Virginia Medicaid Eligibility Verification Options

1
Virginia Medicaid Eligibility Verification
OptionsCMS-1450 Billing Guidelines
Department of Medical Assistance Services

• Nursing Facility Providers
• October 2007
• www.dmas.virginia.gov

2

• This presentation is to facilitate training of
  the subject matter in Chapter V of the Virginia
  Medicaid Nursing Facility Manual.
• This training contains only highlights of this
  manual and is not meant to substitute for or take
  the place of the Nursing Facility Manual.

3
Objectives

• Upon completion of this presentation
  participants will understand
• How to utilize Medicaid Eligibility Verification
  Options
• Timely filing guidelines
• How to properly submit Medicaid claims,
  adjustments and voids

4
As a Participating Provider You Must-

• Determine the patients identity.
• Verify the patients age.
• Verify the patients 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
9 9 9 9 9 9 9 9 9 9 9 9
V I RG I N I A J. R E C I P I E N T
DOB 05/09/1964 F
CARD 00001
6
Medicaid Verification Options

• MediCall
• ARS- Web-Based Medicaid Eligibility

7
MediCall

• 800-884-9730
• 800-772-9996
• 804-965-9732
• 804-965-9733

8
MediCall

• Available 24 hours a day, 7 days a week
• Medicaid Eligibility Verification
• Claims Status
• Prior Authorization Information
• Primary Payer Information
• Medallion Participation
• Managed Care Organization Assignment

9
Automated Response System ARS

• Web-based eligibility verification option
• Free of Charge.
• Information received in real time.
• Secure
• Fully HIPAA compliant

10
Automated Response System

• DMAS has an Automated Response System (ARS) Web
  Site for obtaining claims and eligibility
  information on line at no cost
• The site contains features allowing access to
  business information as well as the User
  Administration Console (UAC)
• Allow providers to manage their own ARS access
  for one or more users
• Providers can access claim information using your
  NPI

11
UAC Registration Process

• https//virginia.fhsc.com
• 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

12
UAC Registration Process

• 3-Step Process
• Step One Request PIN (will be mailed)
• Step Two Register with a PIN
• Step Three Activate your user login ID and
  password
• After this process you will need to log onto the
  UAC, in order to assign your access privileges to
  the ARS, set up additional local administrators
  and assign roles and providers to administrators

13
ARS Users

• Web Support Helpline
• 800-241-8726
• Assistance during the registration process
• General information

14
WebEx Presentation

• To view an ARS pre-recorded presentation
  developed by First Health Services use this link
• https//dmas.webex.com/mw0302l/mywebex/default.do
  ?siteurldmas
• Click on
• Attend a session, recorded session
• Select - NPI Automated Response System/UAC
• View or download presentation

15
Provider Call Center

• Claims, covered services, billing inquiries
• 800-552-8627
• 804-786-6273
• 830am 430pm (Monday-Friday)
• 1100am 430pm (Wednesday)

16
Provider Enrollment

• New provider enrollment, change of address,
• or Electronic Fund Transfer (EFT) sign-up or
  changes
• First Health PEU
• P. O. Box 26803
• Richmond, VA 23261
• 888-829-5373
• 804-270-5105
• 804-270-7027 - Fax

17
Electronic Billing

• Electronic Claims Coordinator
• Mailing Address
• First Health Services CorporationVirginia
  OperationsElectronic Claims Coordinator4300 Cox
  RoadGlen Allen, VA 23060
• E-mail edivmap_at_fhsc.com
• Phone [phone]
• Fax [phone]

18
Billing on the CMS-1450
19
MAIL CMS-1450 FORMS TO

• Virginia Medical Assistance Program
• P. O. Box 27443
• Richmond, Virginia 23261

20
CMS-1450 (UB-04)

• Accommodates
• National Provider Number (NPI)
• Current Medicaid Provider Identification Number
  (PIN)
• Replaced CMS-1450 (UB-92) version for claims
  submitted on or after June 1, 2007

21
Dual Use Timeline

• Began March 26, 2007
• Dual Use is the period for the submission of
  claims using either the NPI or Medicaid PIN
• DMAS will continue Dual Use beyond the initial
  cut off date of May 23, 2007
• A Medicaid Memo will be issued well in advance of
  the new mandatory NPI compliance date

22
Timeline

• June 1, 2007
• Must use the new CMS-1450 only
• Providers can bill with NPI or
• Medicaid PIN can be billed until Memo
  notification of the end of the Dual Use Period

23
TIMELY FILING

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

24
TIMELY FILING

• Submit claims with documentation attached to the
  back of the form, explaining the reason for
  delayed submission
• You should have the word Attachment in the
  Remarks field, Locator 80

25
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

26
CMS-1450 CLAIM FORM
Use ONLY the ORIGINAL RED WHITE UB-04
Invoice Photocopies are not Acceptable Computer
generated claims must match NUBC uniform standards
27
Locator 1 Providers Name, Address and Phone
Number

• Enter the providers 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.

28
Locator 1 Provider Name, Address and Phone
Number
1
Our Place Nursing Facility
121 Friendly Street
Any Town
VA
12345-6456 8049781234
28
29
Locators 3a and 3b

• 3a Patient Control Number - Enter the patients
  unique financial account number which does not
  exceed 20 alphanumeric characters.
• 3b Medical/Health Record - Enter the number
  assigned to the patients medical/health record
  by the provider. This number cannot exceed 24
  alphanumeric characters.

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Locators 3a- Patient Control Number 3b-
Medical/Health Record Number
3a PAT. CNTL
123456789ABCDEFGH012
b. MED REC.
987654321HGFEDCBA1234567
Patient Control Number and Medical/Health Record
Number are required for all UB-04 claim
submissions.
30
31
Locator 4 Type of Bill

• Enter the code as appropriate.
• The Type of Bill field has been increased from
  three digits to four digits by adding a leading
  zero.
• Claims submitted without the required four digit
  bill type will be denied.

32
Locator 4 Type of Bill

• 0211 Original Inpatient Nursing Home Invoice
• 0212 Interim Inpatient Nursing Home Invoice
• 0213 Continuing Inpatient Nursing Home Invoice
• 0214 Last Inpatient Nursing Home Invoice
• 0217 Adjustment Inpatient Nursing Home Invoice
• 0218 Void Inpatient Nursing Home Invoice

33
Locator 4 Type of Bill

• 0621 Original Intermediate Care Inpatient
  Invoice
• 0622 Interim Intermediate Care Inpatient
  Invoice
• 0623 Continuing Intermediate Care Inpatient
  Invoice
• 0624 Last Inpatient Intermediate Care Invoice
• 0627 Adjustment Intermediate Care Invoice
• 0628 Void Intermediate Care Invoice

34
Bill Type Notes

• Bill type 0211 or 621- This bill type should be
  used whenever the admission and the discharge
  date are within the same month.
• Bill type 0212 or 622 This bill type should be
  used when the admission date equals the (from
  date) of service and the resident is still a
  resident as of the thru date of service.

35
Bill Type Notes

• Bill type 0213 or 623 This bill type should be
  used whenever the admission occurred in prior
  months (or billing cycle) and the discharge has
  not occurred. This bill type has no limit on the
  number of occurrences.
• Bill type 0214 or 624 This bill type should be
  used when the resident has been discharged from
  the facility. The discharge date is the date of
  the thru date of service. Should a resident be
  discharged and re-admitted within the same month
  the re-admission would then start with the bill
  types of 0211 or 0212, or 0611 or 0621. Whenever
  interim bill types are utilized the admission
  date remains the same.

35
36
Locator 4 Type of Bill
InterimBill

36
37
Locator 6 Statement Covers Period

• STATEMENT COVERS PERIOD
• FROM THROUGH

083107
080107
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.
37
38
Locator 8 Patient Name/Identifier
8 PATIENT NAME
a

b
Last First M
Enter the last name, first name and middle
initial of the patient.
38
39
Locator 10 Patient Birthdate
10 BIRTHDATE
10011980
Enter the date of birth of the patient using
the following format - MMDDYYYY.
39
40
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
40
41
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
• Nursing Facility - Admission or re-admission
  date

41
42
Locator 12 Admission/Start of Care
ADMISSION 12 DATE
030507

42
43
Locator 13 Admission Hour
ADMISSION 13 HR
14
Enter the hour during which the patient was
admitted to the nursing facility. Medicaid will
allow a default time for nursing facility
patients. NOTE Military time is used as defined
by NUBC.
43
44
Locator 14 Priority Type of Visit

• Appropriate PRIORITY TYPE codes accepted
  by DMAS are

45
Locator 14 Priority (Type) of Visit
ADMISSION 14 TYPE
3
Enter the code indicating the priority of this
admission /visit.
45
46
Locator 15 Source of Referral for Admission or
Visit

• Appropriate codes accepted by DMAS are

47
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.
47
48
Locator 17Patient Discharge Status

• Appropriate codes accepted by DMAS in claims
  processing

48
49
Locator 17Patient Discharge Status

• Appropriate codes accepted by DMAS in claims
  processing

49
50
Locator 17 Patient Discharge Status

• Appropriate codes accepted by DMAS in claims
  processing

50
51
Locator 17 Patient Discharge Status
17 STAT
30
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).
51
52
Locators 18-28 Condition Codes

• These codes are used by DMAS in the adjudication
  of claims

52
53
Locators 18-28 Condition Codes (Required if
Applicable)
Condition Codes 18 19 20 21 22 23 24 25
26 27 28
39 40
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.
53
54
Locator 30Crossover Part A Indicator (Required
if Applicable)

30
CROSSOVER
NOTE DMAS is requiring for Medicare crossover
claims that the word CROSSOVER be in this
locator.
54
55
Locators 31-34Occurrence Code and Dates
(Required if Applicable)

• OCCURRENCE
• CODE DATE

030107
a
A3
b
Enter the code and associated date defining a
significant event relating to this bill. Enter
codes in alphanumeric sequence.
55
56
Locators 35-36Occurrence Code and Span Dates
(Required if Applicable)

• OCCURRENCE SPAN
• CODE FROM THROUGH

a
b
Enter the code and related dates that identify an
event that relates to the payment of the claim.
Enter codes in alphanumeric sequence.
56
57
Locator 37Adjustment Reason Codes

• This field previously was used to identify the
  ICN of the approved claim to be adjusted or
  voided. That information will now be listed in
  Locator 64.

58
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
• 80 Enter the number of covered days for
  inpatient nursing facility or the number of
  days for re-occurring outpatient claims. (Do not
  list covered days as dollars and cents- max 2
  digits)
• 81 Enter the number of non-covered days for
  nursing facility

58
59
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- EOB not required)
• 85 Billed Not Covered/No Payment
• (Documentation must be submitted with
  claim)

59
60
Locators 39-41 Value Codes and Amount

• For Medicare Crossover Claims, the following
  codes must be used with one of the third party
  insurance carrier codes
• A1 Deductible from Part A
• A2 Coinsurance from Part A
• Other codes may be used if applicable.

60
61
Locators 39-41Value Codes and Amount

• VALUE CODES
• CODE AMOUNT

• VALUE CODES CODE AMOUNT

795 29
80 30
83
a
b
c
d
61
62
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.

63
Locator 42 Revenue Code
42 REV. CD.
1
0120
0001
2

3
4
Revenue codes are four digits, leading zero,
left justified and should be reported in
ascending numeric order.
63
64
Locator 43 Revenue Description
43 DESCRIPTION
RB-Semi-Pvt-2 Bed-General
Total Charge

Enter the standard abbreviated description of
the related revenue code categories included on
this bill.
64
65
Locator 44 HCPCS/Rates/HIPPS
Rates Codes
44 HCPCS / RATE / HIPPS CODE
Inpatient Enter the accommodation rate.
65
66
Locator 45 Service Date (Required if
Applicable)
45 SERV. DATE
080107
66
67
Locator 46 Service Units
46 SERV. UNITS
30

Inpatient Enter total number of covered
accommodation days or ancillary units of service
where appropriate.
67
68
Locator 47 Total Charges
47 TOTAL CHARGES
46 SERV. UNITS
1755 75
TOTALS
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.
68
69
Locator 48 Non-Covered Charges (Required if
Applicable)
48 NON-COVERED CHARGES
75
00
To reflect the non-covered charges for the
primary payer as it pertains to the
related revenue code.
69
70
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.

71
Locator 50 Payer Name A-C
50 PAYER NAME
MEDICAID
A Primary Payer B Enter the secondary
payer identification, if
applicable. C Enter the tertiary
payer if applicable.
71
72
Locator 54Prior Payments (Required if
Applicable)
54 PRIOR PAYMENTS
460.29
Enter the patient pay amount shown on the
DMAS-122 Form furnished by the Local Dept. Of
Social Services Office.
72
73
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
  may submit their NPI in this field.

74
Locator 56 NPI
56 NPI
1234567890
10 digit NPI should be listed in this field.
74
75
Locator 57A-C Other Provider Identifier

• Enter the nine-digit Medicaid PIN in this field
  April 1, 2007 Memo notification of the end of
  the Dual Use Period.
• Do not complete this field if the NPI is listed
  on Locator 56.

76
Locator 57A-COther Provider Identifier
001234567
57 OTHER PRV ID
Enter the Medicaid PIN in this locator during
the Dual Use Period only.
76
77
Locator 58 Insureds Name
58 INSUREDS NAME
Virginia J. Recipient
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 enrollee
name when eligibility is verified.
77
78
Locator 59 Patients Relationship to Insured

• Note appropriate codes accepted by DMAS are

78
79
Locator 59 Patients Relationship to Insured
52 REL. INFO
18
Enter the code indicating the relationship of
the insured to the patient.
79
80
Locator 60 Insureds Unique Identification
60 INSUREDS UNIQUE ID
012345678910
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 recipient ID
number is 12 numeric digits.
81
Locator 64Document 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.
• This information was previously required in
  Locator 37 of the UB-92.

82
Locator 64Document Control Number
(Required if Applicable)
64 DOCUMENT CONTROL NUMBER
2006363123456701
The control number assigned to the original
bill by Virginia Medicaid as part of their
internal claims reference number.
82
83
Locator 66 Diagnosis and Procedure Code
Qualifier (ICD Version Indicator)
66 DX
9
The qualifier that denotes the version of
the International Classification of Diseases.
Qualifier 9 for the Ninth Revision. NOTE
Virginia Medicaid will only accept a 9 in this
locator.
83
84
Locator 67 Principal Diagnosis Code
67
A
B
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.
84
85
Locator 69 Admitting Diagnosis

• ADMIT
• DX

4019
Enter the diagnosis code describing the
patients diagnosis at the time of
admission. NOTE Do not use decimals.
85
86
Locator 74 Principal Procedure Code and Date
(Required if Applicable)

• 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.
86
87
Change - Locator 74a-e Other Procedure Codes
and Date (Required if Applicable)

• 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.
87
88
Locator 76 Attending Provider and Identifier

• Enter qualifier 82 and the 9-digit number
  assigned by Medicaid for the physician who has
  overall responsibility for the patients medical
  care and treatment reported on this claim, April
  1, 2007 - Memo notification of the end of the
  Dual Use Period OR
• The NPI may be entered in the field identified as
  NPI beginning April 1, 2007.

89
Locator 76 Attending Provider
76 ATTENDING
NPI 1234567890
Accepted for claims submitted April 1, 2007 and
after.
82
001234567
QUAL
Accepted - April 1, 2007 Memo Notification of
the end of the Dual Use Period.
89
90
Locator 80 Remarks Field
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.
90
91
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

91
92
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.
• 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.

93
Locator 81 Code-Code Field
81CC a b c d
B3 273R00000X
Enter the provider taxonomy code for the billing
provider when the adjudication of the claim is
known to be impacted.
93
94
DMAS Service Types That MAY Require A Taxonomy
Code on Claims
94
95
REMITTANCE VOUCHERSections of the Voucher

• APPROVED for payment.
• PENDING for review of claims.
• DENIED no payment allowed.
• DEBIT () Adjusted claims creating a
  positive balance.
• CREDIT (-) Adjusted/Voided claims
  creating a negative balance.

96
REMITTANCE VOUCHERSections of the Voucher

• FINANCIAL TRANSACTION
• EOB DESCRIPTION
• ADJUSTMENT DESCRIPTION/REMARKS- STATUS
  DESCRIPTION
• REMITTANCE SUMMARY- PROGRAM TOTALS

97
THANK YOU
Department of Medical Assistance Services

• www.dmas.virginia.gov