1. MEDICARE DEDUCTIBLE AND COINSURANCE Common Billing Errors
TITLE XVIII
(DMAS-30)
Department of Medical Assistance Services
February 2010

2. Department of Medical Assistance Services
Medicaid Primary
If problems are encountered with the Medicare Crossover claim process, the DMAS-30 invoice form should be completed and forwarded to:
Practitioner
Department of Medical Assistance Services
P. O. Box 27444
Richmond, VA

3. Title XVIII Common Mistakes
Locator 7 - Other Coverage
Locator 8 - Type Coverage
Locator 17- Charges to Medicare
Locator 18- Allowed By Medicare
Locator 19- Paid By Medicare
Locator 20- Deductible
Locator 21- Coinsurance
Locator 22- Paid By Carrier Other Than Medicare
Locator 23- Patient Pay Amount (LTC Only)

4. 01 Billing Provider Number
Title XVIII- Block 01
01 Billing Provider Number
Enter the provider’s billing or group NPI.

5. 06 Rendering Provider Number
Title XVIII- Block 06
06 Rendering Provider Number
Enter the rendering provider’s NPI.

6. Block 7 Patient only has Medicare and Medicaid coverage- Check 2
Patient has Medicare coverage primary and a secondary plan which has paid on the deductible or coinsurance amount- Check 3 and write the amount paid in Block 22.
Patient has Medicare primary and a secondary plan which has denied the service, or applied the coinsurance to deductible- Check 5 and attach the secondary carrier’s Explanation of Benefits.

7. Title XVIII- Block 07 07
Primary Carrier Information Other Than Medicare
2 No Other Coverage
5 Billed No Coverage
3 Billed and Paid

8. Type Coverage Medicare- Mark type of coverage “B”.
Title XVIII- Block 08 08
Type Of Coverage Medicare
Type Coverage Medicare- Mark type of coverage “B”. B

9. Title XVIII- Block 17 17
Charges To Medicare
Block 17: Charges to Medicare- Enter the total charges submitted to Medicare.

10. Title XVIII- Block 18 18
Allowed By Medicare
Block 18: Allowed by Medicare- Enter the amount of the charges allowed by Medicare.

11. Title XVIII- Block 19 19
Paid By Medicare
Block 19: Paid by Medicare- Enter the amount paid by Medicare (taken from the EOB).

12. Title XVIII- Block 20
Deductible 20
Block 20: Deductible- Enter the amount of the deductible (taken from the Medicare EOB).

13. Title XVIII- Block 21 21
Co-Insurance
Block 21: Coinsurance - Enter the amount of the coinsurance (taken from the Medicare EOB).

14. Paid By Carrier Other Than
Title XVIII- Block 22 22
Paid By Carrier Other Than
Medicare
Block 22: Paid by Carrier Other Than Medicare- Enter the payment received from the secondary carrier (other than Medicare). If Code 3 is marked in Block 7, enter an amount in this block.
(Do not include the Medicare payment.)

15. Patient Pay Amt. LTC Only
Title XVIII- Block 23 23
Patient Pay Amt. LTC Only
Block 23: Patient Pay Amount, LTC Only- Leave Blank.

16. TITLE XVIII- Adjustment Invoice DMAS-31
Block 1 Adjustment/Void Check the appropriate block
Block 2 Billing Provider Number Enter the NPI of the billing provider
Block 6 Rendering Provider Number
Enter the NPI of the rendering provider
Block 2A Reference Number Enter the ICN number taken from the
Remittance Voucher for the line of payment needing
adjustment.

17. TITLE XVIII- Adjustment Invoice
Blocks Refer to instructions for the DMAS-31 for the completion of these blocks.
Remarks This section of the invoice should be used to give a brief explanation of the change needed.
Signature Signature of the provider or agent and the date signed.

18. Department of Medical Assistance Services www.dmas.virginia.gov
THANK YOU
Department of Medical Assistance Services