DMAS Division of Health Care Services

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DMAS Division of Health Care Services

• Billing for Emergency and Non-Emergency
  Transportation Services

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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

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Health Insurance Claim Form CMS 1500

• Whats Changed?
• We want to remind everyone that this is not a
  change in policy.
• Effective April 1, Cross Over claims will be
  processed using the correct manner.
• Medicaid reimbursement for these services is less
  than 80 of the Medicare payment level, Medicare
  crossover claims will be paid at 0.00 with the
  claims edit 364 (Exceeds Medicaid Allowed
  Amount.)
• Use Font size 10 or larger
• Mail all Ground Ambulance claims to First Health,
  address at end of presentation
• Most Common Mistakes
• Using a 2-code system (One code for base rate and
  second code for mileage)
• Trying to bill using CPT/HCPCS mileage codes
  with
• A0425
• A0435
• A0436
• Block 10b, make sure and check yes for auto
  accidents
• Block 10c, make sure to mark for other accidents

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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.

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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.

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Billing on the CMS-1500
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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

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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

9
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

10
TIMELY FILING

• Submit claims with documentation attached
  explaining the reason for delayed submission
• You must have the word Attachment in Locator
  10d and use modifier 22 in Locator 24D
  (Attachments include Run sheets, Call sheets,
  Pre-hospital Patient Care Report (PPCR)

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Block 1

• Enter an X in the MEDICAID box for the Medicaid
  Program

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Block 1
TRICARE
MEDICAID
CHAMPUS
1. MEDICARE
(Medicare )
(Medicaid )
(Sponsor's SSN)
2. PATIENT'S NAME (Last Name, First Name, Middle
Initial)
MEDICAID CLAIM
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Block 1a Recipient ID Number
1a. INSURED'S I.D. NUMBER (FOR PROGRAM
IN ITEM 1)
123456789014
(Be sure to include all 12 digits)
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Block 2 Patient's Name
2. PATIENT'S NAME (Last name, First Name, Middle
Initial)
Smith, Sam
5. PATIENT'S ADDRESS (No., Street)
14
15
Is Patients 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

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Block 10 Accident-Related
10. IS PATIENT'S CONDITION RELATED TO
a. EMPLOYMENT? (CURRENT OR PREVIOUS)
YES
NO
PLACE (State)
b. AUTO ACCIDENT?
WV
YES
NO
c. OTHER ACCIDENT?
NO
YES
You MUST check YES or NO for a, b c
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Block 10d
10d. RESERVED FOR LOCAL USE
ATTACHMENT
You MUST use the word "ATTACHMENT"
if documents are attached to the HCFA form.
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Block 11c - Insurance Plan Name or Program Name

• c. INSURANCE PLAN NAME OR PROGRAM NAME

Other Insurance COPAY
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Is There Another Health Benefit Plan?Block-11d

• Providers should only check yes if there is
  another third party carrier

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Block 11d - Is There Another Health Benefit Plan?

• d. IS THERE ANOTHER HEALTH BENEFIT PLAN?

If yes, return to and complete item 9 a-d.
NO
YES
20
21
Block 21 Diagnosis Codes
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY
31100
1.
3.
30130
2.
4.
May enter up to 4 codes
Omit decimals (List of frequently used diagnosis
codes are in the Transportation Manual)
21
22
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

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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
• Decimal between dollars and cents is required to
  read paid amount correctly
• Must be left justified

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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

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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

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Block 24A Dates of Service
24. A.
DATE(S) OF SERVICE
From
To
MM DD YY
MM DD YY
TPL27.08
06
06
03
01
03
01
1
2
Both FROM and TO dates
must be completed
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Dates must be within same calendar month
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Block 24B Place of Service
B.
41- Ambulance Land Or 42- Ambulance Air or
Water Not both
Place
of
Service
41
Medicaid accepts the same 2 digit CMS Place of
Service codes as Medicare.
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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

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Block 24C EMG
C. EMG
Y
Medicaid will accept a Y in this Locator to
indicate that the procedure was an emergency
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Block 24D Procedure Codes
D.
PROCEDURES, SERVICES, OR SUPPLIES
(Explain Unusual Circumstances)
CPT/HCPCS
MODIFIER
DMAS Recognizes the Following codes A0225 A0427
A0429 A0430 A0431
22
A0225
All Claims must have modifier 22
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Block 24E Diagnosis Code
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY
34431
1.
3.
2963
2.
4.
E.
DIAGNOSIS
POINTER
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.
1
1,2
31
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Block 24 F Charges
F.
CHARGES
500
00
Enter the usual
and customary charges
32
33
Block 24G Days or Units
G.
DAYS
OR
Enter the number of loaded miles of
transport. The 31 is an example that shows
loaded miles.
UNITS
31
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34
ID.QUALBlock-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.

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If Taxonomy codes are usedBlock-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.

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Fill in only if Taxonomy codes are needed Block
24I ID. Qual. 24J Rendering Provider ID
3416A0800X Or 3416L0300X
ZZ
3416A0800X is Air 3416L0300X is Land
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Block 24I ID. Qual. 24J Rendering Provider ID

J. RENDERING PROVIDER ID.
I. ID. QUAL
Taxonomy (if needed)
ZZ
12345647890
NPI
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Block 26 Patients Account Number (Optional)
26. PATIENT ACCOUNT NUMBER
12345678918765
Can not exceed 17 alphanumeric digits
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Total ChargeBlock 28

• DMAS now requires this locator to be completed
• Enter the total charges for the services in 24F
  lines 1-6.

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Block 28 Total Charges
28. TOTAL CHARGE

40
41
Block 29 Amount Paid (By Other Insurance)
29. AMOUNT PAID

41
42
Block 30 Amount Paid (By Other Insurance)
30. Balance Due

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Block 31 Signature Date
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
If there is a signature waiver
on file, you may stamp, print,
or computer-generate the signature.
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Service Facility Location InformationBlock-32

• Enter information for the location where services
  were rendered
• First line-Name
• Second line-Address
• Third line-City, State, 9 digit zip code
• 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

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Service Facility Location InformationBlock-32a-b
Leave Blank
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Block 32 Service Facility Location Information
Your Local Hospital XXXX Anywhere St. Your Town,
ST 12345-1456
32. SERVICE FACILITY LOCATION INFORMATION
Leave Blank
Leave Blank
a.
b.
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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

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Billing Provider Info PH -Block-33a-b

• Enter the 10 digit NPI number of the service
  location in 33a.
• Enter ZZ qualifier with the taxonomy code if
  needed, when using the NPI in 33a (example
  ZZ3416L0300Z)

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Block 33 Billing Provider Info PH
Your Local Hospital XXXX Anywhere St. Your Town,
ST 12345-1456
33. BILLING PROVIDER INFO PH
[phone]
ZZ3416L0300X (If needed)
a.
b.
1234567890
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Block 22 Adjustments and Voids
22. MEDICAID RESUBMISSION
CODE
ORIGINAL REF. NO.
1032
xxxxxxxxxxxxxxxx
From Original
Adjustment or
Remittance
Void
Resubmission Code
Chap. V, Medicaid Transportation Manual has code
list.
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Block 22 Medicaid Resubmission Codes

• Medicaid Resubmission of Adjustment Codes
• Primary Carrier has made additional
  payment
• Primary Carrier has denied payment
• Accommodation charge corrected
• Patient payment amount charged
• Correcting service periods
• Correcting procedure/service code
• Correcting diagnosis code
• Correcting charges
• Correcting units/visits/studies/procedures
• IC reconsideration of allowance,
  documented
• Correcting admitting, referring,
  prescribing,
• provider ID
• 1041 Incorrect Amount paid
• 1053 Adjustment reason is in the Misc.
  Category

• Medicaid Resubmission of Void Invoice Codes
• Original claim has multiple incorrect items
• Wrong provider identification number
• Wrong enrollee eligibility number
• 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
• Miscellaneous
• 1060 Other insurance is available

Original Reference Number/ICN - Enter the claim
reference number/ICN of the paid 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.)
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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. 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 attachments and mail to
• DMAS
• Transportation Unit, Suite 1300
• 600 East Broad Street
• Richmond, Virginia 23219

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Mailing Address for Emergency Air Ambulance Claims

• Emergency Air Ambulance Claims with Attachments
• DMAS
• Transportation Unit, Suite 1300
• 600 East Broad Street
• Richmond, Virginia 23219
• Note All claims must have attachments that
  include ambulance Pre-hospital Patient Care
  Report (PPCR) that establish medical necessity
  for emergency air and ground service. Beginning
  and ending mileage must be included on PPCR.

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Air Ambulance Claim Procedure and Claim
Reconsideration

• All air ambulance claims are reviewed for medical
  necessity of using an emergency air ambulance.
  Claims submitted that do not establish air
  ambulance medical necessity will be paid at 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.

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Mailing Address for Emergency Ground Ambulance
Services

• Emergency Ground and Neonatal Ambulance Claims
  with Attachments
• DMAS-Transportation
• P. O. Box 27447
• Richmond, Virginia 23261-7447
• Note All claims must have attachments that
  include ambulance Pre-hospital Patient Care
  Report (PPCR) that establish medical necessity
  for emergency air and ground service. Beginning
  and ending mileage must be included on PPCR.

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Billing on the DMAS 30 31
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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)

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CHANGES

• Locator 01-Billing Provider Number
• Locator 06-Rendering Provider Number
• Locator 08-Type of Coverage

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Title XVIII- Block 01
01 Billing Provider Number
Enter the billing provider NPI number
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Title XVIII- Block 06
06 Rendering Provider Number
Enter the rendering provider NPI number
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Title XVIII Block 7
Primary Carrier Information Other ThanMedicare

07
2 No Other Coverage

5 Billed No Coverage
3 Billed and Paid
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Title XVIII Block 08
08
Type OfCoverageMedicare
Type Coverage Medicare- Mark type of coverage
B.
B
6
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Title XVIII- Block 17
17
Charges To Medicare
Block 17 Charges to Medicare- Enter the total
charges submitted to Medicare.
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Title XVIII- Block 18
Allowed By Medicare
18
Block 18 Allowed by Medicare- Enter the amount
of the charges allowed by Medicare.

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

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Title XVIII- Block 20
Deductible
20
Block 20 Deductible- Enter the amount of the
deductible (taken from the Medicare EOB).
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Title XVIII- Block 21
Co-Insurance
21
Block 21 Coinsurance - Enter the amount of the
coinsurance (taken from the Medicare EOB).
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Title XVIII- Block 22
Paid By Carrier Other Than Medicare
22
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.)
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Title XVIII- Block 23
Patient Pay Amt. LTC Only
23
Block 23 Patient Pay Amount, LTC Only- Leave
Blank.
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TITLE XVIII- Adjustment InvoiceDMAS-31

• Block 1 Adjustment/Void
  Check the appropriate block
• Block 2 Billing Provider Number Enter
  the NPI of the billing provider
• Block 6 Rendering 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.

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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.

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REMINDERS

• Xeroxed copies 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

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LogistiCare Contact Telephone Number For A0428
Non-Emergency Ambulance Non-Emergency Services

• LogistiCares Medicaid recipients toll-free
  reservation line 1-866-386-8331 - This line is
  intended for recipients, facilities, and
  hospitals to schedule trips
• All A0428 Medicaid Non-Emergency Ambulance trips
  must be pre-authorized, arranged, and paid for
  by LogistiCare.

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Resources

• TrailBlazer Federal Source for Medicaid and
  Medicare Information
• Website 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.gov

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Help Line

• HELPLINE
• The HELPLINE is available to answer questions
  Monday through Friday from 830 a.m. to 430
  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.

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Questions?
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THANK YOU