1. 04/25/07 1 DMAS Division of Health Care Services Billing for Emergency and Non- Emergency Transportation Services With Dates of Service October 31, 2009 and Before

2. 2 Presentation Outline  Health Insurance Claim Form - 1500  Emergency Ground & Neonatal Ambulance Transportation  Emergency Air Ambulance Transportation  Title XVIII (Medicare) Deductible and Coinsurance Invoice  DMAS 30-R  DMAS 31-R  Resources  TrailBlazer  Revs Line  DMAS Website  Contact Information  Questions

3. 3 Health Insurance Claim Form CMS 1500 What’s Changed? We want to remind everyone that this is not a change in policy. Effective April 1, Cross Over claims will be processed using the correct manner. Medicaid reimbursement for these services is less than 80% of the Medicare payment level, Medicare crossover claims will be paid at $0.00 with the claims edit 364 (“Exceeds Medicaid Allowed Amount.”) Use Font size 10 or larger Mail all Ground Ambulance claims to First Health, address at end of presentation Most Common Mistakes Using a 2-code system (One code for base rate and second code for mileage) Trying to bill using CPT/HCPCS mileage codes with: A0425 A0435 A0436 Block 10b, make sure and check yes for auto accidents Block 10c, make sure to mark for other accidents

4. 4 Eligibility and Claims status information DMAS offers a web-based Internet option (ARS) to access information regarding Medicaid or FAMIS eligibility, claims status, check status, service limits, prior authorization, and pharmacy prescriber identification. The website address the use to enroll for access to this system is http://virginia.fhsc.com. The Medical voice response system will provide the same information and can be accessed by calling 1-800- 884-9730 or 1-800-772-9996. Both options are available at no cost to the provider. http://virginia.fhsc.com

5. 5 Transportation for Managed Care Organizations (MCO) The Virginia Medicaid Program includes enrolling eligible Medicaid recipients in Managed Care Organizations (MCO). Eligible enrollees receive emergency air ambulance, emergency ground ambulance and non-emergency transportation services through the MCO. Please contact the appropriate MCO for billing instructions.

6. 6 Billing on the CMS-1500 6

7. 7 Printing Must be RED OCR dropout ink or the exact match Should be 10-pitch Pica type, 6 lines per inch vertical and 10 characters per inch horizontal Claim has to match /line up with the original claim form

8. 8 Printing Print 100% of actual size Set page scaling to ‘none’ Margins must be exact DMAS will not reprocess claims denied for scanning issues as a result of failure to follow the above instructions

9. 9 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 Accident Cases Other Primary Insurance

10. 10 TIMELY FILING Submit claims with documentation attached explaining the reason for delayed submission You must have the word “Attachment” in Locator 10d and use modifier “22” in Locator 24D (Attachments include: Run sheets, Call sheets, Pre-hospital Patient Care Report (PPCR)

11. 11 Block 1 Enter an ‘X’ in the MEDICAID box for the Medicaid Program

12. MEDICAID (Medicaid #) Block 1 CHAMPUS (Sponsor's SSN) 1. MEDICARE (Medicare #) MEDICAID CLAIM 2. PATIENT'S NAME (Last Name, First Name, Middle Initial) 12 TRICARE

13. 1a. INSURED'S I.D. NUMBER (FOR PROGRAM IN ITEM 1) Block 1a: Recipient ID Number (Be sure to include all 12 digits) 123456789014 13

14. Block 2: Patient's Name 2. PATIENT'S NAME (Last name, First Name, Middle Initial) Smith, Sam 5. PATIENT'S ADDRESS (No., Street) 14

15. 15 Is Patient’s Condition Related To Block- 10a,10b & 10c 10a - Mark box with appropriate ‘Yes’ or ‘No’ 10b - If the condition is related to an auto accident, mark ‘Yes’ and place the postal code (i.e. VA, TN, WV) of the state in which the accident occurred. 10c - Mark box with appropriate ‘Yes’ or ‘No’

16. Block 10: Accident-Related 10. IS PATIENT'S CONDITION RELATED TO: a. EMPLOYMENT? (CURRENT OR PREVIOUS) b. AUTO ACCIDENT? c. OTHER ACCIDENT? YESNO PLACE (State) YES NO You MUST check YES or NO for a, b & c 16 WV

17. Block 10d You MUST use the word "ATTACHMENT" if documents are attached to the HCFA form. 10d. RESERVED FOR LOCAL USE ATTACHMENT 17

18. Block 11c - Insurance Plan Name or Program Name c. INSURANCE PLAN NAME OR PROGRAM NAME Other Insurance COPAY 18

19. 19 Is There Another Health Benefit Plan? Block-11d Providers should only check yes if there is another third party carrier

20. Block 11d - Is There Another Health Benefit Plan? d. IS THERE ANOTHER HEALTH BENEFIT PLAN? YES NO If yes, return to and complete item 9 a-d. 20

21. 21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY 1. 2. 3. 4. 31100 Block 21: Diagnosis Codes May enter up to 4 codes Omit decimals (List of frequently used diagnosis codes are in the Transportation Manual) 30130 21

22. 22 Blocks 24A thru 24J These blocks have been divided into open areas and a shaded red line area The shaded area is ONLY for supplemental information Instructions will be given on when the use of the shaded area is required for claims processing

23. 23 TPL Information Block 24A Qualifier ‘TPL’ will be used followed by dollars/cents amount whenever an actual payment is made by a third party carrier No spaces between the qualifier and dollars and no $ symbol used Decimal between dollars and cents is required to read paid amount correctly Must be left justified

24. 24 TPL Information Block 24A DMAS will set COB code based on the information given in locator 11d. No, or nothing indicated-no other carrier-old COB code 2 No, or nothing indicated/system has other insurance-claim will deny bill other insurance No, or nothing indicated/‘TPL’ qualifier with payment in 24a red area-old COB code 3

25. 25 TPL Information Block 24A DMAS will set COB code based on the information given in locator 11d. Yes, but nothing in 24a red area-other carrier billed and made no payment- old COB code 5 Yes, and ‘TPL’ qualifier with payment in 24a red area-other carrier billed and paid-old COB code 3

26. 24. A. DATE(S) OF SERVICE FromTo MM DD YY Block 24A : Dates of Service 03 01 06 03 01 06 1 2 Both FROM and TO dates must be completed Dates must be within same calendar month 26 TPL27.08

27. B. Place of Service Block 24B: Place of Service 41 41- Ambulance – Land Or 42- Ambulance – Air or Water “Not both” Medicaid accepts the same 2 digit CMS Place of Service codes as Medicare. 27

28. 28 Emergency Indicator-24C This locator will be used to indicate whether the procedure was an emergency DMAS will only accept a ‘Y’ for yes in this locator

29. C. EMG Block 24C: EMG Medicaid will accept a ‘Y’ in this Locator to indicate that the procedure was an emergency 29 Y

30. D. Block 24D: Procedure Codes All Claims must have modifier 22 PROCEDURES, SERVICES, OR SUPPLIES (Explain Unusual Circumstances) CPT/HCPCSMODIFIER 22A0225 30 DMAS Recognizes the Following codes: A0225 A0427 A0429 A0430 A0431

31. 21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY 1. 2. 3. 4. 34431 Block 24E: Diagnosis Code E. DIAGNOSI S POINTER 1 2963 1,2 Enter the entry identifier of the ICD-9-CM diagnosis code listed in Locator 21. To identify more than one diagnosis code, separate the indicators with a comma. 31

32. F. $ CHARGES Block 24 F: Charges Enter the usual and customary charges 32 50000

33. G. DAYS OR UNITS Block 24G: Days or Units 31 Enter the number of “loaded miles” of transport. The 31 is an example that shows loaded miles. 33

34. 34 ID.QUAL Block-24I – Shaded Area Qualifier ‘ZZ’ is to be used to indicate the taxonomy code-only when the NPI is used and only if necessary to adjudicate the claim.

35. 35 If Taxonomy codes are used Block-24J If needed the shaded red area will contain the Taxonomy codes If Taxonomy codes are used in shaded area, NPI number must be provided in the open area.

36. Fill in only if Taxonomy codes are needed Block 24I: ID. Qual. & 24J: Rendering Provider ID # 36 ZZ 3416A0800X Or 3416L0300X 3416A0800X is Air 3416L0300X is Land

37. Block 24I: ID. Qual. & 24J: Rendering Provider ID # 37 I. ID. QUAL J. RENDERING PROVIDER ID. # NPI ZZ Taxonomy # (if needed) 12345647890

38. 26. PATIENT ACCOUNT NUMBER Block 26: Patient’s Account Number (Optional) 12345678918765 38 Can not exceed 17 alphanumeric digits

39. 39 Total Charge Block 28 DMAS now requires this locator to be completed Enter the total charges for the services in 24F lines 1-6.

40. 28. TOTAL CHARGE Block 28: Total Charges 40 $

41. 29. AMOUNT PAID Block 29: Amount Paid (By Other Insurance) 41 $

42. 42 30. Balance Due Block 30: Amount Paid (By Other Insurance) 42 $

43. 31. SIGNATURE OF PHYSICIAN OR SUPPLIER INCLUDING DEGREES OR CREDENTIALS (I certify that the statements on the reverse apply to this bill and are made a part thereof.) SIGNED DATE Block 31: Signature & Date If there is a signature waiver on file, you may stamp, print, or computer-generate the signature. 43

44. 44 Service Facility Location Information Block-32 Enter information for the location where services were rendered First line-Name Second line-Address Third line-City, State, 9 digit zip code The zip code must reflect the office location where services were rendered No punctuation in the address Space between city and state Include hyphen for the 9 digit zip code

45. 45 Service Facility Location Information Block-32a-b Leave Blank

46. Block 32: Service Facility Location Information Your Local Hospital XXXX Anywhere St. Your Town, ST 12345-1456 32. SERVICE FACILITY LOCATION INFORMATION Leave Blank a.b. 46

47. 47 Billing Provider Info & PH #- Block-33 Enter the information to identify the provider that is requesting to be paid First line-Name Second line-Address Third line-City, State, 9 digit zip code No punctuation in the address Space between city and state Include hyphen for the 9 digit zip Phone number is to be entered in the area to the right of the field title, no hyphen or space used

48. 48 Billing Provider Info & PH #- Block-33a-b Enter the 10 digit NPI number of the service location in 33a. Enter ‘ZZ’ qualifier with the taxonomy code if needed, when using the NPI in 33a (example – ZZ3416L0300Z)

49. Block 33: Billing Provider Info & PH # Your Local Hospital XXXX Anywhere St. Your Town, ST 12345-1456 33. BILLING PROVIDER INFO & PH # ZZ3416L0300X (If needed) a.b. 1234567890 (123) 456-7890 49

50. 22. MEDICAID RESUBMISSION CODE ORIGINAL REF. NO. Block 22 : Adjustments and Voids 1032 xxxxxxxxxxxxxxxx Adjustment or Resubmission Code From Original RemittanceVoid Chap. V, Medicaid Transportation Manual has code list. 50

51. Block 22 : Medicaid Resubmission Codes Original Reference Number/ICN - Enter the claim reference number/ICN of the paid claim. This number may be obtained from the remittance voucher and is required to identify the claim to be adjusted. Only one claim can be adjusted on each CMS-1500 (08-05) submitted as an Adjustment Invoice. (Each line under Locator 24 is one claim.) Medicaid Resubmission of Adjustment Codes 1023 Primary Carrier has made additional payment 1024 Primary Carrier has denied payment 1025 Accommodation charge corrected 1026 Patient payment amount charged 1027 Correcting service periods 1028 Correcting procedure/service code 1029 Correcting diagnosis code 1030 Correcting charges 1031 Correcting units/visits/studies/procedures 1032 IC reconsideration of allowance, documented 1033 Correcting admitting, referring, prescribing, provider ID 1041 Incorrect Amount paid 1053 Adjustment reason is in the Misc. Category Medicaid Resubmission of Void Invoice Codes 1042 Original claim has multiple incorrect items 1044 Wrong provider identification number 1045 Wrong enrollee eligibility number 1046 Primary carrier has paid DMAS maximum allowance 1047 Duplicate carrier has paid full charge 1048 Primary carrier has paid full charge 1051 Enrollee is not my patient 1052 Miscellaneous 1060 Other insurance is available 51

52. 52 More than One Emergency Air or Ground Claim with Same Day Service Please complete second/third claim using the same billing instructions as the first. Please provide a cover letter explaining this claim is the second or third ambulance claim for the same day service. Please attach cover letter on top of second claim with attachments and mail to: DMAS Transportation Unit, Suite 1300 600 East Broad Street Richmond, Virginia 23219

53. 53 Mailing Address for Emergency Air Ambulance Claims Emergency Air Ambulance Claims with Attachments DMAS Transportation Unit, Suite 1300 600 East Broad Street Richmond, Virginia 23219 Note: All claims must have attachments that include ambulance Pre-hospital Patient Care Report (PPCR) that establish medical necessity for emergency air and ground service. Beginning and ending mileage must be included on PPCR.

54. 54 Air Ambulance Claim Procedure and Claim Reconsideration All air ambulance claims are reviewed for medical necessity of using an emergency air ambulance. Claims submitted that do not establish air ambulance medical necessity will be paid at DMAS emergency ground ambulance rates. In certain cases, the air ambulance provider may not agree with claim being paid at ground rate. The air ambulance provider can request the claim be reconsidered if the original claim was missing attachments or other medical information. For reconsideration please write a brief description or explanation on why the claim needs to be reconsidered. Please mail the letter, a new original CMS 1500 with attachment to: DMAS Transportation Unit, Suite 1300 600 East Broad Street Richmond, Virginia 23219 If reconsideration is denied, then please use the formal appeal process.

55. 55 Mailing Address for Emergency Ground Ambulance Services Emergency Ground and Neonatal Ambulance Claims with Attachments DMAS-Transportation P. O. Box 27447 Richmond, Virginia 23261-7447 Note: All claims must have attachments that include ambulance Pre-hospital Patient Care Report (PPCR) that establish medical necessity for emergency air and ground service. Beginning and ending mileage must be included on PPCR.

56. 56 Billing on the DMAS 30 & 31 56

57. 57 Title XVIII Common Mistakes Locator 7 - Other Coverage Locator 8 - Type Coverage Locator 17- Charges to Medicare Locator 18- Allowed By Medicare Locator 19- Paid By Medicare Locator 20- Deductible Locator 21- Coinsurance Locator 22- Paid By Carrier Other Than Medicare Locator 23- Patient Pay Amount (LTC Only) Locator 7 - Other Coverage Locator 8 - Type Coverage Locator 17- Charges to Medicare Locator 18- Allowed By Medicare Locator 19- Paid By Medicare Locator 20- Deductible Locator 21- Coinsurance Locator 22- Paid By Carrier Other Than Medicare Locator 23- Patient Pay Amount (LTC Only)

58. 58 CHANGES Locator 01-Billing Provider Number Locator 06-Rendering Provider Number Locator 08-Type of Coverage

59. Title XVIII- Block 01 01 Billing Provider Number Enter the billing provider NPI number 59

60. Title XVIII- Block 06 06 Rendering Provider Number Enter the rendering provider NPI number 60

61. 61 Primary Carrier Information Other Than Medicare 07 2 No Other Coverage 5 Billed No Coverage 3 Billed and Paid Title XVIII – Block 7

62. 62 Type Of Coverage Medicare B Type Coverage Medicare- Mark type of coverage “B”. 6 08 Title XVIII – Block 08

63. 63 Title XVIII- Block 17 Charges To Medicare Block 17: Charges to Medicare- Enter the total charges submitted to Medicare. 17

64. 64 Title XVIII- Block 18 Allowed By Medicare Block 18: Allowed by Medicare- Enter the amount of the charges allowed by Medicare. 18

65. 65 Title XVIII- Block 19 Paid By Medicare Block 19: Paid by Medicare- Enter the amount paid by Medicare (taken from the EOB). 19

66. 66 Title XVIII- Block 20 Deductible Block 20: Deductible- Enter the amount of the deductible (taken from the Medicare EOB). 20

67. 67 Title XVIII- Block 21 Co-Insurance Block 21: Coinsurance - Enter the amount of the coinsurance (taken from the Medicare EOB). 21

68. 68 Title XVIII- Block 22 Paid By Carrier Other Than Medicare Block 22: Paid by Carrier Other Than Medicare- Enter the payment received from the primary carrier (other than Medicare). If Code 3 is marked in Block 7, enter an amount in this block. (Do not include Medicare payments.) 22

69. 69 Title XVIII- Block 23 Patient Pay Amt. LTC Only Block 23: Patient Pay Amount, LTC Only- Leave Blank. 23

70. 70 TITLE XVIII- Adjustment Invoice DMAS-31 Block 1 Adjustment/Void Check the appropriate block Block 2 Billing Provider Number Enter the NPI of the billing provider Block 6Rendering Provider Number Enter the NPI of the rendering provider Block 2A Reference Number Enter the ICN number taken from the Remittance Voucher for the line of payment needing adjustment.

71. 71 TITLE XVIII- Adjustment Invoice Blocks 3-20 Refer to instructions for the DMAS-31 for the completion of these blocks. Remarks This section of the invoice should be used to give a brief explanation of the change needed. Signature Signature of the provider or agent and the date signed.

72. 72 REMINDERS Xeroxed copies are still unacceptable Medicaid reimburses providers for the coinsurance and deductible amounts on Medicare claims for Medicaid recipients who are dually eligible for Medicare and Medicaid. However, the amount paid by Medicaid in combination with the Medicare payment will not exceed the amount Medicaid would pay for the service if it were billed solely to Medicaid Use the same CPT/HPCS codes that were billed to Medicare (this means using the two code system) Make sure and attach Medicare EOB to 30-R & 31-R

73. 73 LogistiCare Contact Telephone Number For A0428 Non-Emergency Ambulance Non- Emergency Services LogistiCare’s Medicaid recipients toll-free reservation line: 1-866-386-8331 - This line is intended for recipients, facilities, and hospitals to schedule trips All A0428 Medicaid Non-Emergency Ambulance trips must be “pre-authorized”, arranged, and paid for by LogistiCare.

74. 74 Resources TrailBlazer – Federal Source for Medicaid and Medicare Information Website: http://www.Trailblazerhealth.com/ http://www.Trailblazerhealth.com/ Medicall Line (Eligibility) – 1-800-884-9730 or 1-800-772-9996 DMAS Internet - Providers are encouraged to monitor all Medicaid memorandums and the DMAS website for additional directions. Website: http://www.dmas.virginia.govhttp://www.dmas.virginia.gov

75. 75 Help Line HELPLINE The “HELPLINE” is available to answer questions Monday through Friday from 8:30 a.m. to 4:30 p.m., except state holidays. The “HELPLINE” numbers are: 1-804-786 -6273 Richmond area and out-of-state long distance 1-800-552-8627 All other areas (in-state, toll-free long distance) Please remember that the “HELPLINE” is for provider use only. Please have your Medicaid Provider Number or your NPI number available when you call.

76. 76 Questions?

77. 77 THANK YOU