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Waiver Billing Workshop Presented by: Xerox State Healthcare, LLC Provider Relations.

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Presentation on theme: "Waiver Billing Workshop Presented by: Xerox State Healthcare, LLC Provider Relations."— Presentation transcript:

1 Waiver Billing Workshop Presented by: Xerox State Healthcare, LLC Provider Relations

2 When online use: Ask Service Representative Call Center or New Mexico Web Portal Provider Information section Links and FAQ section Provider Login section Resources

3 Important State Websites STATE WEBSITE: PROGRAM POLICY MANUAL BILLING INSTRUCTIONS REGISTERS AND SUPPLEMENTS:

4 September Provide specific billing information for Home and Community Based (HCBS) Waiver providers. Purpose of the Workshop

5 September Useful Websites New standards for DD Waiver providers are located: Click on General Info on the top left side of the screen.

6 September Useful Websites Go to the bottom of the screen under “Other sites of interest” and click on NM Department of Health. On the right hand side of the screen under ”New And Improved” – learn about what’s new on the Developmental Disabilities Supports Division. Under “WHAT’S NEW?” click on the DD Waiver Standards.

7 September NPI REQUIREMENTS Waiver Providers – if an HCBS waiver provider ONLY renders administrative services such as helping coordinate non-medical services, supports living arrangements (assisted, family, independent, supported, and environmental modifications), supplies homemaker, respite or transportation services, the provider would be “Atypical” and will not need an NPI number.

8 September NPI REQUIREMENTS Waiver Providers – A HCBS waiver provider will need to apply for and use an NPI if any of their services are provided by a licensed healthcare provider such as an RN, an LPN, or a therapist (list not all inclusive).

9 September Use of Taxonomy When a professional services provider (that is, not a hospital or nursing facility) renders multiple types of service under the same business address and the same federal tax ID, one NPI number may be used by that provider. A taxonomy code is required to direct Omnicaid to the appropriate service to pay.

10 September Use of Taxonomy Absence of a valid taxonomy may cause New Mexico Medicaid claim to deny for providers using one NPI for multiple types of service.

11 September Use of Taxonomy Selecting Taxonomy for a Claim – providers that need to reflect taxonomy for use on New Mexico Medicaid claims, must select an approved taxonomy for their provider type from the tables available at:

12 Claim Form Requirements

13 September Claim Form Requirements All claims that do not require an attachment for payment must be submitted electronically. Professional claims are submitted on the 837P electronically and the CMS-1500 on paper. MAD requires that all paper CMS-1500 claim forms be on the original red claim forms. Photocopies of claim forms are returned to the provider’s billing office.

14 Electronic Claim Submission All Fee For Service claims within 90 days from the initial date of service that do not require an attachment for payment must be submitted electronically. For any assistance regarding Electronic Claims Submissions, contact the HIPAA Helpdesk or call

15 Three Ways to Submit Claims Electronically Payerpath – Free HIPAA Compliant web-based claims entry system. The URL to the registration form for Payerpath submissions is: *Pay attention to the RA Newsletter, for upcoming updates to the Payerpath. Through a Clearinghouse EDI Gateway The URL for additional information regarding EDI Gateway electronic submissions is: 0to%20ACS%20EDI.pdf

16 Timely Filing Limits 90 days from the date of service for all providers. Exceptions to the 90 day timely filing limit: Schools, the filing limits are 120 days for the initial filing period and 120 days for the grace period (rather than 90 days). IHS and Tribal 638 compact facilities, the filing limit is 2 years from the date of service with no additional grace period. 16

17 Timely Filing Limits For a claim which met the initial filing period, but was denied, partially denied, or requires an adjustment, there is an additional one-time 90 day grace period counted from the date of payment or denial, during which the claim can be re-filed or an adjustment submitted to Xerox. It is to the provider’s advantage to resubmit a claim, if necessary, within the initial 90 day filing period in order to have the greatest amount of time in which to re-file or submit an adjustment during the 90 day grace period if another re-filing or adjustment is necessary. 17

18 Timely Filing Limits The claim may be re-filed during the 90-day grace period as many times as necessary, but claims filed after the 90 day grace period will be denied. 18

19 Timely Filing Limits Exceptions to the filing limit: When other primary payers have denied or made payment on a claim, the filing limit of 90-days is counted from the date of payment or denial by the other party, but not to exceed 210 days from the date of service. A provider should file claims in sufficient time with other payers to allow submission in time to meet the Medicaid 210 day limit. When the recipient has retroactive eligibility, the initial filing limit is 120 days from the date the eligibility was added to the eligibility file and was therefore available to providers. 19

20 Timely Filing Denials Exceptions to the filing limit: When the provider was not originally enrolled as a MAD provider on the date of service, the filing limit of 90 days is counted from the date the provider was notified of their enrollment, but must not exceed 210 days from the date of service. A provider should submit a provider participation agreement in sufficient time to allow processing and still meet the Medicaid 210 day limit for submitting the claim. When a claim previously paid by a Medicaid managed care organization is recouped from a provider due to retroactive disenrollment of the client from the managed care organization, the filing limit of 90 days is counted from the date of the managed care organization’s notice or recoupment from the provider. 20

21 Timely Filing Denials Re-filing Claims and Submitting Adjustments When resubmitting a claim or requesting an adjustment on a claim that is past the 90 day filing limit but originally met the filing limit, the “TCN” number which appears on the remittance advice (RA) will be used by Xerox to evaluate the claim. The provider must supply that TCN number in order for Xerox to be able to evaluate the claim. 21

22 Timely Filing Denials Re-filing Claims and Submitting Adjustments CMS 1500 form: Put the TCN in block 22 on the paper form. Leave the “Code” blank, and put the TCN in the “Original Reference No.” field. UB Form: Put the TCN in Form Locator 64 “Document Control Number” (DCN) matching the appropriate payer line, using a paper form. Dental Claim Form: Enter the TCN number in Box 35 beginning on the left side. 22

23 September CMS-1500 Claim Submission The following claim is how a paper CMS-1500 claim form is generally filled out. You must use procedure codes, etc. that are specific to your claims.

24 September Patient, Petunia X

25 September X Includes gross Receipts tax 1 Hour unit Joe Provider Rocky Road Mountain View, NM D X U1 A TYPICAL PROVIDER 8 DIGIT ID NUMBER 12 Optional Required Situational

26 X H Includes gross Receipts tax 15 Minute units Joe Provider Rocky Road Mountain View, NM X BILLING PROVIDER’S NPI 12 ZZ X TAXONOMY Optional Required Situational Waiver Providers using an NPI

27 September Place of Service Use place of service (POS) 11 when services are provided at your office (even if that is your home). Use POS 12 when services are provided at the client’s residence. Use POS 99 for all other sites/venues.

28 September Place of Service If billing the same procedure code on the same date(s) of service with two different places of service, bill on the same claim form as a combined service.

29 September Eligibility The waiver client’s eligibility depends on receiving services for 30 days. If that occurs, the client is made eligible for the full month when his/her services began. During this “delay”, denial “0141” could be received. This means that the client’s eligibility has not yet been determined.

30 September Eligibility Once the client has received 30 days of services, check the eligibility on the Web Portal to see if eligibility is on file. If so, resubmit the claim.

31 September Eligibility - COEs Waiver Categories of Eligibility (COE): 90 – For Individuals with AIDS 91 – For the Handicapped and Elderly (Aged) 92 – Mi Via Brain Injury 93 – For the Handicapped and Elderly (Blind) 94 – For the Handicapped and Elderly (Disabled) 95 – For the Medically Fragile 96 – For the Developmentally Disabled

32 September Eligibility - Assessments To bill for case management assessments done prior to the client becoming eligible, enter a 14-digit client ID as follows: The 3-digit Category of Eligibility (COE) for the program for which the client is being assessed. 2 zeros. SSN. The claim will not be paid if the Client ID is not entered as described above. Example:

33 September Approved Budgets Case managers are obligated to immediately provide copies of the approved budget with the assigned prior authorization (PA) number on it to ALL providers authorized on the budget. PA numbers will be given to case managers from the Third Party Assessor – Molina/TPA. – Case Managers can call the UR Agency Molina TPA at (505) (in Albuquerque) (866) (toll-free) Note: A PA number is required on every claim.

34 September Criminal Background Check Waiver providers get paid for criminal background checks by submitting special paperwork to DOH. Do not submit claims to Xerox for this. General Information – (505) For claims for D&E contact Gina Gallardo at (505) For claims for DD contact Lawrence Armijo at (505)

35 September Approved Budgets Waiver providers need to call their Case Manager when: There is no PA number in Omnicaid For status of MAD-046 If there is a discrepancy on PA in Omnicaid do not match the approved MAD-046

36 September Approved Budgets When entering the PA number on the claim, be sure it is the one that covers the dates of service (DOS) being billed.

37 September Approved Budgets A reminder from Medicaid UR for DD waiver case managers: Every third year a level of care abstract must be submitted for review to Medicaid UR. All other waiver providers are required to submit annually.

38 When online use: Ask Service Representative Call Center or New Mexico Web Portal Provider Information section Links and FAQ section Provider Login section Resources

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