Relationship to Insured 52 REL. INFO 18 Enter the code indicating the relationship of the insured to the patient. 66

Locator 60: Insured’s Unique Identification 60 INSURED’S UNIQUE ID For lines A-C, enter the unique identification number of the person insured that is assigned by the payer organization shown on lines A-C, Locator 50. NOTE: The Medicaid member ID number is 12 numeric digits.

Locator 63: Treatment Authorization Codes ABAB 63 TREATMENT AUTHORIZATION CODES Enter the 11 digit service authorization number assigned by KePRO for the appropriate services to be billed to Virginia Medicaid. 68

Locator 64: Document Control Number (DCN) This locator is to be used to list the original Internal Control Number (ICN) for APPROVED claims that are being submitted to adjust or void the original claim. The ICN will be listed on the Remittance Advice with the original approved claim.

Locator 64:Document Control Number (Required if Applicable) DOCUMENT CONTROL NUMBER The internal control number (ICN) assigned to the original payment by Virginia Medicaid as part of the claims process. 70

Locators 67A-Q Principal Diagnosis Code Present on Admission (POA) Indicator The eighth digit of the Principal, Other and External Cause of Injury Codes are to indicate if: –the diagnosis was know at the time of admission, or –the diagnosis was clearly present, but not diagnosed, until after the admission took place or –was a condition that developed during an outpatient encounter

Locator 67 A-Q POA Indicator The POA indicator should be listed in the shaded area. Reporting codes are: CODE DEFINITION Y YES N NO U No information in the record W Clinically undetermined

Locator 67: Principal Diagnosis Code 67A BC IJKL Enter the diagnosis codes corresponding to all conditions that coexist at the time of admission, that develop subsequently, or that affect the treatment received and/or the length of stay. NOTE: Do not use decimals. 73

Locator 69: Admitting Diagnosis 69 ADMIT DX Enter the diagnosis code describing the patient’s diagnosis at the time of admission. Medicaid requires the diagnosis code billed to be a current ICD-9 code. NOTE: Cross check DSM-4 codes with ICD-9 codes. Do not use decimals

Locator 76: Attending Provider 76 ATTENDINGNPI Enter NPI for the physician who has overall responsibility for the patient’s medical care and treatment reported on this claim.. 75

Locator 80: Remarks Field 80 REMARKS Enter additional information necessary to adjudicate the claim. Enter a brief description of the reason for the submission of the adjustment or void. If there is a delay in filing, indicate the reason for the delay here and include an attachment. 76

Locator 81: Code-Code Field DMAS previously assigned different provider numbers for each type of service performed. Medicaid payment was then issued based on the type of service billed. DMAS will be using this field to capture a taxonomy code for claims that are submitted for one NPI with multiple business types or locations (e.g., Residential or Psychiatric units within an acute care facility).

Locator 81: Code-Code Field The taxonomy code will be required for providers who do not have a separate NPI for each different service billed to VA Medicaid. The taxonomy code will also be required for providers who have one NPI for multiple business locations. Code B3 is to be entered in the first small space and the provider taxonomy code is to be entered in the second large space. The third space should be blank.

Locator 81: Code-Code Field 81CC a b c d Enter the provider taxonomy code for the billing provider when the adjudication of the claim is known to be impacted. B3 323P00000X 79

DMAS Services That May Require Taxonomy Codes on Claims Service Type/DescriptionTaxonomy Codes Private Mental Hospital (IP)283Q00000X Hospital General282N00000X Psychiatric Unit of Hospital273R00000X Psychiatric Residential Inpatient Facility 323P00000X – Psychiatric Residential Treatment Facility

THANK YOU Department of Medical Assistance Services