Department of Medical Assistance Services

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Department of Medical Assistance Services

• Eligibility Verification Options
  CMS-1450 (UB-04) Billing Guidelines
• For
• Outpatient Rehabilitation Services
• July 2007
• www.dmas.virginia.gov

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• This presentation is to facilitate training of
  the subject matter in portions of the Virginia
  Medicaid manual on Rehabilitation .
• This training contains only highlights of those
  manuals and is not meant to substitute for or
  take the place of the Rehabilitation manual.

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Objectives

• Upon completion of this training you should be
  able to
• Correctly utilize Medicaid options to verify
  eligibility
• Understand timely filing guidelines
• Properly submit Medicaid claims, adjustments and
  voids

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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
5
Client Medical Management

• DMAS may designate certain recipients to be
  restricted to specific physicians and
  pharmacies.
• When this occurs, providers are notified through
  Medicaids eligibility verification options.

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Client Medical Management
(CMM)
Recipient Monitoring Unit (888)
323-0589 [phone]
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QMB Only Coverage

• Qualified Medicare Beneficiary (QMB)
• Medicaid payment is limited to Medicare
  coinsurance and deductible.
• If Medicare covers the service, Medicaid will
  consider any Medicare deductible and/or
  coinsurance amount
• Medicaid payment of the Medicare coinsurance is
  limited to the Medicaid fee when combined with
  the Medicare payment

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QMB Extended Coverage

• Qualified Medicare Beneficiary-- QMB
  Extended
• Medicaid will consider the Medicare deductible
  and coinsurance
• Patient is eligible for Medicaid-covered services
  listed in Chapter I of Rehabilitation manual
• Recipients may be responsible for copay for
  rehabilitative services

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Important Contacts

• MediCall
• ARS- Web-Based Medicaid Eligibility
• WebEx
• Provider Call Center
• Provider Enrollment
• Cost Reports

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MediCall

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

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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

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Automated Response System ARS

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

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Automated Response System (ARS)

• March 26, 2007 DMAS implemented a new ARS
• NPI Compliant ARS Web Site will allow
• Access to claims status for bills submitted using
  an NPI
• Access to claims status for bills submitted by a
  Group Practice
• Enhanced delegated administration capability
  provided by the User Administration Console (UAC)

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User Administration Console

• No longer will providers have the limitation of
  only one ARS user associated to an individual
  Provider Identification Number
• Providers are required to enroll and establish
  your new access to use the ARS beginning May 23,
  2007.
• Web Support Helpline
• 800-241-8726

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UAC Registration Process

• Go to 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
• Answer the initial Who are you? question by
  selecting I do not have a User ID and need to be
  a Delegated Administrator

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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

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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

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NPI Training and Education

• Comprehensive NPI section of the DMAS website
• http//www.dmas.virginia.gov/npi-home_page.htm
• For training opportunities
• DMAS Learning Network http//www.dmas.virginia.gov
  /LNupcoming_events.htm

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NPI and DMAS

• Virginia Medicaid Providers having questions
  related to the DMAS NPI implementation schedule
  please contact NPI_at_dmas.virginia.gov

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Provider Call Center

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

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Provider Enrollment

• To enroll providers with a NPI or change of
  address
• First Health PEU
• P. O. Box 26803
• Richmond, VA 23261
• 888-829-5373
• 804-270-5105
• 804-270-7027 - Fax

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Cost Reporting

• All rehab agencies are required to maintain
  separate cost accounting records and to file a
  cost report annually using the applicable
  Medicare cost reporting forms and Medicaid forms.

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Cost Reports
Send cost reports directly to Clifton Gunderson
P.L.L.C. 4144-B Innslake Drive Glen Allen, VA
23060-3387 804-270-2200 - Voice 804-270-2311 -
Fax
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Cost Report Payments

• If a payment to the Medicaid Program is due with
  the cost report, the payment/check, but not the
  cost report, must be sent directly to DMAS at the
  following address
• Department of Medical Assistance Services
• Cashiering Unit
• Division of Financial Operations
• 600 East Broad Street, Suite 1300
• Richmond, VA 23219

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Billing on the CMS-1450 (UB-04)
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MAIL UB-04 FORMS TO

• DEPARTMENT OF MEDICAL ASSISTANCE
• SERVICES
• P. O. Box 27443
• Richmond, Virginia 23261

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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

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TIMELY FILING

• Submit claims with documentation attached to the
  back of each claim form explaining the reason for
  delayed submission
• Indicate information is attached in Locator 80-
  REMARKS.

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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
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Locator 1Providers Name, Address and Phone
Number

• Enter the name, complete mailing address and
  telephone number of the provider that is
  submitting the bill and has rendered the service
  billed to Medicaid.
• NOTE DMAS will need to have the 9 digit zip code
  on line four, left justified for adjudicating the
  claim.

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Locator 1 Provider Name, Address and Phone
Number
1
Here To Help Rehab Agency
121 Friendly Street
Any Town
VA
12345-6456 8049781234
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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.
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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.

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Locator 4 Type of Bill
Type of Bill 0741- Original Bill 0747-
Adjustment Invoice 0748- Void Invoice

• TYPE
• OF BILL

0741
Only Approved claims can be Adjusted
or Voided.
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Locator 6 Statement Covered Period

• Enter the beginning and ending service dates
  reflected by this invoice (include both covered
  and non-covered days).
• Use both from and through for a single day.
• If the total days of service exceed 31 days, use
  additional billing invoices.
• Claims submitted which exceed the 31 day
  limitation will be denied.

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Locator 6 Statement Covers Period

• STATEMENT COVERS PERIOD
• FROM THROUGH

050507
050507
Enter the beginning and ending service dates
reflected by this invoice (include both covered
non-covered days). Use both from and through
for a single day.
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Locator 7 Reserved for AssignmentNOT REQUIRED
7
NOTE This locator on the UB-92 contained the
covered days of care. Locators 39-41 on the
UB-04, are the appropriate fields to enter
covered and non-covered days.
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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.
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Locator 10 Patient Birthdate
10 BIRTHDATE
10011980
Enter the date of birth of the patient using
the following format - MMDDYYYY.
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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
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Locator 12 Admission/Start of Care
ADMISSION 12 DATE
050507

Please enter the start date of this episode of
care.
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Locator 13 Admission Hour
ADMISSION 13 HR
14
Enter the hour during which the patient was
admitted for outpatient care. Outpatient
Rehab Agencies may use a default time for all
patients. NOTE Military time is used as defined
by NUBC.
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Locator 14 Priority Type of Visit

• Appropriate PRIORITY TYPE codes accepted
  by DMAS are

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

• Appropriate codes accepted by DMAS are

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Locator 15 Source of Referral for Admission
Visit
15 SRC
1
Enter the code indicating the source of
the Referral for this admission or visit.
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Locator 17Patient Discharge Status

• Appropriate codes accepted by DMAS in claims
  processing

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Locator 17Patient Discharge Status

• Appropriate codes accepted by DMAS in claims
  processing

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Locator 17 Patient Discharge Status

• Appropriate codes accepted by DMAS in claims
  processing

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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).
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Locators 18-28 Condition Codes
Codes used by DMAS in the adjudication of claims
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Locators 18-28 Condition Codes(Required if
Applicable)
Condition Codes 18 19 20 21 22 23 24 25
26 27 28
A1 A5
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.
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Locator 29 Accident State(Conditional)

• ACDT STATE

VA
Enter if known, the state ( two digit Postal
State Code abbreviation) where the motor vehicle
accident occurred.
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Locator 30Crossover Part A Indicator(Required
if Applicable)

30
CROSSOVER
NOTE DMAS is requiring for Medicare Part
A crossover claims that the word CROSSOVER be
in this locator.
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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.
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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.
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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.
• Providers can use this locator to list the 4
  digit adjustment/void code when correcting an
  approved claim.
• A complete list of adjustment and void codes can
  be found in Chapter V of the Rehabilitation
  manual.

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Locators 39-41Value Codes and Amount

• Note DMAS will be capturing the number of
  covered day (s) or units for outpatient services
  with these required value codes
• 80 Enter the number of days for re-occurring
  outpatient rehab claims.
• All claim submissions must have number listed.

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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
• No Other Coverage
• Billed and Paid
  (enter amount paid by primary carrier)
• 85 Billed Not Covered/No Payment

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Locators 39-41Value Codes and Amount

• For Part A 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.

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Locators 39-41Value Codes and Amount

• VALUE CODES
• CODE AMOUNT

• VALUE CODES CODE AMOUNT

15
83 225 00
80
a
b
c
d
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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.

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Locator 42 Revenue Code
42 REV. CD.
1
0421
0431
2
0441
3
0001
4
Revenue codes are four digits, leading zero,
left justified and should be reported in
ascending numeric order.
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Locator 43 Revenue Description
43 DESCRIPTION
Physical Therapy Visit Charge
Occupational Therapy Visit Charge
Speech Language Pathology Visit Charge
Enter the standard abbreviated description of
the related revenue code categories included on
this bill.
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Locator 44 HCPCS/Rates/HIPPS
Rates Codes
44 HCPCS / RATE / HIPPS CODE
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Locator 45 Service Date(Required if Applicable)
45 SERV. DATE
050507
Enter the date the outpatient rehab service was
provided.
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Locator 46 Service Units
46 SERV. UNITS
6
12
Outpatient Enter the unit (s) of service for
physical therapy, occupational therapy or
speech-language pathology visit or session (1
visit 1 unit, even if more than 1 modality is
done).
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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.
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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.

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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.
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Locator 51 Health Plan Identification
51 HEALTH PLAN ID
Note DMAS will no longer use this locator to
capture the Medicaid provider number. Refer to
locators 56 and 57.
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Locator 56National Provider Identification
(NPI)

• DMAS will send a confirmation letter once a
  providers NPI has been successfully added by the
  Provider Enrollment Unit (PEU) to VAMMIS.
• Providers may submit their NPI in this field.

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Locator 56 NPI
56 NPI
1234567890
Once the DMAS Dual Use Period is completed, the
NPI will be required for all claims submissions.
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Locator 57A-C Other Provider Identifier

• Enter the nine-digit Medicaid PIN number in this
  field April 1, 2007 Memo notification of the
  end of the Dual Use Period.
• For providers who are given an Atypical Provider
  Identifier (API) Number, the API will be listed
  in this locator.

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Locator 57A-COther Provider Identifier
001234567
57 OTHER PRV ID
Enter the Medicaid PIN in this locator during
the Dual Use Period only. Atypical Provider
Number (API) will also be listed in this field.
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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.
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Locator 59 Patients Relationship to Insured

• Note appropriate codes accepted by DMAS are

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Locator 59 Patients Relationship to Insured
52 REL. INFO
18
Enter the code indicating the relationship of
the insured to the patient.
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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.
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Locator 63 Treatment Authorization Codes
63 TREATMENT AUTHORIZATION CODES
A B
12345678910
Enter the 11 digit preauthorization number
assigned by KePro for the appropriate outpatient
services to be billed to Virginia Medicaid.
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Locator 64Document Control Number (DCN)

• This locator is to be used to list the original
  Internal Control Number (ICN) listed on your
  Remittance Advice (RA) 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.

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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.
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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
Currently, Virginia Medicaid will only accept a 9
in this locator.
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Locator 67 Principal Diagnosis Code Locators
67A-Q Other Diagnosis Codes
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.
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Locator 69 Admitting Diagnosis

• ADMIT
• DX

82101
Enter the diagnosis code describing the
patients diagnosis at the time of
admission. NOTE Do not use decimals.
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Locator 72 External Cause of Injury(Required
if Applicable)
E895
c
72 ECI
b
Enter the diagnosis code pertaining to
external causes of injuries, poisoning, or
adverse effect.
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Locator 74 Principal Procedure Code and Date

• Note for outpatient claims, a procedure code
  must appear in this locator when revenue codes
  0360-0369, 0420-0429, 0430-0439, and 0440-0449
  (if covered by Medicaid) are used in Locator 42
  or the claim will be rejected.

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Locator 74a-e Other Procedure Codes and
Date(Required if Applicable)

• OTHER PROCEDURE
• CODE DATE

9339
030507
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.
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Locator 76 Attending Provider and Identifier

• Outpatient 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.
• The NPI may be entered in the field identified as
  NPI beginning April 1, 2007.

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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.
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Locators 78-79Other Provider Name and
Identifiers

• This field will be used to list the ID number for
  the Primary Care Physician (PCP) who authorized
  the outpatient visit.
• For MEDALLION patients referred to the Home
  Health Agency, enter the ID number for the PCP
  who authorized the treatment.
• This information is required for all MEDALLION
  patients treated for non-emergency services.

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Locators 78-79Other Provider Name and
Identifiers

• For Client Medical Management (CMM) patients
  referred to the Home Health Agency by the PCP,
  enter the providers ID number and attach the
  Practitioner Referral Form (DMAS-70).
• Enter the qualifier DN and the nine digit number
  assigned by Medicaid for the PCP, April 1, 2007-
  Memo Notification of the End of the Dual Use
  Period.
• The NPI may be entered in the field identified as
  NPI.

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Locators 78-79 Other Provider Name and
Identifier
78 OTHER
NPI 1234567890
Accepted for claims submitted April 1, 2007 and
after.
DN
001234567
QUAL
Accepted April 1, 2007 Memo Notification of
the End of the Dual Use Period
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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.
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96
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 (e.g., Home
  Health Agency also providing Personal Care
  Services).

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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.

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Locator 81 Code-Code Field
81CC a b c d
B3 251E00000X
Enter the provider taxonomy code for the billing
provider when the adjudication of the claim is
known to be impacted.
98
99
DMAS Service Types May Require A Taxonomy Code on
Claims
Taxonomy Codes
99
100
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.

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REMITTANCE VOUCHERSections of the Voucher

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

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102
Please complete and turn in your evaluation form
103
THANK YOU
Department of Medical Assistance Services

• www.dmas.virginia.gov