2. 1 CMS-1500 (08-05) Billing Guidelines Department of Medical Assistance Services February 2010 www.dmas.virginia.gov

3. 2 This presentation is to facilitate training of the subject matter in Chapter V of the Virginia Medicaid Physicians Manual. This training contains only highlights of this manual and is not meant to substitute for or take the place of the PhysiciansManual. Providers are responsible for reviewing and adhering to the Physicians Manual requirements.

4. 3 Objectives To familiarize the providers with the billing guidelines of the CMS-1500 claim form. To give the providers clear instructions on the requirements of DMAS for the completion of the CMS-1500 claim form.

5. 4 Participating Providers 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.

6. 5 DOB: 05/09/1994 F CARD# 00001 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 9 9 9 9 9 9 9 9 9 9 9 99 9 9 9 9 9 9 9 9 9 9 9 002286

7. 6 MediCall/Automated Response System (ARS) Available 24 hours a day, 7 days a week Medicaid Eligibility Verification Claims Status Patient Pay Information Prior Authorization Information Primary Payer Information Medallion Participation Managed Care Organization Assignment

8. 7 MediCall 800-884-9730 800-772-9996 804-965-9732 804-965-9733

9. 8 Automated Response System (ARS) Web-based eligibility verification option Free of Charge. Information received in “real time”. Secure Fully HIPAA compliant

10. 9 ARS Registration Process https://uac.fhsc.com/uac/pages/unsecured/common/h ome.jsf Select the ARS tab on FHSC ARS Home Page Choose “User Administration” Follow the on-screen instructions for help with registration, this is a 3-step process to request, register and activate a new account Answer the initial ‘Who are you?’ question by selecting ‘I do not have a User ID and need to be a Delegated Administrator’

11. 10 ARS – Users ARS User’s Guide http://www.dmas.virginia.gov/prclaims_billing.htm Web Support Helpline- 800-241-8726

12. 11 Important Contacts Provider Call Center Provider Enrollment Electronic Claims Coordinator

13. 12 Provider Helpline Claims, covered services, billing inquiries: 800-552-8627 804-786-6273 8:30am – 4:30pm (Monday-Friday) 11:00am – 4:30pm (Wednesday)

14. 13 Provider Enrollment New provider enrollment, Electronic Fund Transfer (EFT) or change of address: First Health – PEU P. O. Box 26803 Richmond, VA 23261 888-829-5373 804-270-5105 804-270-7027 - Fax

15. 14 Electronic Billing Electronic Claims Coordinator Mailing Address First Health Services Corporation Virginia Operations Electronic Claims Coordinator 4300 Cox Road Glen Allen, VA 23060 E-mail: edivmap@fhsc.comedivmap@fhsc.com Phone: (800) 924-6741 Fax: (804) 273-6797

16. 15 Claim Attachment Form DMAS-3 The DMAS-3 form is to be used by Electronic Data Interchange (EDI) billers only to submit a non-electronic attachment to an electronic claim. See Chap. V Exhibits pg. 5 Attachment Control Number (ACN) should be indicated on the electronic claim submitted. The ACN number is the combined information from: Patient Account Number Date of Service Sequence Number

17. 16 Claim Attachment Form DMAS 3 – Sample ACN# Patient Account Number 123456789 Date of Service 09/11/2009 Sequence Number 12345 ACN number listed on form will be- 1234567890911200912345

18. 17 Billing on the CMS-1500 7

19. 18 MAIL CMS-1500 FORMS TO: DEPARTMENT OF MEDICAL ASSISTANCE SERVICES PRACTITIONER P. O. Box 27444 Richmond, Virginia 23261

20. 19 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

21. 20 TIMELY FILING Submit claims with documentation attached to the back of the claim form, explaining the reason for delayed submission

22. 21 Block 1 The locator will now be used to indicate if the claim is Medicaid, TDO, or ECO. Enter an ‘X’ in the MEDICAID box for the Medicaid Program Enter an ‘X’ in the OTHER box for Temporary Detention Order (TDO) or Emergency Custody Order (ECO)

23. MEDICAID (Medicaid #) Block 1 CHAMPUS (Sponsor's SSN) 1. MEDICARE (Medicare #) MEDICAID CLAIM 2. PATIENT'S NAME (Last Name, First Name, Middle Initial) 13 TRICARE

24. GROU P (SSN or ID) Block 1 BKL LUNG (SSN) CHAMPVA (Member ID#) TDO or ECO CLAIM 14 FECA HEALTH PLAN OTHER (ID)

25. 1a. INSURED'S I.D. NUMBER (FOR PROGRAM IN ITEM 1) Block 1a: Recipient ID Number (Be sure to include all 12 digits) 123456789014 15

26. Block 2: Patient's Name 2. PATIENT'S NAME (Last name, First Name, Middle Initial) Smith, Sam 5. PATIENT'S ADDRESS (No., Street) 16

27. 26 Is Patient’s Condition Related To? Block-10 If the condition is related to an auto accident, and you have this information, place the postal code (i.e. VA, TN, WV) of the state in which the accident occurred.

28. 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 18 WV

29. 28 Insurance Plan Name or Program Name Block-11c Providers that are billing for non-Medicaid Managed Care Organizations (MCO) co-pays please insert ‘HMO COPAY’ The amount billed to Medicaid in 24F (Charges) must represent only the enrollees co-payment amount for the HMO, and the Explanation of Benefits (EOB) must be attached. Use the CPT or HCPCS procedure code that was billed as the primary procedure to the HMO. This does not apply to enrollees in a Medicaid HMO, e.g., Medallion II.

30. Block 11c - Insurance Plan Name or Program Name c. INSURANCE PLAN NAME OR PROGRAM NAME HMO COPAY 21

31. 30 CHANGE – Is There Another Health Benefit Plan? Block-11d Providers should always check ‘YES’ if there is verification of Third Party Liability If there is no other coverage check no or leave blank

32. 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. 23 DMAS does not require items 9 a-d to be completed.

33. Blocks 17 and 17b- Conditional 17. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE 17- Name of the Recipient’s PCP 17b- PCP’s NPI 17a. 17b.NPI 1234567890 58

34. Block 19- Conditional Use 19. RESERVED FOR LOCAL USE Clinical Laboratory Improvement Amendment (CLIA) Number of the physician office laboratory (POL) performing the service. 28

35. 21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY 1. 2. 3. 4. 3441 Block 21: Diagnosis Codes May enter up to 4 codes Omit decimals 2963 29

36. 35 Prior Authorization Number Block-23 If service requires prior authorization, enter the eleven digit PA number assigned by KePRO Enter the number pre-assigned to the TDO or ECO form that is obtained from the magistrate authorizing the TDO/ECO.

37. 23. PRIOR AUTHORIZATION NUMBER Block 23: Prior Authorization Number - Conditional 31

38. 37 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

39. 38 TPL Information Block 24A-shaded red area 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

40. 24. A. DATE(S) OF SERVICE FromTo MM DD YY Block 24A : Dates of Service 12 01 09 12 01 09 1201 09 1231 09 1 2 TPL27.08 amount paid by primary carrier $27.08 68 TPL Information

41. 40 TPL Billing Scenarios No other insurance Check ‘NO’ in Locator 11d or leave blank Do not document any information in the shaded red area of 24A Primary Carrier pays covered service Provider receives Explanation of Benefits (EOB) Check ‘YES’ in Locator 11d Document primary payment information in the shaded red area of 24A on claim form

42. 41 TPL Billing Scenarios Primary carrier does not pay Payment applied to deductible/claim denied Provider receives EOB Check ‘YES’ in Locator 11d Attach copy of EOB showing non-payment to the back of the DMAS claim form Do not document any information in the shaded red area of 24A

43. 42 TPL Billing Scenarios Primary carrier does not pay Service not covered Check ‘YES’ in Locator 11d Attach EOB documenting that services are not covered or, attach letter verifying the service is not covered Do not document any information in the shaded red area of 24A

44. 43 TPL Billing Scenarios Primary carrier does not pay Provider not enrolled with carrier Check ‘YES’ in Locator 11d Attach letter documenting the provider is not enrolled with the primary carrier Do not document any information in the shaded red area of 24A

45. 44 TPL Billing Scenarios Primary carrier does not pay Policy is no longer active/coverage terminated Check ‘YES’ in Locator 11d Attach EOB verifying that the policy is not active or, attach letter verifying the policy is not active Do not document any information in the shaded red area of 24A

46. 45 NDC Information Block-24A Qualifier ‘N4’ is used followed by the National Drug Code (NDC) whenever a HCPCS J-code is submitted in 24D. No spaces between the qualifier and the NDC number Must be left justified

47. 24. A. DATE(S) OF SERVICE FromTo MM DD YY Block 24A : Dates of Service 12 01 09 12 01 09 120109121609 1 2 37 N400026064871 NDC Information

48. 24. A. DATE(S) OF SERVICE FromTo MM DD YY Block 24A : Dates of Service 12 01 09 12 01 09 120109123109 1 2 TPL and NDC information 31 TPL27.08 N400026064871 If both NDC and TPL apply to a single procedure both must be placed on the same line, it does not matter which comes first

49. 24. A. DATE(S) OF SERVICE FromTo MM DD YY Block 24A : Dates of Service 12 01 09 12 01 09 120109121609 1 2 Both FROM and TO dates must be completed Dates must be within same calendar month 36

50. B. Place of Service Block 24B: Place of Service 11 11-Office location 21- Inpatient Medicaid accepts the same 2 digit CMS Place of Service codes as Medicare. 37 Note: Type of Service is no longer required

51. 50 Emergency Indicator Block 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 If there was no emergency leave blank

52. C. EMG Block 24C: EMG Medicaid will accept a ‘Y’ in this Locator to indicate that the procedure was an emergency 39 Y

53. D. Block 24D: Procedure Codes PROCEDURES, SERVICES, OR SUPPLIES (Explain Unusual Circumstances) CPT/HCPCSMODIFIER 22 99254 40

54. 53 J Code Mandate: Block 24D When billing a J Code the red shaded area must have the unit of measurement (UOM) qualifier. Valid qualifiers: F2: international unit ML: milliliter GR: gram UN: unit

55. 54 J-Code Mandate: Block 24D Enter the actual metric decimal quantity (units) administered to the patient If reporting a fraction of a unit, use the decimal point The maximum number of bytes allowed for the quantity is 13, including the decimal point.

56. D. Block 24D: Procedure Codes PROCEDURES, SERVICES, OR SUPPLIES (Explain Unusual Circumstances) CPT/HCPCSMODIFIER J0881 GR0.0004 J0881 constitutes 1mcg of a drug, the quantity given was 400 mcg which converts to 0.0004 grams

57. 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. 41

58. F. $ CHARGES Block 24 F: Charges Enter the usual and customary charges 42

59. G. DAYS OR UNITS Block 24G: Days or Units 1 Enter the number of times or hours the procedure, service, or item was provided during the service period. 31 43

60. H. Block 24H: EPSDT/Family Plan 44 1 EPSDT Family Plan 1-EPSDT 2-Family Planning Service

61. 60 CHANGE – ID.QUAL Block-24I Qualifier ‘1D’ is to be used in the red shaded area for claims being submitted using the Atypical Provider Identifier (API). 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.

62. 61 CHANGE – Rendering Provider ID # Block-24J The shaded red area will contain the current Atypical Provider Identifier (API) or; The open area will contain the NPI of the provider rendering the service

63. Block 24I: ID. Qual. & 24J: Rendering Provider ID # 48 I. ID. QUAL J. RENDERING PROVIDER ID. # NPI ID 9876543210

64. Block 24I: ID. Qual. & 24J: Rendering Provider ID # 49 I. ID. QUAL J. RENDERING PROVIDER ID. # NPI ZZ Taxonomy (if needed) 12345647890

65. 26. PATIENT ACCOUNT NUMBER Block 26: Patient’s Account Number (Optional) 12345678918765 50 Can not exceed 17 alphanumeric digits

66. 65 Total Charge Block 28 DMAS now requires this locator to be completed Enter the total charges for the services in 24F lines 1-6.

67. 28. TOTAL CHARGE Block 28: Total Charges 52 $

68. 67 Amount Paid (Personal/Waiver Services ONLY) Block 29 Patient pay amount is taken from services billed on 24A – line 1 If multiple services are provided on the same date of service another form must be completed since only one line can be submitted if patient pay is to be considered in the processing of this service

69. 28. AMOUNT PAID Block 29: Amount Paid (Personal and Waiver Services ONLY) 54 $ Enter the Patient Pay amount as indicated on the DMAS-122

70. 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. 55

71. 70 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 Physicians with multiple offices-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

72. 71 Service Facility Location Information Block-32a-b Enter the 10 digit NPI number of the service provider in 32a OR; Enter ‘1D’ qualifier with the API in 32b

73. Block 32: Service Facility Location Information 32. SERVICE FACILITY LOCATION INFORMATION a.b. NPI 58

74. 73 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

75. 74 Billing Provider Info & PH #Block-33a-b Enter the 10 digit NPI number of the service location in 33a OR; Enter ‘1D’ qualifier with the API in 33b

76. Block 33: Billing Provider Info & PH # 33. BILLING PROVIDER INFO & PH # a.b. NPI ( ) 61

77. 22. MEDICAID RESUBMISSION CODE ORIGINAL REF. NO. Block 22 : Adjustments and Voids 1032 xxxxxxxxxxxxxxxx Adjustment or Resubmission Code From original remittanc eVoid Chap. V, Medicaid Physician’s Manual has code list. 64

78. 77 THANK YOU Department of Medical Assistance Services www.dmas.virginia.gov