Presentation on theme: "Department of Medical Assistance Services Medicaid 101 www.dmas.virginia.gov."— Presentation transcript:
Department of Medical Assistance Services Medicaid 101
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. 2
4 DMAS Website Current, most up-to-date information on Virginia Medicaid programs Provider memos available for review Access to Medicaid manuals 50 Common Error Reason Codes with Resolutions Numeric Insurance Code List Primary Carrier Coverage Code List
5 DMAS Website Financial Reason Code Description List Hospital DRG Rates Medicaid Forms 2010 Medicaid/FAMIS-PLUS Handbook
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 exclusion Medicaid providers may be subject overpayment liability and civil monetary penalties when they do not abide by this Federal Regulation
8 This ban includes payment for administrative and management services not directly related to patient care Providers are required to identify excluded individuals and entities This ensures that DMAS is not paying any excluded individuals or entities for services rendered Excluded Individual/Entities
9 How to Ensure Program Integrity Screen all employees and contractors to determine whether they have been excluded Search HS-OIG List of Excluded Individuals/Entities (LEIE) website monthly Immediately report to DMAS any exclusion information discovered
10 Reporting Discoveries are to be sent in writing to the address below and should include the: –individual or business name –provider identification number State action, if any, has been taken DMAS Attn: Program Integrity/Exclusions 600 E. Broad St. Ste 1300 Richmond, VA 23219
11 Accessing the LEIE HHS-OIG maintains the LEIE Provides information about parties excluded from participation in Medicare, Medicaid and all other Federal healthcare programs The online database is located at
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.
13 DOB: 05/09/1964 F CARD# 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
14 Medicaid Verification Options MediCall Medicaid Web Portal
15 MediCall/Medicaid Web Portal Information Available Medicaid member eligibility/benefit verification Service limit information Claim status Service authorization Provider check log Primary Payer Information Medallion Participation Managed Care Organization Assignment
16 Copay Indicators Code A –Under 21- No copay exists Code B –Long Term Care, Home or Community Based Waiver Services, Hospice-No copay Code C –All other members – collect any/all applicable copays
17 Copay Exemptions Members in managed care may not have copays Pregnancy related/family planning services Emergency services
Copay Amounts Inpatient hospital $ per admission Outpatient hospital clinic $3.00 per visit Clinic visit $1.00 per visit Physician office visit $1.00 per visit Other physician visit $3.00 per visit 18
19 General Exclusion Payment 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.
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.
22 Medicaid Web Portal Web-based eligibility verification option –Free of Charge. –Information received in “real time”. –Secure –Fully HIPAA compliant
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 Status –Payment History –Remittance Advices –Service Authorization
Registration Process First Time Users –Go to –Establish an user ID and password –By registering you are acknowledging yourself as a staff member with administrative rights for the organization Established Users- Delegated Administrators – will receive a letter containing their NPI and instructions on accessing the Web Portal –must access the Web Portal and change their temporary password no later than June 27, 2010 –will be able to add new users beginning June 28,
25 ACS Web Registration Support Call Center Questions regarding new user registration, existing user access letter, or temporary password – –Available after June 8, 2010 –8 am – 5 pm Monday thru Friday –No holidays
26 Key Dates and Times May 26 th –New registration to FHS/UAC discontinued Through June 27 th –Current FHS/UAC users can continue to request password resets, routine maintenance, or access information as normal June 27 th –Access to ARS via FHS/UAC will be discontinued
27 Key Dates and Times June 28 th –new registration and users can be added via the new Virginia Medicaid Web Portal –access to eligibility and claims information will be available in the new Virginia Medicaid Web Portal at 7:01 am
29 Provider Enrollment NPI enrollment, EFT sign-up, update facility contact and , change of address or phone number: Provider Enrollment Unit P. O. Box Richmond, VA Fax
Medicaid Programs/ Benefit Packages
31 Medicaid Programs Medicaid Fee-for- Service No Primary Care Physician (PCP) No mandatory referral from the PCP. Medallion Primary Care Physician who directs all care. PCP referral required for all non-emergency services.
32 Medicaid Programs FAMIS –Medicaid program for children under age 19 –First 30 days coverage provided under the FAMIS fee-for-service program –Mandatory Managed Care Organization assignment (where available) after the initial 30 days of coverage
33 Medicaid Programs FAMIS MOMS –For pregnant women with incomes above the Medicaid income guidelines –Managed Care Organization assignment rules same as FAMIS –Apply thru local Department of Social Services or Central Processing Unit –Baby is not covered until application submitted and approved
34 Medallion II MCO ID Cards Issued by the Managed Care Organizations Medicaid member will have both MCO and Medicaid cards Eligibility verification is a REQUIREMENT Each verification option will give the MCO enrollment information if applicable
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.
36 Medallion II MCO ID Cards CareNet identifies the Southern Health Services card for Medicaid members. AMERIGROUP of Virginia is for Medicaid members.
Virginia Medicaid MCO Contacts Medicaid HMO PlanTelephone Number Anthem HealthKeepers Plus Optima Family Care Virginia Premier CareNet AMERIGROUP of Virginia
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 15 th 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.
40 Client Medical Management- CMM Mandatory Primary Care Physician (PCP) and Pharmacist who directs all care Responsibilities: –coordinating routine medical care –making referrals to specialists as necessary –arrange 24 hour coverage when not available –explain to members all procedures to follow when office is closed or there is an urgent or emergency situation
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 harm –on written referral from PCP using the Practitioner Referral Form (DMAS-70), includes covering physicians –covered services excluded from CMM program requirements If not a medical emergency or no referral form is attached, hospital emergency room CMM claims will be denied, not paid at a reduced rate CMM patient can be billed for these non- emergency services 41
42 Aliens Section 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.
43 Aliens Emergency medical treatment only Eligibility requests should be sent to the local DSS Emergency Medical Certification form required for claim submission
44 Aliens Covered services must meet emergency treatment criteria and are limited to : Emergency room care Physician services Inpatient hospitalization not to exceed limits established for other Medicaid recipients Ambulance service to the emergency room Inpatient and outpatient pharmacy services related to the emergency treatment
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.
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 history –Comprehensive unclothed physical exam –Appropriate immunizations according to age and health history –Laboratory tests (including blood lead screening) –Health education
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.
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.
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 payment
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.
51 Plan First Medicaid fee-for-service family planning waiver program Men and women ages 19 years and older may be eligible Participant income must be less than or equal to 133% of federal poverty level Must meet citizenship and identity requirements
52 Plan First Plan First includes coverage of those services necessary to prevent or delay a pregnancy Family 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.
53 Plan First Not eligible for the waiver: –Individuals who have major medical insurance –Individuals who are eligible for full Medicaid benefits coverage –Individuals who have had a sterilization procedure
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.
55 Spend Down Medicaid 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.
56 Spend Down If 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.
57 Medicaid Waiver There 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.
58 Medicaid Waiver In 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).
59 VA Medicaid Waivers Alzheimer’s Assisted Living Waiver Assisted Technology and Environmental Modifications Elderly or Disabled With Consumer Direction HIV/AIDS Individual and Family Developmental Supports (IFDDS) Intellectual Disabilities/Mental Retardation (ID/MR) Technology Assisted (Tech)
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, 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.
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.
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. 62
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.
Fiscal Agent Transition Updates and Changes
Paper Claims Process for submitting claims remains the same Continue to send to the appropriate P.O. Box Claims received –By close of business 6/21 will process as usual Inquiry on clean claims should be available on or after 6/28 Should be on 7/2 remit –From 6/22-6/27 will be held and processed on 6/28 Inquiry on clean claims will not be available until at least 6/28 Will not be on remit until 7/9 65
66 Paper Claims Requirements Claims must be submitted on the original red and white claim form The National Uniform Billing Committee and National Uniform Claims Committee standards and specifications must be met for margins, formats, and fonts: 10 pitch Pica type 6 lines per in vertical 10 characters per inch
67 Electronic Data Interchange (EDI) EDI Claims received by 5:00 pm June 24 –Will process as usual –Should be available for inquiry 6/28 –Should be on 7/9 remit EDI Claims received after 5:00 pm June 24 –Will be processed starting June 28
68 Electronic Data Interchange (EDI) Requirements –You or your designee must have established and been given a New user ID New password New File Transfer Protocol (FTP)
69 Trader Partner Testing Communications validation testing is being conducted –Clearinghouses –Service centers –Software vendors Letter sent to all trading partners containing information regarding testing of EDI batch processing
70 Trader Partner Testing If you or your designee has not received this letter – –four position submitter ID –contact information
71 Hospital Billing Guidelines
72 MAIL CMS-1450 FORMS TO: DEPARTMENT OF MEDICAL ASSISTANCE SERVICES Facility P. O. Box Richmond, Virginia
73 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 –Accidents –Other Primary Insurance
74 TIMELY FILING Submit claims with documentation attached (to the back of claim) explaining the reason for delayed submission
CMS-1450 CLAIM FORM: Use ONLY the ORIGINAL RED & WHITE Invoice Photocopies are not Acceptable Computer generated claims must match NUBC uniform standards 75
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.
Locator 1: Provider Name, Address and Phone Number 77 1 Our Neighborhood Hospital 121 Friendly Street Any TownVA
3a PAT. CNTL # b. MED REC. # ABCDEFGH HGFEDCBA Patient 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. Locators 3a: Patient Control Number 3b: Medical Record Number
4 TYPE OF BILL Locator 4: Type of Bill 0111 Original Bill Inpatient Hospital 79
0111- Original Inpatient Hospital Invoice Interim Inpatient Hospital Invoice* Continuing Inpatient Hospital Invoice* Last Inpatient Hospital Invoice * Adjustment Inpatient Hospital Void Inpatient Hospital Invoice Only “APROVED” claims can be adjusted or voided Locator 4: Enter the code as appropriate. Valid codes for VA Medicaid Inpatient Bill Types 12 80
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.
4 TYPE OF BILL Locator 4: Type of Bill 0131 Original Bill Outpatient Hospital Original Outpatient Invoice Adjustment Outpatient Invoice Void Outpatient Invoice 82
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.
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 Locator 6: Statement Covers Period
b 8 PATIENT NAMEa Enter the last name, first name and middle initial of the patient. Last First M 85 Locator 8: Patient Name/Identifier
10 BIRTHDATE Enter the date of birth of the patient using the following format - MMDDYYYY Locator 10: Patient Birthdate
11 SEX Enter the sex of the patient as recorded at admission, outpatient or start of care. M = Male; F = Female; U = Unknown F 87 Locator 11: Sex
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
ADMISSION 12 DATE 89 Locator 12: Admission/Start of Care
ADMISSION 13 HR 22 Enter the hour during which the patient was admitted for inpatient or outpatient care. NOTE: Military time is used as defined by NUBC. 90 Locator 13: Admission Hour
Appropriate PRIORITY TYPE codes accepted by DMAS are: CODEDESCRIPTION 1Emergency 2Urgent 3Elective 5Trauma 9Information not available Locator 14: Priority Type of Visit 91
ADMISSION 14 TYPE 9 Enter the code indicating the priority of this admission /visit. 92 Locator 14: Priority Type of Visit
Source of Referral for Admission or Visit Appropriate codes accepted by DMAS are: CodeDescription 1Physician Referral 2Clinic Referral 4Transfer from Another Acute Care Facility 5Transfer from a Skilled Nursing Facility 6Transfer from Another Health Care Facility 7Emergency Room 8Court/Law Enforcement 9Information not available DTransfer from Hospital Inpatient in the Same Facility
8 15 SRC Enter the code indicating the source of the Referral for this admission or visit. 94 Locator 15: Source of Referral for Admission/Visit
16 DHR 15 Enter the code indicating the discharge hour of the patient from inpatient care. NOTE: Military time is used as defined by the NUBC. Locator 16: Discharge Hour 95
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
Locator 17: Patient Discharge Status Appropriate codes accepted by DMAS in claims processing: CodeDescription 07Left Against Medical Advice/Discontinued Care 20Expired 30Still a Patient 50Hospice – Home 51Hospice – Medical Care Facility
Locator 17: Patient Discharge Status CodeDescription 61Discharge/transfer to Hospital Based Medicare Approved Swing Bed 62Discharged/transferred to an Inpatient Rehabilitation Facility 63Discharged/transferred to a Medicare Certified Long Term Care Hospital 64Discharged/transferred to Nursing Facility Certified Under Medicaid but not Medicare 65Discharged/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.
17 STAT 01 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). NOTE: If the patient was a one-day treatment, enter code “01”. 100 Locator 17: Patient Discharge Status
Locators 18-28: Condition Codes These codes are used by DMAS in the adjudication of claims: CodeDescription 39Private Room Necessary 40Same Day Transfer A1EPSDT A4Family Planning A5Disability A7Induced Abortion Danger to Life
Locators 18-28: Condition Codes These codes are used by DMAS in the adjudication of claims: CodeDescription AAAbortion Performed Due to Rape ABAbortion Performed Due to Incest ADAbortion Performed Due to Life Endangering Physical Condition AHElective Abortion AISterilization
Condition Codes Enter the code (s) in alphanumeric sequence Used to identify conditions or events related to this bill that may affect adjudication. NOTE: DMAS limits the number of codes to a maximum of 8 on one claim Locators 18-28: Condition Codes (Required if Applicable)
VA 29 ACDT STATE Enter if known, the state ( two digit Postal State Code abbreviation) where the motor vehicle accident occurred. 104 Locator 29: Accident State (Conditional)
30 CROSSOVER NOTE: DMAS is requiring for Medicare Part A crossover claims that the word “CROSSOVER” be in this locator. 105 Locator 30: Crossover Part A Indicator (Required If Applicable)
31 OCCURRENCE CODE DATE Enter the code and associated date defining a significant event relating to this bill. Enter codes in alphanumeric sequence. a b A Locators 31-34: Occurrence Codes and Dates (Required If Applicable)
Enter the code and related dates that identify an event that relates to the payment of the claim. Enter codes in alphanumeric sequence. 35 OCCURRENCE SPAN CODE FROM THROUGH a b 107 Locators 35-36: Occurrence Codes and Span Dates (Required If Applicable)
108 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. 81Enter the number of non-covered days for inpatient hospitalization Locators 39-41: Value Codes and Amounts
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) 85Billed 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: A1Deductible from Part A A2Coinsurance from Part A Other codes may be used if applicable.
a b c d VALUE CODES CODE AMOUNT 40 VALUE CODES CODE AMOUNT 41 VALUE CODES CODE AMOUNT 83 A Value Codes and Amount LOCATORS 39-41:
112 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
42 REV. CD Revenue codes are four digits, leading zero, left justified and should be reported in ascending numeric order. 113 Locator 42: Revenue Code
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.
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.
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
N UN Radiology 43 DESCRIPTION Enter the standard abbreviated description of the related revenue code categories included on this bill. 120 Locator 43: Revenue Description
R&B-2 Bed-Pediatric Drugs-Generic Laboratory (Lab) General 43 DESCRIPTION Enter the standard abbreviated description of the related revenue code categories included on this bill. 121 Locator: Revenue Description
44 HCPCS / RATE / HIPPS CODE Inpatient: Enter the accommodation rate. Outpatient: Enter the applicable code. When billing for outpatient surgery, enter the CPT code on the same line as revenue code Locator 44: HCPCS/Rates/HIPPS Rate Codes 122
45 SERV. DATE Enter the date the outpatient service was provided Locator 45: Service Date
46 SERV. UNITS 6 12 Outpatient: Enter the unit (s) of service for physical therapy, occupational therapy or speech-language pathology visit or session (1 visit = 1 unit, even if more than 1 modality is done). Inpatient: Enter the total number of covered accommodation days or ancillary units of service where appropriate. 124 Locator 46: Service Units
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 Locator 47: Total Charges
48 NON-COVERED CHARGES 7500 To reflect the non-covered charges for the primary payer as it pertains to the related revenue code. 126 Locator 48: Non-Covered Charges
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.
50 PAYER NAME A Primary Payer B Enter the secondary payer identification, if applicable. C Enter the tertiary payer if applicable. 128 Medicaid Locator 50: Payer Name
56 NPI Providers must list their NPI in this field. Locator 56: NPI National Provider Identifier
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 130 Locator 58: Insured’s Name
52 REL. INFO 18 Enter the code indicating the relationship of the insured to the patient. 132 Locator 59: Patient’s Relationship to Insured
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 60: Insured’s Unique Identification
ABAB 63 TREATMENT AUTHORIZATION CODES Enter the 11 digit Service Authorization (SA) number assigned by KePRO for the appropriate inpatient and outpatient services as required by Virginia Medicaid. 134 Locator 63: Treatment Authorization Codes
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.
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 Locator 64: Document Control Number
9 66 DX The qualifier that denotes the version of the International Classification of Diseases. Qualifier = 9 for the Ninth Revision. NOTE: Virginia Medicaid currently only accepts a 9 in this locator. 137 Locator 66: Diagnosis and Procedure Code Qualifier (ICD Version Indicator)
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, 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
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 DEFINITION Y YES N NO U No information in the record W Clinically undetermined 139
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. 140 Locator 67: Principal Diagnosis Code Locators A-Q Present on Admission (POA) Indicator
69 ADMIT DX Enter the diagnosis code describing the patient’s diagnosis at the time of admission. NOTE: Must be a current ICD-9 code. Do not use decimals Locator 69: Admitting Diagnosis
34501 bc 70 PATIENT REASON DX Enter the diagnosis code describing the patient’s reason for visit at the time of outpatient registration. 142 Locator 70a-c: Patient’s Reason for Visit (Required If Applicable)
E895 c 72 ECI b Enter the diagnosis code pertaining to external causes of injuries, poisoning, or adverse effect. 143 Locator 72: External Cause of Injury (Required If Applicable)
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
PRINCIPAL PROCEDURE CODE DATE Enter the ICD-9-CM procedure code that identifies the inpatient principal procedure Performed at the claim level during the period Covered by this bill and the corresponding date Locator 74: Principal Procedure Code and Date (Required If Applicable)
a. OTHER PROCEDURE CODE DATE Enter the ICD-9-CM procedure codes identifying all 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 Locator 74a-e: Other Procedure Codes and Date (Required If Applicable)
76 ATTENDINGNPI Enter the NPI for the physician who has overall responsibility for the patient’s medical care and treatment reported on this claim. 147 Locator 76: Attending Provider
77 OPERATINGNPI Enter the NPI of the individual with the primary responsibility for performing the surgical procedure (s). 148 Locator 77: Attending Provider
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).
78 OTHER NPI The NPI of the Primary Care Physician is required for Medallion and Client Medical Management (CMM) patients admitted for non-emergency treatment. 151 Locator 78: Other Provider Name and Identifier
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. 152 Locator 80: Remarks Field
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.
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 282N00000X 155 Locator 83: Code-Code Field
DMAS Service Types That May Require a Taxonomy Codes Service Type DescriptionTaxonomy Code (s) Hospital, General282N00000X Laboratory291U00000X Rehabilitation Unit of Hosp.273Y00000X Psychiatric Unit of Hospital273R00000X Private Mental Hospital (IP)283Q00000X Rehabilitation Hospital283X00000X 156
Outpatient Surgery For 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
Medicare Primary Crossover Claims
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 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).
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 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 Days Providers 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 Days DO 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 Days If 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 Note If the Medicaid member does not have Part A coverage, the COB code should be 82 (No Other Coverage).
THANK YOU Department of Medical Assistance Services