DMAS Division of Health Care Services

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
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
Health Insurance Claim Form CMS 1500

• Whats 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
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
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.

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
Billing on the CMS-1500
6
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
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
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
TIMELY FILING

• Submit claims with documentation attached
  explaining the reason for delayed submission

12
Block 1

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

13
Block 1
TRICARE
MEDICAID
CHAMPUS
1. MEDICARE
(Medicare )
(Medicaid )
(Sponsor's SSN)
2. PATIENT'S NAME (Last Name, First Name, Middle
Initial)
MEDICAID CLAIM
12
14
Block 1a Recipient ID Number
1a. INSURED'S I.D. NUMBER (FOR PROGRAM
IN ITEM 1)
123456789014
Be sure to include all 12 digits of the VA
Medicaid ID.
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
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

17
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
16
18
Block 10d If Applicable
10d. RESERVED FOR LOCAL USE
ATTACHMENT
Emergency Ground Ambulance trips 200 miles and
over, and more than one transport with same
service day MUST use the word "ATTACHMENT"

• Trips over 200 miles must have Pre-Hospital
  Patient Care Report (PPCR) attached
• More than one transport per day, attach statement
  This is second/third/forth transport.

17
19
Block 11c - Insurance Plan Name or Program Name

• c. INSURANCE PLAN NAME OR PROGRAM NAME

Other Insurance Name
18
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?

If yes, return to and complete item 9 a-d.
NO
YES
20
22
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
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
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
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
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
Block 24A Dates of Service (TPL example added if
applicable)
24. A.
DATE(S) OF SERVICE
From
To
MM DD YY
MM DD YY
TPL27.08
09
09
01
11
11
01
1
TPL8.60
11
01
09
11
01
09
2
Both FROM and TO dates
must be completed
26
Dates must be within same calendar month
28
Block 24B Place of Service
B.
Place
41- Ambulance Land Or 42- Ambulance Air or
Water Not both
of
Service
41
41
Medicaid accepts the same 2 digit CMS Place of
Service codes as Medicare.
27
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
Block 24C EMG
C. EMG
Y
Y
Medicaid will accept a Y in this Locator to
indicate that the procedure was an emergency
29
31
Block 24D Procedure Codes Neonatal Transport
with U1 Modifier
D. PROCEDURES, SERVICES, OR SUPPLIES
(Explain Unusual Circumstances)
CPT/HCPCS
MODIFIER
DMAS Recognizes the Following codes A0225
w/A0425 U1 A0427 w/A0425 A0429 w/A0425 A0433
w/A0425 A0430 w/A0435 A0431 w/A0436
A0225
A0425
U1
U1 Modifier is for Neonatal Mileage Only
30
32
Block 24D Procedure Codes Service and Mileage
CPT Codes One CPT Code on Each Line
D. PROCEDURES, SERVICES, OR SUPPLIES
(Explain Unusual Circumstances)
CPT/HCPCS
MODIFIER
DMAS Recognizes the Following codes A0225
w/A0425 U1 A0427 w/A0425 A0429 w/A0425 A0433
w/A0425 A0430 w/A0435 A0431 w/A0436
A0427
A0425
No Modifier is required
30
33
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.
1,2
1,2
31
34
Block 24 F Charges
F.
CHARGES
00
1500
500
00
Enter the usual and customary charges for each
CPT code
32
35
Block 24G Days or Units
G.
DAYS
OR
UNITS
Enter 1 for one unit of service. Enter the
number of loaded miles of transport.
1
31
33
36
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.
• Make sure to follow these instructions for each
  line.
• Taxonomy code must be used for each CPT code line.

37
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.
• 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
3416A0800X Or 3416L0300X
ZZ
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.
36
39
Block 24I ID. Qual. 24J Rendering Provider ID

J. RENDERING PROVIDER ID.
I. ID. QUAL
Taxonomy (if needed)
ZZ
12345647890
NPI
Make sure and use ZZ and same taxonomy code for
each line.
37
40
Block 26 Patients Account Number (Optional)
26. PATIENT ACCOUNT NUMBER
12345678918765
Can not exceed 17 alphanumeric digits
38
41
Total ChargeBlock 28

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

42
Block 28 Total Charges
28. TOTAL CHARGE

40
43
Block 29 Amount Paid (By Other Insurance)
29. AMOUNT PAID

41
44
Block 30 Balance Due (Block 28 minus Block 29)
30. Balance Due

42
45
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.
43
46
Service Facility Location InformationBlock-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
Service Facility Location InformationBlock-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
Leave Blank
a.
b.
46
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
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
[phone]
ZZ3416L0300X (If needed)
a.
b.
1234567890
49
52
Block 22 Adjustments and Voids Send in
Adjustment for MILEAGE CODE ONLY with mileage ICN
number.
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.
50
53
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 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.)
51
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
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
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
Billing on the DMAS 30 31
56
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
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
Title XVIII Block 7
Primary Carrier Information Other ThanMedicare

07
2 No Other Coverage

5 Billed No Coverage
3 Billed and Paid
63
Title XVIII Block 08
08
Type OfCoverageMedicare
Type Coverage Medicare- Mark type of coverage
B.
B
6
64
Title XVIII- Block 17
17
Charges To Medicare
Block 17 Charges to Medicare- Enter the total
charges submitted to Medicare.
65
Title XVIII- Block 18
Allowed By Medicare
18
Block 18 Allowed by Medicare- Enter the amount
of the charges allowed by Medicare.

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

67
Title XVIII- Block 20
Deductible
20
Block 20 Deductible- Enter the amount of the
deductible (taken from the Medicare EOB).
68
Title XVIII- Block 21
Co-Insurance
21
Block 21 Coinsurance - Enter the amount of the
coinsurance (taken from the Medicare EOB).
69
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.)
70
Title XVIII- Block 23
Patient Pay Amt. LTC Only
23
Block 23 Patient Pay Amount, LTC Only- Leave
Blank.
71
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.

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

75
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

76
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.

77
Questions?Or email question(s) to
Transportation_at_DMAS.Virginia.gov
78
THANK YOU