1. Department of Medical Assistance
Services
Medicaid Eligibility Verification Options & Residential Treatment Facility CMS-1450 (UB-04) Billing Requirements September – October 2010

2. This presentation is to facilitate training of the subject matter in the Virginia Medicaid Psychiatric Services manual.
This training contains only highlights of the manuals 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.

3. Agenda 1. Medicaid Eligibility Verification Options
2. Service Authorizations
3. Timely Filing
4. CMS-1450 (UB-04) Billing Requirements

4. As a Participating Provider You Must-
Determine the patient’s identity.
Verify the patient’s age.
Verify the patient’s eligibility.
Accept, as payment in full, the amount paid by Virginia Medicaid.
Bill any and all other third party carriers.

5. COMMONWEALTH OF VIRGINIA
DEPARTMENT OF MEDICAL ASSISTANCE SERVICES
002286
V I RG I N I A J. MEMBER
DOB: 05/09/ F CARD# 00001

6. Important Contacts MediCall ARS- Web-Based Medicaid Eligibility
Provider Call Center
Provider Enrollment
Electronic Claims Coordinator

7. MediCall/ Automated Response System (ARS)
Available 24 hours a day, 7 days a week
Medicaid Eligibility Verification
Claims Status
Service Limits
Service Authorization Information
Primary Payer Information
Medallion Participation
Managed Care Organization Assignment

8. MediCall

9. Automated Response System (ARS)
Web-based eligibility verification option
Free of Charge.
Information received in “real time”.
Secure
Fully HIPAA compliant

10. Registration Process First Time Users
To establish an user ID and password go to:
By registering you are acknowledging yourself as a staff member with administrative rights for the organization

11. Registration Process Established Users- Delegated Administrators
Received a letter containing their NPI and instructions on accessing the Web Portal
Must have accessed the Web Portal and changed their temporary password
Capable of adding or deleting ARS users

12. ACS Web Registration Support Call Center
Questions regarding new user registration, existing user access letter, or temporary passwords
8 am – 5 pm Monday thru Friday
No holidays
If 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.

13. 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)

14. Provider Enrollment Provider Enrollment Unit P. O. Box 26803
NPI enrollment, EFT sign-up, update provider phone contact or change of address:
Provider Enrollment Unit
P. O. Box 26803
Richmond, VA 23261
Fax

15. ARS Prior Authorization Status Codes/Descriptions
Accepted AJ
Approved and rejected AM
Approved and modified AR
Approved/Received (New Data Received) C
Cancelled D
Denied DR
Denied/Received (Supporting Document Received) 15

16. ARS Prior Authorization Status Codes/DescriptionsJ
Rejected P
Pend PR
Pend/Received (Supporting Document Received) R
Received RJ
Received/Rejected 16

17. Service Authorization Log
Service Authorization ID Header Status
Rejected
Service Line Item Information
Procedure
Code
Begin
Date
End
Date
Authorized
Units
Authorized
Amount
Units
Used
Used
Amount
Remaining
Units
/12/ /12/
Please review the status of your service authorization. Just
because an authorization number was assigned to your request,
that does not mean it was approved. All requests are assigned
a Service Authorization ID. 17

18. Electronic Billing Electronic Claims Coordinator Phone: (866) 352-0766
Fax: (888)

19. MAIL CMS-1450 (UB-04) FORMS TO:
Virginia Medical Assistance Program
P. O. Box 27443
Richmond, Virginia

20. TIMELY FILING
ALL CLAIMS MUST BE SUBMITTED AND PROCESSED WITHIN ONE YEAR FROM THE DATE OF SERVICE
EXCEPTIONS
Retroactive/Delayed Eligibility
Denied Claims
NO EXCEPTIONS
Other Primary Insurance

21. TIMELY FILING
Submit claims with documentation attached (to the back of claim) explaining the reason for delayed submission

22. Printing
Must be RED OCR dropout ink or the exact match
Computer generated form must match/line up with National Uniform Claim Committee standard
Print 100% of actual size, set page scaling to “none”
Set page scaling to ‘none’
Margins must be exact
DMAS will not reprocess claims denied for scanning issues as a result of failure to follow the above instructions

23. RED & WHITE CMS-1450 CLAIM FORM: Use ONLY the ORIGINAL UB-04 Invoice
Photocopies are not Acceptable
Computer generated claims must match NUBC uniform standards

24. 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.

25. Our Place Facility 121 Friendly Street Any Town VA
Locator 1: Provider Name, Address and Phone Number 1
Our Place Facility
121 Friendly Street
Any Town VA 25

26. Locators 3a and 3b
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. 26

27. Locators 3a- Patient Control Number & 3b- Medical/Health Record Number
CNTL #
ABCDEFGH012
b. MED
REC. #
HGFEDCBA
Patient Control Number and Medical/Health
Record Number are required for all UB-04
claim submissions. 27

28. Locator 4 :Type of Bill Enter the code as appropriate.
The Type of Bill field is four digits with a leading zero.
Claims submitted without the required four digit bill type will be denied.

29. Locator 4: Type of Bill 0161 Original Residential Treatment Invoice
First Interim Residential Treatment Invoice
Subsequent Residential Treatment Invoice (s)
Final Residential Treatment Invoice
Adjustment Residential Treatment Invoice
Void Residential Treatment Invoice
Only approved claims can be adjusted or voided. 29

30. Locator 4: Type of Bill
0161-
Use this bill type for patients who are admitted and discharged within the same month.
For established patients who leave your facility for admission to an acute care hospital, and return within the same month, two separate claims must be submitted.

31. Example: Same Month Admit/Discharge/Re-Admit
First claim will be a Bill Type 0164, as the patient was discharged to be admitted to the acute care facility.
The second claim, billed for the patient being readmitted to your facility, will be a Bill Type 0162.

32. Admit/Discharge/Re-Admit
Patient admitted to residential facility 08/13/10. Patient developed pneumonia and was admitted to a hospital on 09/12/10. Patient returned to the residential facility on 09/20/10.
Bill Type 0164 for dates 09/01/10 – 09/12/10, with a status of 02.
Bill Type 0162 for dates 09/20/10 – 09/30/10, with a status code of 30.

33. 0162 Locator 4: Type of Bill Interim Bill 4 TYPE OF BILL Residential
Treatment
Facility
Interim Bill
0162 33

34. Locator 6: Statement Covers Period
FROM THROUGH
080110
083110
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. Invoice billing periods cannot overlap months. 34

35. Locator 8: Patient Name/Identifierb
Last First M
Enter the last name, first name and middle initial of the patient. 35

36. Locator 10: Patient Birthdate
Enter the date of birth of the patient using the
following format - MMDDYYYY. 36

37. M = Male; F = Female; U = Unknown
Locator 11: Sex
11 SEX F
Enter the sex of the patient as recorded at
admission, outpatient or start of care.
M = Male; F = Female; U = Unknown 37

38. 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:
Residential Treatment Facility – Original admission date or new date the patient is re-admitted to the facility.

39. Locator 12: Admission/Start of Care
12 DATE
080110 39

40. Locator 13: Admission Hour
13 HR 14
Enter the hour during which the patient was
admitted to the facility. Medicaid will allow a default time for Residential Facility patients.
NOTE: Military time is used as defined by NUBC. 40

41. Locator 14: Priority Type of Visit
Appropriate PRIORITY TYPE codes accepted by DMAS are:
CODE
DESCRIPTION 1
Emergency 2
Urgent 3
Elective 5
Trauma 9
Information not available 41

42. Locator 14: Priority (Type) of Visit
ADMISSION
14 TYPE 3
Enter the code indicating the priority of this admission /visit. 42

43. Locator 15: Source of Referral/Admission
Code
Description 1
Physician Referral 2
Clinic Referral 4
Transfer From Another Acute Care Facility 6
Transfer From Another Healthcare Facility 7
Emergency Room 8
Court Law Enforcement 9
Information Not Available

44. Locator 15: Source of Referral for Admission Visit
15 SRC 6
Enter the code indicating the source of the
Referral for this admission or visit. 44

45. Locator 17:Patient Discharge Status
Appropriate codes accepted by DMAS in claims processing:
Code
Description 01
Discharge to Home 02
Discharged/transferred to Short Term General Hospital for Inpatient Care 03
Discharged/transferred to SNF 04
Discharged/transferred to ICF 05
Discharged/transferred to Another Facility not Defined Elsewhere 45

46. Locator 17: Patient Discharge Status
Appropriate codes accepted by DMAS in claims processing:
Code
Description 07
Left Against Medical Advice/Discontinued Care 20
Expired 30
Still a Patient 46

47. Locator 17: Patient Discharge Status30
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). 47

48. Locators 18-28: Condition Codes
These codes are used by DMAS in the adjudication of claims:
Code
Description 39
Private Room Necessary A1
EPSDT
NOTE: Condition Code A1 is a required for all Residential Facility Claims submitted to DMAS. 48

49. Locators 18-28: Condition Codes (Required if Applicable) A1
Enter the code (s) in alphanumeric sequence
Used to identify conditions or events related to
this bill that may affect adjudication. 49

50. Locators 39-41:Value Codes and Amount
Note: DMAS will be capturing the number of covered or non-covered day (s) or units for outpatient services with these required value codes:
Enter the number of covered days for inpatient facility.
Enter the number of non-covered days for facility.

51. 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
Billed and Paid (enter amount
paid by primary carrier)
85 Billed Not Covered/No Payment

52. LOCATORS 39-41: Value Codes and Amount
CODE AMOUNT
VALUE CODES
CODE AMOUNT
41 VALUE CODES
CODE AMOUNT a 83
1529 08 b c d 52

53. 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

54. Locator 42: Revenue Code 42 REV. CD. 0120 00013 4
Revenue codes are four digits, leading zero, left
justified and should be reported in ascending
numeric order. 54

55. Locator 43: Revenue Description
R&B-Semi-Pvt-2 Bed-General
Total Charge
Enter the standard abbreviated description
of the related revenue code categories
included on this bill. 55

56. Locator 44: HCPCS/Rates/HIPPS Rates Codes
44 HCPCS / RATE / HIPPS CODE
Inpatient: Enter the accommodation rate. 56

57. Locator 45: Service Date (Required if Applicable)
45 SERV. DATE
080110 57

58. Locator 46: Service Units
46 SERV. UNITS 30
Inpatient : Enter total number of covered accommodation days or ancillary units of service where appropriate. 58

59. Locator 47: Total Charges
46 SERV. UNITS
47 TOTAL CHARGES
TOTALS
Whenever revenue code 0658 is billed the total charges must reflect the number of covered days times the nursing facility rate.
Enter the total charge(s) for the primary payer during the ‘statement covers period’ including both covered and non-covered charges Note: Use code “0001” for TOTAL. 59

60. 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.

61. Locator 50: Payer Name A-C
MEDICAID
A Primary Payer
B Enter the secondary
payer identification,
if applicable.
C Enter the tertiary
payer if applicable. 61

62. Locator 56: National Provider Identification (NPI)
Providers must share their NPI with the DMAS Provider Enrollment Unit (PEU).
Once your NPI is on file with the PEU, providers will bill their NPI in this field.

63. Locator 56: NPI
56 NPI
10 digit NPI should be listed in this field. 63

64. Locator 58: Insured’s Name
Virginia J. Member A B C
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. 64

65. Locator 59: Patient’s Relationship to Insured
Note: appropriate codes accepted by DMAS are:
Code
Description 01
Spouse 18
Self 19
Child 21
Unknown 39
Organ Donor 40
Cadaver Donor 53
Life Partner G8
Other Relationship

66. Locator 59: Patient’s Relationship to Insured
52 REL. INFO 18
Enter the code indicating the relationship of
the insured to the patient. 66

67. 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.

68. Locator 63: Treatment Authorization CodesB
Enter the 11 digit service authorization number
assigned by KePRO for the appropriate services
to be billed to Virginia Medicaid. 68

69. Locator 64: Document Control Number (DCN)
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.
The ICN will be listed on the Remittance Advice with the original approved claim.

70. Locator 64:Document Control Number (Required if Applicable)
The internal control number (ICN) assigned to the original payment by Virginia Medicaid as part of the claims process. 70

71. Locators 67A-Q Principal Diagnosis Code 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
Claims submitted on the UB04 will require a present on admission indicator for each listed DX-

72. Locator 67 A-Q POA Indicator
The POA indicator should be listed in the shaded area. Reporting codes are:
CODE DEFINITION
Y YES
N NO
U No information in the record
W Clinically undetermined
Of course if a determination cannot be made from medical record, U for no information in the record or W for clinically undetermined should be listed

73. Locator 67: Principal Diagnosis CodeB C I J K L
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. 73

74. Locator 69: Admitting DiagnosisDX
2963
Enter the diagnosis code describing the
patient’s diagnosis at the time of admission.
Medicaid requires the diagnosis code billed to
be a current ICD-9 code.
NOTE: Cross check DSM-4 codes with
ICD-9 codes. Do not use decimals. 74

75. Locator 76: Attending Provider
NPI
Enter NPI for the physician who has overall responsibility for the patient’s medical care and treatment reported on this claim.. 75

76. Locator 80: Remarks Field
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. 76

77. Locator 81: Code-Code Field
DMAS previously assigned different provider numbers for each type of service performed.
Medicaid payment was then issued based on the type of service billed.
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., Residential or Psychiatric units within an acute care facility).

78. 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.

79. Locator 81: Code-Code Field
81CC a b c d
B P00000X
Enter the provider taxonomy code for the
billing provider when the adjudication of the
claim is known to be impacted. 79

80. DMAS Services That May Require Taxonomy Codes on Claims
Service Type/Description
Taxonomy Codes
Private Mental Hospital (IP)
283Q00000X
Hospital General
282N00000X
Psychiatric Unit of Hospital
273R00000X
Psychiatric Residential Inpatient Facility
323P00000X – Psychiatric Residential Treatment Facility

81. Department of Medical Assistance Services
THANK YOU
Department of Medical Assistance Services