1. 04/25/07 1 DMAS Division of Health Care Services New Billing Instructions for Emergency Air Ambulance, Emergency Ground Ambulance, and Neonatal Ambulance Services. Instructions include Medicare Cross Over Claims. Two Code Methodology to Begin with Dates of Service November 1, 2009 and After.

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? Beginning with Date of Service (DOS) November 1, 2009 and forward, Emergency Air, Emergency Ground Ambulance, and Neonatal Ambulance claims will be will be processed using the two CPT/HCPCS code payment methodology. This includes Medicare cross-over claims as well. Two CPT/HCPCS codes meaning “service” with corresponding “mileage” code. When Medicare “total payment” for both service and mileage added together exceed DMAS maximum rate, crossover claims will be paid at $0.00 with the claims edit 364 “Exceeds Medicaid Allowed Amount”. All Emergency Ground and Air Ambulance claims will no longer require attachments. No longer use Modifier “22” in block 24D. Except for claims that are over 200 miles and more than one transport on same day service. (see billing instructions) All Emergency Air and Emergency Ground Ambulance claims will be subject to post review. Emergency Air Ambulance Claims will change to a Post Review for Medical Necessity. CMS 1500 requires Font size 10 or larger Adjustments must be submitted for only one line of the pair. Mail all Ground Ambulance claims to First Health, address at end of presentation

4. 4 Health Insurance Claim Form CMS 1500 Most Common Mistakes Claims with DOS October 30, 2009 and before still require one code billing. Block 10b, make sure and check yes for auto accidents Block 10c, make sure to mark for other accidents Third party liability claims – if primary insurance pays at $00.00 make sure block 11d is marked “yes” and block 24a shaded area has TPL00.00. This needs to be entered for each CPT code line. If primary insurance pays, make sure 11d is marked “yes” and block 24a shaded area has dollar amount paid for each CPT code line example: TPL53.69 Make sure providers NPI number match for blocks 24j and 33a. DO NOT use a physicians NPI in block 24j. Do not bill DMAS for regular non-emergency service codes A0426, A0428, A0434 and corresponding A0425. However, DMAS is responsible for all emergency and non-emergency Medicare cross-over claims (see billing instructions for cross over claims).

5. 5 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

6. 6 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.

7. 7 Billing on the CMS-1500 6

8. 8 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

9. 9 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

10. 10 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

11. 11 TIMELY FILING Submit claims with documentation attached explaining the reason for delayed submission

12. 12 Block 1 Enter an ‘X’ in the MEDICAID box for the Medicaid Program

13. 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

14. 1a. INSURED'S I.D. NUMBER (FOR PROGRAM IN ITEM 1) Block 1a: Recipient ID Number Be sure to include all 12 digits of the VA Medicaid ID. 123456789014 13

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

16. 16 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’

17. 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

18. Block 10d If Applicable *Emergency Ground Ambulance trips 200 miles and over, and more than one transport with same service day MUST use the word "ATTACHMENT" l Trips over 200 miles must have Pre-Hospital Patient Care Report (PPCR) attached l More than one transport per day, attach statement “This is second/third/forth transport”. 10d. RESERVED FOR LOCAL USE *ATTACHMENT 17

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

20. 20 Is There Another Health Benefit Plan? Block-11d Providers should only check yes if there is another third party carrier If Medicare pays $00.00 mark this block “yes” and follow instructions for shaded area block 24A.

21. 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

22. 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

23. 23 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

24. 24 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 (TPL00.00 or TPL payment amount: TPL123.45) Decimal between dollars and cents is required to read paid amount correctly Must be left justified Enter dollar amount paid for each CPT Code line

25. 25 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

26. 26 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

27. 24. A. DATE(S) OF SERVICE FromTo MM DD YY Block 24A: Dates of Service (TPL example added if applicable) 11 01 09 1101 09 1 2 Both FROM and TO dates must be completed Dates must be within same calendar month 26 TPL8.60 TPL27.08 1101091101 09

28. 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 41

29. 29 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 Make sure and mark ‘Y’ on both service and mileage lines

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

31. Block 24D: Procedure Codes Neonatal Transport with “U1” Modifier “U1” Modifier is for Neonatal Mileage Only D. PROCEDURES, SERVICES, OR SUPPLIES (Explain Unusual Circumstances) CPT/HCPCSMODIFIER A0225 30 DMAS Recognizes the Following codes: A0225 w/A0425 “U1” A0427 w/A0425 A0429 w/A0425 A0433 w/A0425 A0430 w/A0435 A0431 w/A0436 A0425 U1

32. 32 Block 24D: Procedure Codes Service and Mileage CPT Codes One CPT Code on Each Line No Modifier is required D. PROCEDURES, SERVICES, OR SUPPLIES (Explain Unusual Circumstances) CPT/HCPCSMODIFIER A0427 30 DMAS Recognizes the Following codes: A0225 w/A0425 “U1” A0427 w/A0425 A0429 w/A0425 A0433 w/A0425 A0430 w/A0435 A0431 w/A0436 A0425

33. 21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY 1. 2. 3. 4. 34431 Block 24E: Diagnosis Code E. DIAGNOSI S POINTER 1,2 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

34. F. $ CHARGES Block 24 F: Charges Enter the usual and customary charges for each CPT code 32 500 001500 00

35. G. DAYS OR UNITS Block 24G: Days or Units 1 Enter “1” for one unit of service. Enter the number of “loaded miles” of transport. 33 31

36. 36 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. Make sure to follow these instructions for each line. Taxonomy code must be used for each CPT code line.

37. 37 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. Make sure and follow these instructions for both lines.

38. Fill in only if Taxonomy codes are needed Block 24I: ID. Qual. & 24J: Rendering Provider ID # 36 ZZ 3416A0800X Or 3416L0300X 3416A0800X is Taxonomy code for Air Transport 3416L0300X is Taxonomy code for Land Transport If taxonomy codes are used, make sure and use same codes for each line.

39. Block 24I: ID. Qual. & 24J: Rendering Provider ID # Make sure and use ZZ and same taxonomy code for each line. 37 I. ID. QUAL J. RENDERING PROVIDER ID. # NPI ZZ Taxonomy # (if needed) 12345647890

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

41. 41 Total Charge Block 28 DMAS now requires this locator to be completed Enter the total charges together for the services in 24F lines 1-6.

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

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

44. 44 30. Balance Due Block 30: Balance Due (Block 28 minus Block 29) 42 $

45. 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

46. 46 Service Facility Location Information Block-32 Enter information for the location where recipient was dropped off - services were rendered First line-Name Second line-Address Third line-City, State, 9 digit zip code The zip code must reflect the hospital/facility location where services were rendered No punctuation in the address Space between city and state Include hyphen for the 9 digit zip code

47. 47 Service Facility Location Information Block-32a-b Leave Blank

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

49. 49 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

50. 50 Billing Provider Info Block-33a-b 33a - Enter the 10 digit NPI number of the service location in 33a. (This is required on all claims). 33b – If applicable, Enter ‘ZZ’ qualifier with the taxonomy code in 33b (example – ZZ3416L0300Z). NOTE: 33a and 33b - NPI number and taxonomy codes must match information in blocks 24I and 24J

51. 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

52. 22. MEDICAID RESUBMISSION CODE ORIGINAL REF. NO. Block 22 : Adjustments and Voids Send in Adjustment for MILEAGE CODE ONLY with mileage ICN number. 1032 xxxxxxxxxxxxxxxx Adjustment or Resubmission Code From Original RemittanceVoid Chap. V, Medicaid Transportation Manual has code list. 50

53. Block 22 : Medicaid Resubmission Codes Original Reference Number/ICN - Enter the claim reference number/ICN of the mileage code paid on the 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

54. 54 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 plus in block 10d add the word “ATTACHMENT” and add modifier “22” in block 24d. 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 PPCR/run/call sheets and mail to: DMAS Transportation Unit, Suite 1300 600 East Broad Street Richmond, Virginia 23219

55. 55 Air Ambulance Claim Procedure and Claim Reconsideration All air ambulance claims with a date of service November 1, 2009 and after are subject to a post claim review. Claims submitted that do not establish air ambulance medical necessity will be adjusted to 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.

56. 56 Mailing Address for Emergency Ground Ambulance, Emergency Air Ambulance, and Neonatal Ambulance Service Claims Emergency Air, Emergency Ground and Neonatal Ambulance Claims with a Date of Service on or after November 1, 2009 mail to: DMAS-Transportation P. O. Box 27447 Richmond, Virginia 23261-7447 Note: Emergency ground ambulance claims with 200 miles and over and/or multiple emergency transports on the same day must be mailed to: DMAS Transportation Unit, Suite 1300 600 East Broad Street Richmond, Virginia 23219

57. 57 Billing on the DMAS 30 & 31 56

58. 58 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)

59. 59 CHANGES Locator 01-Billing Provider Number Locator 06-Rendering Provider Number Locator 08-Type of Coverage

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

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

62. 62 Primary Carrier Information Other Than Medicare 07 2 No Other Coverage 5 Billed No Coverage 3 Billed and Paid Title XVIII – Block 7

63. 63 Type Of Coverage Medicare B Type Coverage Medicare- Mark type of coverage “B”. 6 08 Title XVIII – Block 08

64. 64 Title XVIII- Block 17 Charges To Medicare Block 17: Charges to Medicare- Enter the total charges submitted to Medicare. 17

65. 65 Title XVIII- Block 18 Allowed By Medicare Block 18: Allowed by Medicare- Enter the amount of the charges allowed by Medicare. 18

66. 66 Title XVIII- Block 19 Paid By Medicare Block 19: Paid by Medicare- Enter the amount paid by Medicare (taken from the EOB). 19

67. 67 Title XVIII- Block 20 Deductible Block 20: Deductible- Enter the amount of the deductible (taken from the Medicare EOB). 20

68. 68 Title XVIII- Block 21 Co-Insurance Block 21: Coinsurance - Enter the amount of the coinsurance (taken from the Medicare EOB). 21

69. 69 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

70. 70 Title XVIII- Block 23 Patient Pay Amt. LTC Only Block 23: Patient Pay Amount, LTC Only- Leave Blank. 23

71. 71 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.

72. 72 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.

73. 73 REMINDERS Xeroxed copies of DMAS forms 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

74. 74 LogistiCare Contact Telephone Number For A0426, A0428, and A0434 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 A0426, A0428, and A0434 Medicaid Non-Emergency Ambulance trips must be “pre-authorized”, arranged, and paid for by LogistiCare.

75. 75 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

76. 76 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.

77. 77 Questions? Or email question(s) to: Transportation@DMAS.Virginia.gov

78. 78 THANK YOU