Presentation on theme: "Department of Medical Assistance Services"— Presentation transcript:
1 Department of Medical Assistance Services Medicaid 101Good morning and welcome to our Hospital Medicaid 101- The Basics presentation. This presentation is recommended for staff responsible for patient registration, eligibility verification, billing and follow-up. The training will be divided into 2 sections. Part I will covered general information and Medicaid programs and packages. We will have a 15 minute break and part II will cover VA Medicaid’s UB-04 billing guidelines. Each section has been running about 90 minutes which includes time for your questions.
2 This presentation is to facilitate training of the subject matter in Virginia Medicaid Hospital Manual.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.Read slide2
4 DMAS Website www.dmas.virginia.gov Current, most up-to-date information on Virginia Medicaid programsProvider memos available for reviewAccess to Medicaid manuals50 Common Error Reason Codes with ResolutionsNumeric Insurance Code ListPrimary Carrier Coverage Code ListWebsite is the provider’s first link to current informationMemos alerting you to program or policy changes any updates can be reviewedManuals for all programs are available for reviewThe 50 Common Error Reason Codes have just been updated and from this point forward will be updated each quarter.For members with other insurance coverage, the primary plan is identified with a 5 digit number. On the website under provider services, you have access to a numeric listing of the plans. We also have an address on file to submit your claims. We strongly recommend that you request a current insurance card from the patient as that will have accurate billing informationThe coverage code list corresponds with a description of the type of medical coverage the primary plan provides
5 DMAS Website www.dmas.virginia.gov Financial Reason Code Description ListHospital DRG RatesMedicaid Forms2010 Medicaid/FAMIS-PLUS HandbookReadThe Medicaid/FAMIS Plus handbook is a useful tool. This is the same information received by the member upon approval. It details the members financial responsibilities- such as copays.
6 Point out the What’s new info . DMAS is in the process of a fiscal agent transition from FHS to ACS. Any new provider requirements and info can be found hereUpcoming training events is where you can find invitations to any scheduled Medicaid training sessionOn the left hand tool bar the information available includes the Learning Network where we post copies of training presentations. Today’s training will also be posted here
7 Excluded Individual/Entities No payment can be made for any items or services ordered or prescribed by an excluded physician when the furnishing party either knew or should have known of the exclusionMedicaid providers may be subject overpayment liability and civil monetary penalties when they do not abide by this Federal RegulationRead slide
8 Excluded Individual/Entities This ban includes payment for administrative and management services not directly related to patient careProviders are required to identify excluded individuals and entitiesThis ensures that DMAS is not paying any excluded individuals or entities for services renderedRead SlideApril 7, 2009 Medicaid memo explained that this is a federal requirement. Part of the money paid by Medicaid is federal dollars.
9 How to Ensure Program Integrity Screen all employees and contractors to determine whether they have been excludedSearch HS-OIG List of Excluded Individuals/Entities (LEIE) website monthlyImmediately report to DMAS any exclusion information discoveredDMAS is requiring due diligence from all providers. You must screen all new hires and screen your current employees, minimally once per year. The screening can be done by state or a national search. You will enter the employee’s name. No match document. Many of us have common names. If there is a name match, the next step is to enter the employee’s SSN. If there is no match, document your findings- this is not your EE and the screening is complete. If the SSN matches, check the reason the EE is on the list look to see if there is an exception that will allow you to keep the EE in your employ. If yes document, no exception you must take corrective action- terminate the EE.
10 Attn: Program Integrity/Exclusions ReportingDiscoveries are to be sent in writing to the address below and should include the:individual or business nameprovider identification numberState action, if any, has been takenDMASAttn: Program Integrity/Exclusions600 E. Broad St. Ste 1300Richmond, VA 23219Documentation of your corrective actions should be sent to DMAS- address listed on slide 10.
11 Accessing the LEIE HHS-OIG maintains the LEIE Provides information about parties excluded from participation in Medicare, Medicaid and all other Federal healthcare programsThe online database is located atThe link to screen your employees is listed here and the April 7, 2009 memo also gives additional links with the Office of the Inspector General if you have questions.
12 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.Read Slide
13 COMMONWEALTH OF VIRGINIA DEPARTMENT OF MEDICAL ASSISTANCE SERVICES002286Standard card explanation- number/name/date of birth/sexV I RG I N I A J. R E C I P I E N TDOB: 05/09/ F CARD# 00001
14 Medicaid Verification Options MediCallMedicaid Web PortalWe will be discussing the free options Medicaid has available for providers to check information
15 MediCall/Medicaid Web Portal Information Available Medicaid member eligibility/benefit verificationService limit informationClaim statusService authorizationProvider check logPrimary Payer InformationMedallion ParticipationManaged Care Organization AssignmentBecause of HIPPA only those who have the need to know will have access to Medicaid member information. A current NPI on file with VA Medicaid will allow access to MediCall and the online option.Break explanation of the info shared for each bullet point
16 Copay Indicators Code A Code B Code C Under 21- No copay exists Long Term Care, Home or Community Based Waiver Services, Hospice-No copayCode CAll other members – collect any/all applicable copaysCode A- Medicaid considers anyone under the age of 21 a child and children do not have any copaysCode B- This could be a patient in a nursing facility, a member enrolled in a Medicaid waiver or a patient who has elected hospice- no one in this group will have any copays.Code C- is everyone else. This group is subject to any and all identified copays. The copay will be deducted from the amount VA Medicaid pays you- clearly identified on your RA.
17 Copay Exemptions Members in managed care may not have copays Pregnancy related/family planning servicesEmergency servicesManaged care plan copays will be listed on the MCO plan card- if applicableFor the pregnancy related and family planning services- the diagnosis billed will be used to determine whether or not copays applyEmergency services- the diagnosis bill will determine whether the treatment meets the Medicaid definition of a medical emergency
18 Copay Amounts Inpatient hospital $100.00 per admission Outpatient hospital clinic $3.00 per visitClinic visit $1.00 per visitPhysician office visit $1.00 per visitOther physician visit $3.00 per visitRead Slide18
19 General ExclusionPayment cannot be made under the Medicaid Program for certain items and services, and Virginia Medicaid will not reimburse providers for these non-covered services.Medicaid members have been advised that they may be responsible for payment to providers for non-covered services.Read Slide
20 General Exclusion - Directive Prior to the provision of service, the provider must advise the Medicaid member that he or she may be billed for a non-covered service.A directive signed by the patient, meets Virginia Medicaid’s requirement of patient notification of financial responsibility for non-covered services.We have lots of providers who ask when can a Medicaid member be billed for non-covered services.Read Slide
21 MediCallHere are the phone numbers to access MediCall- your current NPI will be required to access the system
22 Medicaid Web Portal Web-based eligibility verification option Free of Charge.Information received in “real time”.SecureFully HIPAA compliantAs you noticed with the transition- the Automated Response System description has been changed to Web Portal-Read slide
23 Changes-A new enhanced web portal will allow providers to transact all Medicaid business via one central location.The web portal will provide access to:Member Eligibility StatusPayment HistoryRemittance AdvicesService AuthorizationRead slide-Emphasis on the batch process for eligibility verification- 10 members at timeRemittance advice will be available for all providers. This will be the same RA received by providers submitting paper claims. This will be a plus for those of you having problems interpreting the electronic remits.
24 Registration Process First Time Users Go toEstablish an user ID and passwordBy registering you are acknowledging yourself as a staff member with administrative rights for the organizationEstablished Users- Delegated Administratorswill receive a letter containing their NPI and instructions on accessing the Web Portalmust access the Web Portal and change their temporary password no later than June 27, 2010will be able to add new users beginning June 28, 2010.Registration will be required for the web portal. For first time users of our system beginning June 28th, you must register through the web portal at the link given. Understand that by registering you are acknowledging that you are a staff member with administrative rights for the organization given.For those providers that are already established on our system as delegated administrations you will receive a letter with your NPI and instructions on how to gain entry into the new web portal. Once this letter is received you must access the portal and change the temporary password given no later than June 27th. Once this is done beginning on June 28th the delegated administrator will be able to add new users.24
25 ACS Web Registration Support Call Center Questions regarding new user registration, existing user access letter, or temporary passwordAvailable after June 8, 20108 am – 5 pm Monday thru FridayNo holidaysIf you have any questions on the registration process, whether it is regarding new user registration or the steps that will be required for existing users detailed in your access letter, please contact the ACS Web Registration Support Call Center. This Call Center will be available from 8am to 5pm Monday through Friday at the number given after June 8th. It will not be available on holidays.
26 Key Dates and Times May 26th Through June 27th June 27th New registration to FHS/UAC discontinuedThrough June 27thCurrent FHS/UAC users can continue to request password resets, routine maintenance, or access information as normalJune 27thAccess to ARS via FHS/UAC will be discontinuedNow we will take the time to review some key dates and times in our transition.On May 26th we will discontinue any new registration to First health Services User Administration Console, however, through June 27th current users will be able to access information as normal and there will be support for requested password resets and routine maintenance.On June 27th we will discontinue access to the Automated Response System through First Health
27 Key Dates and Times June 28th new registration and users can be added via the new Virginia Medicaid Web Portalaccess to eligibility and claims information will be available in the new Virginia Medicaid Web Portal at 7:01 amBeginning June 28th at 7:01 am the new Virginia Medicaid Web Portal will be available. First time users will be able to register and delegated administrator can add new users. Once this is done providers will have access to eligibility and claims information.Are there any questions?
28 800-552-8627 804-786-6273 Provider Call Center Claims, covered services, billing inquiries:8:30am – 4:30pm (Monday-Friday)11:00am – 4:30pm (Wednesday)Your first line of assistance will be the provider Helpline. We have a call documentation system. You are required enter your NPI. The call center representative will document your issue and any resolution. There may be times where your problem cannot be handled within the 3-5 minute phone call. Each call is assigned a ticket number. This is a tracking mechanism. Before the conclusion of your call make sure you receive the ticket number. If the issue requires referral to another unit or analyst, you will be able to track it with the ticket number.
29 Provider Enrollment Provider Enrollment Unit P. O. Box 26803 NPI enrollment, EFT sign-up, update facility contact and , change of address or phone number:Provider Enrollment UnitP. O. Box 26803Richmond, VA 23261FaxFor any changes with your NPI, If you add additional services with a new NPI- contact provider enrollment. To initiate electronic fund transfer or if you are currently enrolled for EFT and change banks- contact provider enrollment. We are requesting a current facility phone number, contact person and their address for your facility. We anticipate that in the future the facility contact information will be updated via the web portal.Any questions on the information reviewed thus far?
30 Medicaid Programs/ Benefit Packages Now we will discuss Medicaid programs and benefit packages.
31 Medicaid Programs Medicaid Fee-for-Service Medallion No Primary Care Physician (PCP)No mandatory referral from the PCP.MedallionPrimary Care Physician who directs all care.PCP referral required for all non-emergency services.Medicaid fee for service provides coverage for medically necessary treatment provided by participating providers. No referral is required.In areas of the state where there are no managed care organizations- mainly far south west Virginia- Medicaid has Medallion. In this program, members select a Primary Care Physician who is responsible for directing the patient’s medical care. All treatment the patient receives that is not considered a medical emergency, will require a referral form the PCP. For VA Medicaid the referral is the PCP’s NPI listed on your claim submission. DMAS will use the diagnosis billed to determine if the treatment provided meets our definition of a medical emergency. For emergencies- no referral will be required.
32 Medicaid Programs FAMIS Medicaid program for children under age 19 First 30 days coverage provided under the FAMIS fee-for-service programMandatory Managed Care Organization assignment (where available) after the initial 30 days of coverageFAMIS is VA Medicaid’s Child Health Insurance Program. In most states it is called CHIP, but since we are special in VA we names our program FAMIS. This program provides coverage for children whose families make too much money to qualify for regular Medicaid yet cannot afford health coverage.FAMIS members will be enrolled in the fee for service program for the first 30 days of coverage. In areas of the state with no MCO plans- the member will remain in the fee for service program. Where the MCO plans are available- the member will have a 90 day period to select a plan. We go into detail regarding the selection process a little later in the presentation.
33 Medicaid Programs FAMIS MOMS For pregnant women with incomes above the Medicaid income guidelinesManaged Care Organization assignment rules same as FAMISApply thru local Department of Social Services or Central Processing UnitBaby is not covered until application submitted and approvedPregnant women whose income exceed the guidelines for regular Medicaid, may qualify for the FAMIS Moms program. Applications will be accepted at the local DSS office or at the DMAS central processing unit. The mother’s expenses for the pregnancy are covered.The baby will not have any coverage until an application is submitted and approved.If the baby qualifies for Medicaid- the mother can request on the application for retro-active eligibility. This request will have DSS check eligibility qualifications for up to 90 days prior to the application date.If the baby qualifies for FAMIS, the application must be received in the month of the child’s birth. The effective date can be no earlier than the first day of the month the application is received. Baby born on June 15. Mom completes the application and mails July 7. The baby meets the FAMIS criteria. The earliest date of eligibility will be July 1. The baby’s hospital charges would not be covered.
34 Medallion II MCO ID Cards Issued by the Managed Care OrganizationsMedicaid member will have both MCO and Medicaid cardsEligibility verification is a REQUIREMENTEach verification option will give the MCO enrollment information if applicableMedallion II is VA Medicaid’s managed care plan. Members should have both the Medicaid card and the MCO plan card. Because we know that often the member only has the Medicaid card or no card at all. Eligibility verification is mandatory. The verifications options discussed today will give the member’s MCO enrollment information.
35 Medallion II MCO ID Cards The Anthem card for Medicaid members indicates Anthem Health Keepers Plus (PLUS identifies the Medicaid plan).The Optima Card for Medicaid members indicates Optima Family Care (FAMILY CARE identifies the Medicaid plan).Virginia Premier - anyone presenting a VA Premier Card is a Medicaid client.Many of the health plans providing Medicaid managed care also have commercial plans. we wanted to give you some information to help identify the Medicaid MCO members.Read slide
36 Medallion II MCO ID Cards CareNet identifies the Southern Health Services card for Medicaid members.AMERIGROUP of Virginia is for Medicaid members.Read slide
37 Virginia Medicaid MCO Contacts Medicaid HMO PlanTelephone NumberAnthem HealthKeepers PlusOptima Family CareVirginia PremierCareNetAMERIGROUP of VirginiaWe are giving you the MCO contact information to contact the plan if you have questions. You will need to participate with the MCO in order to be paid for services rendered to a member enroll in the plan. Each of the plans have guidelines to handle emergency treatment provided to one of their Medicaid members. Also Medicaid members travel. If your facility is in far southwest VA, and do not participate with the MCO plans, you will need to contact the plan for guidance if one of their members comes to your facility.37
38 Member Choice - MCO Selection (Areas Where MCO is Available) Member will be enrolled in Medicaid fee-for-service plan for the first 30 days.Member will then have 90 days to select an MCO plan.During the 90 day period, a member can select a new MCO for the upcoming month as long as the request is received by the 15th of the current month.At the end of the 90 day period, the member will be enrolled in the chosen MCO until the next open enrollment period.Read slideWe cannot stress the importance of verifying eligibility each time the patient comes to your facility. During the patient’s MCO selection period, the member could potentially have fee-for-service coverage and 3 different MCO’s within a 4 month time frame.Also, by law if official communication- mail- from DMAS to the member is returned due to incorrect or insufficient mailing address- the member’s coverage is terminated. Once the member contacts local DSS, coverage will be re-instated. Depending on how long it takes for coverage to be reinstated, the MCO selection process could start all over again.
39 (Translation Services Available) Managed Care HelplineTDD#Monday – Friday8:30 a.m. – 6:00 p.m.(Translation Services Available)Here is the phone number for our Managed Care Helpline, for members who have questions regarding the MCO plans or the selection process. Providers can also utilize this tool for assistance.
40 Client Medical Management- CMM Mandatory Primary Care Physician (PCP) and Pharmacist who directs all careResponsibilities:coordinating routine medical caremaking referrals to specialists as necessaryarrange 24 hour coverage when not availableexplain to members all procedures to follow when office is closed or there is an urgent or emergency situationFor members who abuse or over utilize their Medicaid plan, the could be placed into our Client Medical Management program. Example- Mary goes to the emergency room every day at 2:00 PM stating she has a headache. The member should be seeking treatment at her physician’s office. Also members who pharmacy shop- seeking prescriptions from various drugstores. These members will be assigned a primary care physician an designated drugstore.Read slide..For CMM members seeking non-emergency treatment at your facility, a referral from the PCP will be required in order for Medicaid to pay for the services.
41 Client Medical Management - CMM Services received by a CMM member not provided by the PCP will be reimbursed only:in a medical emergency/delay in treatment may cause death, lasting injury or harmon written referral from PCP using the Practitioner Referral Form (DMAS-70), includes covering physicianscovered services excluded from CMM program requirementsIf not a medical emergency or no referral form is attached, hospital emergency room CMM claims will be denied, not paid at a reduced rateCMM patient can be billed for these non-emergency servicesIn addition to the PCP’s being required on the claim submission, for CMM members, a paper referral will also be required. Only a DMAS-70 referral is the acceptable form. The DMAS-70 must be signed and dated by the PCP to be valid. It must also list your facility and date range matching the dates billed.CMM member claims submitted for non-emergency use of the ER will be denied. This is different from the process for non-CMM members. The claims will be denied and not paid at a reduced rate.The CMM member can be billed for non-emergency use of the ER if the PCP refuses to give the facility a referral.41
42 AliensSection 1903v of the Social Security Act requires Medicaid to cover emergency services for specified aliens when the services are provided in an emergency room or inpatient hospital setting.Hospital outpatient follow-up visits or physician office visits are not included in the covered services.Read slide
43 Aliens Emergency medical treatment only Eligibility requests should be sent to the local DSSEmergency Medical Certification form required for claim submissionThis process is usually handled after treatment is rendered. The medical records will be sent to the local DSS as part of the application process. DSS send the medical records to DMAS for review and approval. Once approved, only the treatment provided during the approved medical emergency time period will be consider for benefits.Stroke, accident, heart attack are examples of a medical emergencyChild birth is consider a medical emergency- not false labor and not sterilization. Alien claims submitted with sterilization will be denied.
44 Aliens Emergency room care Physician services Covered services must meet emergency treatment criteria and are limited to :Emergency room carePhysician servicesInpatient hospitalization not to exceed limits established for other Medicaid recipientsAmbulance service to the emergency roomInpatient and outpatient pharmacy services related to the emergency treatmentIt is important to note that no follow up treatment or x-rays will be considered covered services.
45 Early Periodic Screening Diagnosis and Treatment - EPSDT The EPSDT Program is Medicaid’s comprehensive and preventative child health program for individuals under the age of 21.Federal law requires a broad range of outreach, coordination, and health services under EPSDT distinct from general state Medicaid requirements.The goal of EPSDT is to identify and treat health problems as early as possible.EPSDT provides examination and treatment at no cost to the individual.Read slide
46 Early Periodic Screening Diagnosis and Treatment - EPSDT For individuals under age 21, EPSDT must include the services listed below-Screening services, which encompass all of the following services:Comprehensive health and developmental historyComprehensive unclothed physical examAppropriate immunizations according to age and health historyLaboratory tests (including blood lead screening)Health educationRead slide
47 Qualified Medicare Beneficiaries- QMB Eligible only for Medicaid payment of Medicare premiums, deductibles, coinsurance and Medicare Advantage Plan copays.Medicaid will consider the Medicare deductibles, coinsurance and copays for benefits.If Medicare does not cover the service, the service cannot be billed to Medicaid.Read slideFor members with this benefit package- if Medicare does not cover the service, Medicaid will not cover the service.When verifying eligibility on MediCall- this plan will be identified as QMB onlyFor the online system, the line of coverage will readMED DED & COINSThere will be no line of coverage for Fee-For-Service
48 Qualified Medicare Beneficiaries- QMB Extended This group is eligible for Medicaid coverage of premiums, deductibles, coinsurance and Medicare Advantage Plans copays, plus all other Medicaid-covered services.Medicaid will consider the Medicare deductibles, coinsurance and copays for benefits.Members are also eligible for all Medicaid covered services.Members with this benefit package qualify for Medicaid to pay the Medicare part B premium, we will consider the Medicare deductible, coinsurance and if in a Medicare Advantage plan- also copays.The extended means this member is eligible for all Medicaid covered services.
49 Medicare Advantage Plans VA Medicaid handles and processes Medicare Advantage Plans the same way as traditional Medicare.DMAS does not process the Medicare Advantage Plans as Third Party Liability (TPL)Advantage Plan deductible, copay or coinsurance amounts submitted, will be considered by VA Medicaid for paymentRead slide
50 Special Low-Income Beneficiaries- SLMB This group is only eligible for Medicaid coverage of the Medicare Part B premium only.The member will have a Medicaid number, but will not received a Medicaid card.Medicaid will not cover any medical services for this member.Members with this benefit package have been approved to have Medicaid pay their part b Medicare premiums only. This member will not receive a Medicaid card, but will have a number in our system. We are telling about this because the member may not understand and be under the false impression that Medicaid will pay for their medical care. When this coverage us identified- no payment will be made to you for medical treatment.
51 Plan First Medicaid fee-for-service family planning waiver program Men and women ages 19 years and older may be eligibleParticipant income must be less than or equal to 133% of federal poverty levelMust meet citizenship and identity requirementsRead Slide
52 Plan FirstPlan First includes coverage of those services necessary to prevent or delay a pregnancyFamily planning does not include counseling about, recommendations for or performance of abortions, hysterectomies or procedures performed for medical reasons such as the removal of intrauterine devices due to infections.Read slideMembers enrolled in Plan First will not be covered for treatment of any medical condition. It the member develops an infection due to an intrauterine device, treatment of the infection is not considered a service for which Medicaid will pay. Payment will be only considered for services to prevent or delay pregnancy.Facility charges related to sterilization can be considered. A hysterectomy is not a sterilization procedure and any related costs would not be covered for a Plan First member.
53 Plan First Not eligible for the waiver: Individuals who have major medical insuranceIndividuals who are eligible for full Medicaid benefits coverageIndividuals who have had a sterilization procedureRead slide
54 Plan First- Covered Services Plan First covers routine and periodic family planning office visits and related services.Medicaid will only reimburse approved procedure codes and the code must be accompanied with a V25 category (family planning) as a primary diagnosis on the claim.Please review the Plan First manual, Chapter IV for codes.Read slideThe Plan First manual has a list of covered procedures and diagnosis codes.Only these codes are acceptable when billed for a Plan First member
55 Spend DownMedicaid applicants whose income is over the Medicaid limit, the applicant may become eligible for a limited period of Medicaid coverage if all other eligibility factors are met.This process is called a “spend-down”.The applicant’s medical expenses must equal or exceed the difference between his or her income and the Medicaid income limit.Read Slide
56 Spend DownIf the allowable expenses of the applicant equal this spend-down amount before the end of a budget period (six months for non-institutionalized individuals or a one month period for institutionalized individuals), the applicant may receive a limited period of Medicaid coverage which will stop at the end of the budget period.Eligibility must be re-determined in order to establish eligibility in subsequent budget periods.Mary who is sick goes to local DSS to apply for Medicaid. She is informed that she is $3000 over the limit to be Medicaid eligible. Once Mary has incurred $3000 worth of medical expenses, she must bring the bills to DSS. Mary gets sick, comes to your facility stays 3 days. The bill is $3000. She takes her hospital bill to DSS. She has met the limit. Your facility bill cannot be billed to Medicaid. Mary is financially responsible for paying it. It is your bill which allowed her to met the income limits for Medicaid eligibility for the remainder of the six month period. Mary is admitted to your hospital 4 weeks later. She is now Medicaid eligible and qualifies for coverage. Her health improves. At the end of her Medicaid eligibility period, Mary applies for coverage again. She is $3000 over the income limit. The process starts again. Eligibility verification is so important when Medicaid is involved.
57 Medicaid WaiverThere are key requirements with which a state’s Medicaid program must comply.These basic requirements govern Medicaid programs nationwide.State must make services available to individuals on a comparable basis.State must guarantee members freedom of choice in selecting service providers when obtaining Medicaid services.State must make Medicaid services available statewide and provide that individuals have ready access to them.Read Slide
58 Medicaid WaiverIn some cases the states may request waivers of some of these requirements.Medicaid home and community-based service waiver programs operate under these rules.The waiver allows Medicaid to pay for additional services not covered by traditional Medicaid.The state has the ability to decide who gets funded for what service (criteria for eligibility and coverage).Read slideAgain we want you to understand the coverage information share thru our verification options
59 VA Medicaid Waivers Alzheimer’s Assisted Living Waiver Assisted Technology and Environmental ModificationsElderly or Disabled With Consumer DirectionHIV/AIDSIndividual and Family Developmental Supports (IFDDS)Intellectual Disabilities/Mental Retardation (ID/MR)Technology Assisted (Tech)Here is a list of the current VA Medicaid WaiversRead slide
60 Temporary Detention Order The General Assembly directed DMAS to process all requests for payment of services rendered as a request of Civil/Criminal Mental Temporary Detention Orders (TDO) effective July 1, 1995.Any magistrate may, within the specified guidelines, issue a temporary detention.A law enforcement officer executes Temporary Detention Orders.Employee of the community services board or its designee shall determine the facility of temporary detention for all individuals.Read slide
61 Temporary Detention Order The duration of the temporary detention shall not exceed 48 hours prior to a hearing.If the forty-eight hour period herein specified terminated on a Saturday or Sunday, or a legal holiday, such person shall be detained until the next day which is not a Saturday, Sunday or legal holiday, but in no event may be detained longer than 96 hours.Read slideAlso if the patient stays more than the allotted time due to inclement weather, please advise as part of your claim submission. Special consideration may be allowed for weather issues.
62 Temporary Detention Order Hospitals and physicians must submit claims to DMAS as the result of issuance by a court.DMAS will accept only the original claim forms.All TDO submissions must have the TDO form attached to the claim with the pre-printed case identification number.Failure to provide the TDO form will result in claims being returned to the provider for incomplete information.The Execution section on the TDO form must be signed by the law enforcement officer and dated to be valid.Read slide62
63 Temporary Detention Order Processing of TDO claims includes both Medicaid-eligible and non-Medicaid eligible patients.TDO is the payer of last resort and attempts must always be made to first bill the primary carrier , including Medicaid, prior to billing TDO.Each claim will be researched for coverage by another resource.If the patient has other resources, the claim will be returned to the provider.The returned claim will have a letter attached, advising the provider to bill primary payer.Read slide
64 Fiscal Agent Transition Updates and ChangesWe just want to pass on some additional information regarding the fiscal agent transition.
65 Paper Claims Process for submitting claims remains the same Continue to send to the appropriate P.O. BoxClaims receivedBy close of business 6/21 will process as usualInquiry on clean claims should be available on or after 6/28Should be on 7/2 remitFrom 6/22-6/27 will be held and processed on 6/28Inquiry on clean claims will not be available until at least 6/28Will not be on remit until 7/9The process for submitting claims to DMAS will not change, nor will the billing addresses. However, due to the need to transition from FHS to ACS there will be a slight delay in processing. Claims received by close of business on June 21st will be processed as usual, clean claims should be available for inquiry on or after June 28 and be on the July 2nd remit. Those claims received from June 22nd to the 27th will be held and not submitted for processing until June 28th, claims held will not be available for inquiry until at least June 28th and will not be on your remittance advice until July 9th.Processing of claims should return to normal timeframes beginning June 28th.65
66 Paper Claims Requirements Claims must be submitted on the original red and white claim formThe National Uniform Billing Committee and National Uniform Claims Committee standards and specifications must be met for margins, formats, and fonts:10 pitch Pica type6 lines per in vertical10 characters per inchDMAS requires that all paper claims be submitted on an original red and white claim form because the individual is attesting to the statement made on the reverse side of the form and these statements become part of the original billing invoice. DMAS follows the National Uniform Billing Committee (NUBC) and the National Uniform Claims Committee (NUCC) standards and specifications for format, fonts and margins for all paper claims.
67 Electronic Data Interchange (EDI) EDI Claims received by 5:00 pm June 24Will process as usualShould be available for inquiry 6/28Should be on 7/9 remitEDI Claims received after 5:00 pm June 24Will be processed starting June 28Electronic Data Interchange or EDI claims received by 5pm on Thursday June 24 will be processed as usual. These claims should be available for inquiry by June 28 and should be on your remittance of July 9th. EDI files received after 5pm on June 24th will be processed starting June 28th.
68 Electronic Data Interchange (EDI) RequirementsYou or your designee must have established and been given aNew user IDNew passwordNew File Transfer Protocol (FTP)Please ensure that your or your designee have established and been give an new user ID, password and File Transfer Protocol or FTP address to which files will need to be sent. All of these will be required to submit claims through EDI.
69 Trader Partner Testing Communications validation testing is being conductedClearinghousesService centersSoftware vendorsLetter sent to all trading partners containing information regarding testing of EDI batch processingACS is conducting communications validation tests with clearinghouses, service centers and other software vendors to ensure that on the first day of the transition you will be able to conduct business with ACS just as you do with the our fiscal agent today. A letter containing information regarding testing of EDI batch processing has been sent from ACS to all trading partners under a separate cover.
70 Trader Partner Testing If you or your designee has not received this letterfour position submitter IDcontact informationPlease send an at the address given if you have not received this letter from ACS. Be sure and document your four position submitter ID and contact information in the . A copy of the letter can be found on the Fiscal Agent Transition page on the DMAS website
72 MAIL CMS-1450 FORMS TO: DEPARTMENT OF MEDICAL ASSISTANCE SERVICES FacilityP. O. Box 27443Richmond, Virginia
73 TIMELY FILINGALL CLAIMS MUST BE SUBMITTED AND PROCESSED WITHIN ONE YEAR FROM THE DATE OF SERVICEEXCEPTIONSRetroactive/Delayed EligibilityDenied ClaimsNO EXCEPTIONSAccidentsOther Primary Insurance
74 TIMELY FILINGSubmit claims with documentation attached (to the back of claim) explaining the reason for delayed submission
75 RED & WHITE CMS-1450 CLAIM FORM: Use ONLY the ORIGINAL Invoice Photocopies are not AcceptableComputer generated claims must match NUBC uniform standards75
76 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.
77 Our Neighborhood Hospital 121 Friendly Street Locator 1: Provider Name, Address and Phone Number1Our Neighborhood Hospital121 Friendly StreetAny TownVA77
78 Locators 3a:Patient Control Number 3b: Medical Record Number CNTL #ABCDEFGH012b. MEDREC. #HGFEDCBAPatient Control Number (not to exceed 20 characters) and Medical/Health Record Number (not to exceed 24 characters) are required for all UB-04 claim submissions.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.78
79 0111 Locator 4: Type of Bill Original Bill 4 TYPE OF BILL Inpatient HospitalOriginal Bill0111Enter the code as appropriate.Claims submitted without the required four digit bill type will be denied.79
80 Locator 4: Enter the code as appropriate. Valid codes for VA MedicaidInpatient Bill Types0111- Original Inpatient Hospital Invoice0112- Interim Inpatient Hospital Invoice*0113- Continuing Inpatient Hospital Invoice*0114- Last Inpatient Hospital Invoice *0117- Adjustment Inpatient Hospital0118- Void Inpatient Hospital InvoiceOnly “APROVED” claims can be adjusted or voided8012
81 *The proper use of these codes will enable DMAS to reassemble cycle-billed claims to form DRG cases for purposes of DRG payment calculations and cost settlement.
82 0131 Locator 4: Type of Bill Original Bill 4 TYPE OF BILL OutpatientHospitalOriginal Bill01310131- Original Outpatient Invoice0137- Adjustment Outpatient Invoice0138- Void Outpatient Invoice82
83 Locator 6: Statement Covered Period For hospital admissions, the billing cycle for general medical surgical services has been expanded to a minimum of 120 days for both children and adults, except for psychiatric services.Interim claims (bill types 0112 or 0113) submitted with less than 120 days will be denied.Bill types 0111 or 0114 submitted with greater than 120 days will be denied.These guidelines also apply to SLH claims.
84 030710 030710 Locator 6: Statement Covers Period FROM THROUGH030710030710Enter the beginning and ending service datesreflected by this invoice (include both coverednon-covered days). Use both “from” and “to”for a single day.84
85 Last First M Locator 8: Patient Name/Identifier b Enter the last name, first name and middle initial of the patient.85
86 10011980 Locator 10: Patient Birthdate 10 BIRTHDATE Enter the date of birth of the patient using thefollowing format - MMDDYYYY.86
87 M = Male; F = Female; U = Unknown Locator 11: Sex11 SEXFEnter the sex of the patient as recorded atadmission, outpatient or start of care.M = Male; F = Female; U = Unknown87
88 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:IP- Day admitted OP- Day episode of care began
89 Locator 12:Admission/Start of CareADMISSION12 DATE03051089
90 22 Locator 13: Admission Hour ADMISSION 13 HR Enter the hour during which the patient wasadmitted for inpatient or outpatient care.NOTE: Military time is used as defined by NUBC.90
91 Locator 14: Priority Type of Visit Appropriate PRIORITY TYPE codes accepted by DMAS are:CODEDESCRIPTION1Emergency2Urgent3Elective5Trauma9Information not available91
92 9 Locator 14: Priority Type of Visit ADMISSION14 TYPE9Enter the code indicating the priority of this admission /visit.92
93 Source of Referral for Admission or Visit Appropriate codes accepted by DMAS are:CodeDescription1Physician Referral2Clinic Referral4Transfer from Another Acute Care Facility5Transfer from a Skilled Nursing Facility6Transfer from Another Health Care Facility7Emergency Room8Court/Law Enforcement9Information not availableDTransfer from Hospital Inpatient in the Same Facility
94 8 Locator 15: Source of Referral for Admission/Visit 15 SRC For TDO and ECO claims, your admission source should be 8.Enter the code indicating the source of theReferral for this admission or visit.94
95 15 Locator 16: Discharge Hour 16 DHR Enter the code indicating the discharge hour ofthe patient from inpatient care.NOTE: Military time is used as defined bythe NUBC.TDO-Enter the hour the patient appeared at the Involuntary Detention Hearing.SLH-Enter the hour the patient was discharged from inpatient care.95
96 Locator 17: Patient Discharge Status Appropriate codes accepted by DMAS in claims processing:CodeDescription01Discharge to Home02Discharged/transferred to Short Term General Hospital for Inpatient Care03Discharged/transferred to SNF04Discharged/transferred to ICF05Discharged/transferred to Another Facility not Defined Elsewhere
97 Locator 17: Patient Discharge Status Appropriate codes accepted by DMAS in claims processing:CodeDescription07Left Against Medical Advice/Discontinued Care20Expired30Still a Patient50Hospice – Home51Hospice – Medical Care Facility
98 Locator 17: Patient Discharge Status CodeDescription61Discharge/transfer to Hospital Based Medicare Approved Swing Bed62Discharged/transferred to an Inpatient Rehabilitation Facility63Discharged/transferred to a Medicare Certified Long Term Care Hospital64Discharged/transferred to Nursing Facility Certified Under Medicaid but not Medicare65Discharged/transferred to Psychiatric Hospital or Psychiatric Distinct Part Unit of Hospital
99 Locator 17: Patient Status Correct reporting of patient status code will facilitate quick and accurate determination of DRG reimbursement. In particular, accurate reporting of the values 01,02,05, and 30 will be very important in DRG methodology.
100 01 Locator 17: Patient Discharge Status NOTE: If the patient was a one-day treatment, enter code “01”.17 STAT01Enter the code indicating the disposition orDischarge status of the patient at the end for theService period covered on this bill (StatementCovered Period, Locator 6).100
101 Locators 18-28: Condition Codes These codes are used by DMAS in the adjudication of claims:CodeDescription39Private Room Necessary40Same Day TransferA1EPSDTA4Family PlanningA5DisabilityA7Induced Abortion Danger to Life
102 Locators 18-28: Condition Codes These codes are used by DMAS in the adjudication of claims:CodeDescriptionAAAbortion Performed Due to RapeABAbortion Performed Due to IncestADAbortion Performed Due to Life Endangering Physical ConditionAHElective AbortionAISterilization
103 Locators 18-28: Condition Codes (Required if Applicable) 3040Enter the code (s) in alphanumeric sequenceUsed to identify conditions or events related tothis bill that may affect adjudication.NOTE: DMAS limits the number of codes to a maximum of 8 on one claim.103
104 VA Locator 29: Accident State (Conditional) ACDT STATE Enter if known, the state ( two digit PostalState Code abbreviation) where the motorvehicle accident occurred.104
105 Crossover Part A Indicator Locator 30:Crossover Part A Indicator(Required If Applicable)30CROSSOVERNOTE: DMAS is requiring for Medicare Part Acrossover claims that the word “CROSSOVER”be in this locator.105
106 Occurrence Codes and Dates Locators 31-34:Occurrence Codes and Dates(Required If Applicable)OCCURRENCECODE DATEa030110A3bEnter the code and associated date defininga significant event relating to this bill. Entercodes in alphanumeric sequence.106
107 Occurrence Codes and Span Dates (Required If Applicable) Locators 35-36:Occurrence Codes and Span Dates(Required If Applicable)OCCURRENCE SPANCODE FROM THROUGHabEnter the code and related dates that identifyan event that relates to the payment of theclaim. Enter codes in alphanumeric sequence.107
108 Locators 39-41: Value Codes and Amounts DMAS will capture the number of covered or non-covered day (s) or units for outpatient services with these required value codes:80 Enter the number of covered days for inpatient hospitalization or the number of days for re-occurring outpatient claims.81 Enter the number of non-covered days for inpatient hospitalization
109 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 benefitsNo Other CoverageBilled and Paid(Enter Amount Paid by Primary Carrier)85 Billed Not Covered/No Payment (Documentation Required)109
110 Locators 39-41: Value Codes and Amount For Part A Medicare Crossover Claims, the following codes must be used with one of the third party insurance carrier codes:A1 Deductible from Part AA2 Coinsurance from Part AOther codes may be used if applicable.
111 LOCATORS 39-41: Value Codes and Amount VALUE CODES 80 25 a 83 7841 08 CODE AMOUNTVALUE CODESCODE AMOUNT41 VALUE CODESCODE AMOUNTa83784108Abcd111
112 Locator 42: Revenue CodeEnter 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 servicesDMAS has a limit of five pages for one claimThe Total Charge revenue code (0001) should be the last line of the last page of the claim
113 Locator 42: Revenue Code 42 REV. CD. 0123 0251 0300 0330 Revenue codes are four digits, leading zero, leftjustified and should be reported in ascendingnumeric order.113
114 Outpatient Hospital Setting Billing Requirements for NDC CMS requirements related to the Deficit Reduction Act (DRA) of 2005, mandate DMAS to require hospital providers who bill drug products administered in an outpatient hospital setting to include the National Drug Code (NDC) information of the drug dispensed on all claim submissions.
115 Outpatient Hospital Setting NDC Billing Requirements The NDC information will be required on all electronic (ASC X12N:837I) and paper (Universal Billing “UB”) claim submissions.This requirement also applies to Medicare Crossover claim submissions.Outpatient hospital claims submitted without a valid NDC will have the revenue code line reduced to a non-covered service line.
116 Outpatient Hospital Setting NDC Billing Requirements Providers billing for compound medication with more than one NDC included in the medication dispensed, each applicable NDC must be submitted on a separate claim line to include both prescription and over-the-counter ingredients.Each claim line submitted with pharmacy revenue codes and will require the NDC information.
117 Outpatient Hospital Setting NDC Billing Requirements Effective 07/01/08, a valid NDC will be required for all drug products administered in an outpatient hospital setting.By definition, a valid NDC is a formatted number using the format, i.e., 5-digits, followed by 4-digits, followed by 2-digits:Each NDC must be an 11-digit code unique to the manufacturer of the specific product administered to the patient.117
118 Outpatient Hospital Setting NDC Locator 43: Billing Requirements Form Locator 43 must have N4 modifier as the first indicator in this field, the corresponding 11-digit NDC number, followed by the Unit of Measure Qualifier and the NDC unit quantity.Billing for the same medication dispensed in different packages, each package size MUST be listed separately using N4 modifier, the revenue code, and all the required information on separate lines.The DMAS system will not consider these drugs as duplicates.
119 Outpatient Hospital Setting NDC Billing Requirements If available, providers should enter the HCPCS code in Locator 44 (HCPCS/Rate/HIPPS Code) and the HCPCS units in Locator 46 (Serv Unit).DMAS will validate all HCPCS codes.Submission of an invalid HCPCS code will cause denial of the entire claim.The NDC number submitted to Medicaid must be the actual NDC number on the package or container from which the medication was administered.119
120 Locator 43: Revenue Description N UNRadiologyRadiologyEnter the standard abbreviated descriptionof the related revenue code categoriesincluded on this bill.120
121 Locator: Revenue Description R&B-2 Bed-PediatricDrugs-GenericLaboratory (Lab) GeneralEnter the standard abbreviated descriptionof the related revenue code categoriesincluded on this bill.121
122 HCPCS/Rates/HIPPS Rate Codes Locator 44:HCPCS/Rates/HIPPS Rate Codes44 HCPCS / RATE / HIPPS CODEInpatient: Enter the accommodation rate.Outpatient: Enter the applicable code.When billing for outpatient surgery, enter the CPTcode on the same line as revenue code 0490.112122
123 030510 Locator 45: Service Date 45 SERV. DATE Enter the date the outpatient servicewas provided.123
124 Locator 46: Service Units Inpatient: Enter the total number of coveredaccommodation days or ancillary units of service where appropriate.46 SERV. UNITS612Outpatient: Enter the unit (s) of service forphysical therapy, occupational therapyor speech-language pathology visit or session(1 visit = 1 unit, even if more than 1 modality is done).124
125 1755 75 29 305 Locator 47: Total Charges 47 TOTAL CHARGES Enter the total charge (s) for the primary payer pertaining to the related revenue code for the current billing period as entered in the statement covers period. Total charges include both covered and non-covered charges Note: Use code “0001” for TOTAL.125
126 75 00 Locator 48: Non-Covered Charges 48 NON-COVERED CHARGES To reflect the non-covered charges for theprimary payer as it pertains to the relatedrevenue code.126
127 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.
128 Locator 50: Payer Name Medicaid 50 PAYER NAME A Primary Payer B Enter the secondarypayer identification,if applicable.C Enter the tertiarypayer if applicable.128
129 Providers must list their NPI in this field. Locator 56: NPINational Provider Identifier56 NPIProviders must list their NPI in this field.129
130 Locator 58: Insured’s Name Virginia J. MemberABCEnter the name of the insured person covered bythe payer in locator 50. The name on the Medicaidline must correspond with the member namewhen eligibility is verified.130
131 Patient’s Relationship to Insured Locator: 59Patient’s Relationship to InsuredNote: appropriate codes accepted by DMAS are:CodeDescription01Spouse18Self19Child21Unknown39Organ Donor40Cadaver Donor53Life PartnerG8Other Relationship
132 18 Locator 59: Patient’s Relationship to Insured 52 REL. INFO18Enter the code indicating the relationship ofthe insured to the patient.132
133 012345678910 Locator 60: Insured’s Unique Identification 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.
134 Enter the 11 digit Service Authorization (SA) number Locator 63:Treatment Authorization Codes63 TREATMENT AUTHORIZATION CODESABEnter the 11 digit Service Authorization (SA) numberassigned by KePRO for the appropriate inpatient and outpatient services as required by Virginia Medicaid.134
135 Locator 64: Document Control Number 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.
136 2009363123456701 Locator 64: Document Control Number The control number (ICN) assigned to the original bill by Virginia Medicaid as part of their internal claims reference number. Only required to adjust or void previously approved claims.91
137 9 Locator 66: Diagnosis and Procedure Code Qualifier (ICD Version Indicator)66DX9The qualifier that denotes the version of theInternational Classification of Diseases. Qualifier = 9 for the Ninth Revision.NOTE: Virginia Medicaid currently only accepts a 9 in this locator.137
138 Locator 67 Principal Diagnosis Code Locators 67A-Q 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, orthe diagnosis was clearly present, but not diagnosed, until after the admission took place orwas a condition that developed during an outpatient encounter
139 Locators 67 A-Q: Present on Admission (POA) Indicator The POA indicator should be listed in the shaded area. This field is required for hospitals, (06/30/09 Memo). Reporting codes are:CODE DEFINITIONY YESN NOU No information in the recordW Clinically undetermined139
140 67 A I J K L Locator 67: Principal Diagnosis Code Locators A-Q Present on Admission (POA) Indicator67ABCIJKLEnter the diagnosis codes corresponding to allconditions that coexist at the time of admission,that develop subsequently, or that affect thetreatment received and/or the length of stay.NOTE: Do not use decimals.140
141 4019 Locator 69: Admitting Diagnosis ADMIT DX Enter the diagnosis code describing thepatient’s diagnosis at the time of admission.NOTE: Must be a current ICD-9 code. Do notuse decimals.141
142 Patient’s Reason for Visit Locator 70a-c:Patient’s Reason for Visit(Required If Applicable)34501bc70 PATIENTREASON DXEnter the diagnosis code describing thepatient’s reason for visit at the time ofoutpatient registration.142
143 External Cause of Injury Locator 72:External Cause of Injury(Required If Applicable)E895c72ECIbEnter the diagnosis code pertaining to externalcauses of injuries, poisoning, or adverse effect.143
144 Locator 74: Principal Procedure Code and Date Note: for outpatient claims, a procedure code must appear in this locator when revenue codes , , , and (if covered by Medicaid) are used in Locator 42 or the claim will be rejected.For inpatient claims, a procedure code or one of the diagnosis codes of V64.1 through V64.3 must appear in this locator (or Locator 67) when revenue codes are used in Locator 42 or the claim will be rejected.144
145 030510 6501 Locator 74: Principal Procedure Code and Date (Required If Applicable)PRINCIPAL PROCEDURECODE DATE0305106501Enter the ICD-9-CM procedure code thatidentifies the inpatient principal procedurePerformed at the claim level during the periodCovered by this bill and the corresponding date.145
146 6601 030710 Locator 74a-e: Other Procedure Codes and Date (Required If Applicable)OTHER PROCEDURECODE DATE6601030710Enter the ICD-9-CM procedure codes identifyingall significant procedures other than the principal procedure and the dates on which the procedures were performed. Report those that are most important for the episode of care and specifically any therapeutic procedures closely related to the principal diagnosis.146
147 1234567890 Locator 76: Attending Provider NPIEnter the NPI for the physician who has overall responsibility for the patient’s medical care and treatment reported on this claim.147
148 1234567890 Locator 77: Attending Provider 77 OPERATINGNPIEnter the NPI of the individual with the primary responsibility for performing the surgical procedure (s).148
149 Locators 78-79: Other Provider Name and Identifiers This field will be used to list the NPI for the Primary Care Physician (PCP) who authorized the inpatient stay or outpatient visit.For MEDALLION patients referred to an outpatient clinic, enter the NPI for the PCP who authorized the outpatient visit.This information is required for all MEDALLION patients treated for non-emergency services.
150 Locators 78-79: Other Provider Name and Identifiers For Client Medical Management (CMM) patients referred to the emergency room by the PCP or admitted for non-emergency inpatient stay, enter the provider’s ID number and attach the Practitioner Referral Form (DMAS-70).
151 1234567890 Locator 78: Other Provider Name and Identifier NPI78 OTHERThe NPI of the Primary Care Physician is required for Medallion and Client Medical Management (CMM) patients admitted for non-emergency treatment.151
152 Locator 80: Remarks Field Enter additional information necessary toadjudicate 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.152
153 TAXONOMY Locator 81: Code-Code Field 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., Rehabilitative or Psychiatric units within an acute care facility, Home Health Agency with multiple locations).
154 TAXONOMY 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.
155 Locator 83: Code-Code Field 81CCabcdB N00000XEnter the provider taxonomy code for thebilling provider when the adjudication of theclaim is known to be impacted.155
156 DMAS Service Types That May Require a Taxonomy Codes Service Type DescriptionTaxonomy Code (s)Hospital, General282N00000XLaboratory291U00000XRehabilitation Unit of Hosp.273Y00000XPsychiatric Unit of Hospital273R00000XPrivate Mental Hospital (IP)283Q00000XRehabilitation Hospital283X00000X156
157 Outpatient SurgeryFor elective outpatient surgical procedures which require Service Authorization (SA) by Medicaid Medical Support (Physician’s Manual, Appendix B), submit paper claim.Contact the surgeon and request a copy of his SA letter ( the facility services do not required service authorization).Attach a copy of the SA letter to the back of your claim form.Do not put the Physician’s SA # on your claim.Charges- including facility- for elective surgery not approved with a service authorization, will be denied.157
159 Medicare Primary Billing Instructions for CMS-1450 The word “CROSSOVER” must be entered in Block 30 of the UB-04 to identify Medicare crossover claims.Coordination of Benefits (COB) codes 83 and 85 must be accurately printed in Blocks of the UB-04.
160 Medicare Primary Billing Instructions for CMS-1450 The first occurrence code 83 indicates that Medicare paid and there should always be a dollar value associated with this code. The A1 indicates Medicare deductible and code A2 indicates Medicare coinsurance
161 Medicare Primary: Blocks 39-41 Line a 83 = Billed and Paid (enter amount paid by Medicare or other insurance).Line a A1 = Deductible Payer A. (enter Medicare Deductible Amount listed on the EOMB).Line a A2 = Co-Insurance Payer A. (enter Medicare Co-Insurance amount listed on the EOMB).
162 Medicare Primary Billing Instructions for CMS-1450 Note: Complete all information in Locators 39a through 41a first (payments by Medicare or payments by other insurance) before entering information in 39b through 41b locators etc.COB code 85 is to be used when another insurance carrier is billed and there is no payment from that carrier.For the deductibles and co-insurance due from any other carrier (s) (not Medicare) the code for reporting the amount paid is B1 for the deductibles and B2 for the coinsurance.162
163 Medicare Exhaust Days MEDICARE PRIMARY/Days Exhausted Service authorization from KePRO is required.Proof of exhausted Medicare days must be submitted with service authorization request.
164 Medicare Exhaust Days All days must be billed. Initial stay less than 120 days, bill type 0111.First 120 days bill type 0112 – next 120 days bill type 0113 – continue bill type 0113 for any additional 120 day periods.Final bill type 0114.
165 Medicare Exhaust DaysProviders should list the amount Medicare paid on the 0112 bill type (less than 120 days list payment on 0111 bill type).Medicare payment should be listed in Block 39a and use COB code 83 (billed and paid).
166 Medicare Exhaust DaysDO NOT WRITE the word CROSSOVER in Block 30 (Medicare is exhausted and the days billed to Medicaid were not paid by Medicare)Block 80- providers MUST put write a statement MEDICARE DAYS EXHAUSTED and attach something showing Medicare are exhausted (Medicare EOB).
167 Medicare Exhaust DaysIf Medicaid has considered a crossover claim for deductible and coinsurance on days Medicare paid or any Part B charges-If the provider keeps all charges on the claim submitted for Medicare Exhaust days, all payments must be listed.If the provider deletes Part B charges, do not list any Part B payment amounts.
168 Special NoteIf the Medicaid member does not have Part A coverage, the COB code should be 82 (No Other Coverage).
169 Department of Medical Assistance Services THANK YOU