Presentation on theme: "Medicaid Eligibility Verification Options & CMS-1500 (08-05) Billing Guidelines October – December 2008 www.dmas.virginia.gov Department of Medical Assistance."— Presentation transcript:
Medicaid Eligibility Verification Options & CMS-1500 (08-05) Billing Guidelines October – December 2008 www.dmas.virginia.gov 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# 00001 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 9 9 9 9 9 9 9 9 9 9 9 99 9 9 9 9 9 9 9 9 9 9 9 002286
6 Important Contacts MediCall ARS- Web-Based Medicaid Eligibility Provider Call Center Provider Enrollment
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 https://virginia.fhsc.comhttps://virginia.fhsc.com 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) 800-241-8726 http://virginia.fhsc.com
16 MAIL CMS-1500 FORMS TO: DEPARTMENT OF MEDICAL ASSISTANCE SERVICES PRACTITIONER P. O. Box 27444 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
1a. INSURED'S I.D. NUMBER (FOR PROGRAM IN ITEM 1) Block 1a: Recipient ID Number (Be sure to include all 12 digits) 123456789014 22
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 1. 2. 3. 4. 3441 Block 21: Diagnosis Codes May enter up to 4 codes Omit decimals 2963 26
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 09 01 08 09 01 08 090108091608 1 2 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 11 11-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
D. Block 24D: Procedure Codes PROCEDURES, SERVICES, OR SUPPLIES (Explain Unusual Circumstances) CPT/HCPCSMODIFIER T1016 90806 36
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY 1. 2. 3. 4. 34431 Block 24E: Diagnosis Code E. DIAGNOSI S POINTER 1 2963 1,2 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. 31 39
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 43 0012345671
Block 24I: ID. Qualifier & 24J: Rendering Provider ID # I. ID. QUAL J. RENDERING PROVIDER ID. # NPI 1234567890 ZZTaxonomy (if needed) 44 National Provider Identifier
26. PATIENT ACCOUNT NUMBER Block 26: Patient’s Account Number 12345678918765 Can not exceed 14 alphanumeric digits 45
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.