Welcome Nursing Facilities

1
Welcome Nursing Facilities

• Department of Human Services
• June 2009

2
Goal

• To provide you with the tools and resources that
  are necessary to access and perform many of the
  features and functions that you
  need to submit your claims for payment processing.

3
Objectives

• After completing the Nursing Facility training
  tutorial, you will
• Have a basic understanding of the replacement
  MMIS and how it impacts Nursing Facility
  providers.
• Be able to submit Institutional (UB-04) claims
  on paper, through the provider Web portal, or by
  submitting through Electronic Data Interchange
  (EDI).
• Be able to perform basic Web portal functions.
• Be able to perform claim searches and
  adjustments by using the Web portal.

4
DHS at a glance
5
DHS structure
DHS Director Bruce Goldberg, MD
Addictions and
Mental Health (AMH)
Administrative Services Division (ASD)
Children, Adult and Families
Division (CAF)
Seniors and People with Disabilities (SPD)
Division of Medical Assistance Programs
(DMAP)
Public Health Division (PHD)
6
Department of Human Services

• The Department of Human Services (DHS) mission
• To make it possible for people to lead lives that
  are independent, healthy and safe.
• DHS provides
• Services to more than 1 million Oregonians every
  year.
• More than 300 programs and different services
  through 170 field offices located throughout the
  state.
• Approximately 85 of our biennial budget flows
  directly to clients and communities as payments
  to
• Foster parents
• Nursing homes
• Healthcare providers and clinics
• Local governments, and
• Other service providers

7
Seniors and People with Disabilities

• SPD provides services to seniors and people with
  disabilities, including physical and
  developmental disabilities.
• Services are determined by an individuals
  financial circumstances and/or personal daily
  needs.
• SPD determines eligibility for state and federal
  programs.

8
Division of Medical Assistance Programs

• Administers state programs that provide medical
  coverage to low-income Oregonians.
• Processes health care claims according to the
  policies of the State of Oregons Medicaid
  programs.
• Issues payment to enrolled Medicaid providers.

9
DMAP programs

• DHS Programs administered by DMAP
• Medicaid (OHP)
• Childrens Health Insurance Program (CHIP)
• Breast and Cervical Cancer Program (BCCP)
• Senior Prescription Drug Assistance Program
  (SPDA)
• Disease Case Management Program (DCM)

10
Medicaid Management Information System (MMIS)
11
Medicaid Management Information System

• Previous MMIS
• Implemented in 1980.
• Designed to handle paper claims and track
  eligibility.
• It was decided that a replacement MMIS was needed
  due to outdated technology.
• It was unable to meet the demands of federal,
  state and local legislation.
• Replacement MMIS
• Implemented in 2008/2009.
• Provides real-time client eligibility.
• Allows for faster claims processing.
• Self-service access via the Internet.

12
MMIS

• The replacement MMIS, has a secure Web portal
  feature that will allow DHS authorized Nursing
  Facility providers access to perform various
  internet-based self-service functions, such as
• Verify and view current client eligibility.
• Submit, track and view claims online.
• Track and view Plan of Care (POC) online.

13
Provider Web portal

• The Provider Web portal is free of charge and
  designed to be accessible 24 hours a day, 7 days
  a week.
• Access to the Web portal requires
• An Internet connection.
• Microsoft Internet Explorer 6 or 7, or Firefox
  2.0.
• Authorization from DHS to access Web portal
  services.
• Your Provider ID and the Personal Identification
  Number (PIN) issued by DHS.

14
ID and PIN

• To access the Provider Web portal for the first
  time, providers must login using their DHS
  provider ID and a Personal Identification Number
  (PIN) sent by DHS.
• After the account has been set up, providers will
  login using their own usernames and passwords
  you will no longer need the PIN letter.
• If you have not received your PIN or you need to
  have your PIN reset, contact
• DMAP Provider Services
• 800-336-6016
• DMAP.providerservices_at_state.or.us
• Team.Provider-ACCESS_at_state.or.us
• Monday - Friday, 800 a.m. to 500 p.m.

15
Eligibility verification
16
Verification of eligibility

• Providers are responsible to verify eligibility
  prior to providing services in order to ensure
  reimbursement of services.
• Providers are responsible to verify that a person
  is enrolled in a benefit package that covers the
  services rendered.
• Providers assume full financial responsibility in
  serving a person whose
  eligibility was not
  confirmed on the date(s) of service.

17
Resources

• Two options are available to verify medical
  eligibility
• Automated Voice Response (AVR)
• Provides free, phone-based eligibility
  verification.
• MMIS Provider Web portal
• Provides free, real-time eligibility
  verification over the Web.

18
Automated Voice Response (AVR)
19
What is AVR?

• The AVR is a computer system that gives
• Client eligibility.
• Status of a claim.
• Status of a prior authorization.
• Recent payment or suspended claim information.
• Benefit limits for eye exams and optical
  services.
• Allows providers to complete automated inquiries
  using a touch-tone telephone.
• AVR is available 24 hours a day, 7 days a week.

20
What does AVR provide?

• The AVR can tell you the following information
• The clients Medicaid identification number.
• The clients date of birth.
• If a client is eligible on a specific date of
  service.
• Which benefit plan the client is eligible for.
• The clients copayment requirement.
• If the service is covered in the clients benefit
  plan.
• If the client is enrolled in a managed care plan.
• If the client has other insurance coverage.
• The date of the clients last vision exam and
  glasses.

21
Personal Identification Number

• To access AVR, providers must use the personal
  identification number (PIN) sent by DHS.
• If you have not received your PIN from DHS or you
  need to have your PIN reset, contact
• DMAP Provider Services
• 800-336-6016
• DMAP.providerservices_at_state.or.us
• Team.Provider-ACCESS_at_state.or.us
• Monday - Friday, 800 a.m. to 500 p.m.

22
(No Transcript)
23
Web portal eligibility verification
24
Getting started

• In the address field of your Internet browser,
  type https//www.or-medicaid.gov.
• The session times out after 20 minutes of
  inactivity.
• Any work or changes that have not been submitted
  will be lost.
• If your session expires, you will receive a
  message.

25
Accessing the Web portal
Click here to access the Web portal.
26
Web Portal login

• 1. Select Account.
• 2. Select Secure Site.
• 3. Enter your User Name and Password.
• 4. Select Login.

27
Home page
This is the DHS provider that corresponds with
the user name entered on the previous screen.
Provider ID MCD Taxonomy
Zip Code -

• Select Eligibility

28
Eligibility verification request

• To search for client eligibility use one of three
  combinations
• 1. Client ID and dates of service
• 2. Client SSN, birth date and dates of service
• 3. Client name, birth date and dates of service.
• The Procedure Code field is used to identify
  service limitations for a specific procedure such
  as the next available eye exam. This field would
  not apply to Nursing Facilities.

29
Eligibility verification request
XXX
12/01/2008 12/31/2008

• Enter one of the 3 combinations as indicated on
  the previous page and click Search.
• You can view 13 months of historical eligibility
  up to todays date.
• The Provider Web portal will not give future
  eligibility information. All end dates listed in
  your search results are either the date the
  clients coverage ended or the To DOS you
  listed in your request.

30
Eligibility search results displays 6 sections
XXX
Doe Jane

• Client information.
• Benefit Plan (formerly benefit package).
• TPL (third party liability).
• Managed Care.
• Lockin.
• Service Limitations.

31
Client information section
XXX
Doe Jane

• The client information section displays basic
  information about the client
• Medicaid ID number
• SSN
• Last dental visit
• Branch ID and phone number
• Name of client
• Medicare Parts A, B or D effective dates

32
Benefit plan section
Should have all 3 plans
BMH - OHP Plus
BMD - OHP with Limited Drug
BMM - QMB OHP with Limited Drug
KIT - OHP Standard
MED - Qualified Medicare Beneficiary
CWM - Citizen/Alien-Waived
Emergency Medical (CAWEM)
CWX - CAWEM Plus
NFC - Nursing Home NFG -
Nursing Facility Developmental Disability
Specialized Services NFS - Nursing
Home Short Term NOTE NFS is not currently
using, but maybe at a later date.
SMHS Title 19 State Plan Mental Health Services

• The client benefit plan section gives information
  about the clients benefit plan (formerly benefit
  package).
• If you see a benefit plan that is not listed in
  the boxes above, disregard all other codes they
  are for internal use only.

33
Third party liability (TPL) section
Carrier Name Policy Number
Policy Holder Coverage Type
Effective Date End
Date Blue Cross
Doe, John
Major Medical 08/01/2000
11/30/2008
Prime Dental
Health
Doe, John Dental
08/01/2000
11/30/2008

• Displays specific information about the clients
  third-party resources (other insurance).

34
Managed Care section

• The Managed Care section displays information
  about which managed care plan or primary care
  manager the client is enrolled in.
• Plan types are
• FCHP - Fully Capitated Health Plan (watch for
  this one)
• DCO - Dental Care Organization
• MHO - Mental Health Organization
• PCO - Physician Care Organization
• PCM - Primary Care Manager (and this one)
• CDO - Chemical Dependency Organization

35
Lockin section
Lockin Plan Effective Date
End Date Provider
Provider Name Provider
Phone Pharmacy
08/01/2000 10/31/2007
NPI My Pharmacy
(503) -

• If the client is required to use a specific
  pharmacy through the Pharmacy Management Program
  (PMP), the pharmacy information will be listed in
  this section.

36
Service limitation section
Service Limitation has been found for Procedure
Code 92002, next possible date of service is
12/01/2008

• Note This section does not apply to Nursing
  Facilities.
• This section shows the next available date for a
  specific service that has limitations according
  to Oregon Administrative Rules.

37
Open card example

• 1. This example shows a From/To DOS date
  range.
• 2. Indicates that the client has Medicare Parts
  A and B coverage.
• 3. Indicates the client is in the BMM (Qualified
  Medicare Beneficiary and OHP with Limited Drug)
  and NFC (Nursing Home) benefit plans. Ignore
  SMHS.
• No rows found indicates the client is not
  enrolled in a managed care plan during the
  From/To DOS listed in this request.

XXX
Doe Jane
XXX
38
Managed care example

• 1. This example shows a From/To DOS date
  range.
• 2. Indicates that the client does not have
  Medicare coverage.
• 3. Indicates the client is in the BMH (OHP
  Plus) and NFC (Nursing Home) benefit plans.
  Ignore SMHS.
• Indicates the client is enrolled with FCHP, MHO
  and DCO managed care plans.

XXX
XXX
Doe Jane
39
Client not eligible example
XXX

• 1. This example shows a specific from/to DOS
  date range.
• 2. Indicates that the client is not eligible for
  the requested date range.

40
Plan of Care
41
Plan of Care
Select POC
XXX

• The POC search screen allows you to look up an
  approved and active Plan of Care.
• There are four ways to search for a Plan of Care.
• Enter the From/To date of service and Client ID.
• Enter the Client ID only.
• Enter the From/To dates of services.
• Leave all fields blank.

42
POC results

• The POC search results returns all active POCs
  based on the criteria that was entered at the
  Search screen.
• To review the details of the POC, click on the
  line and the detail information will appear.

43
Detail information
Revenue Code 100 All
inclusive/room and board
SPD Resident Stay
Nursing Facility
XXX Jane Doe
System price
01/01/2008 04/15/2008
106 0.00
0
0.00

• POC detail information includes
• Referring provider name/number
• Client ID number
• Client name

• Service
• Revenue center code
• Service description
• Effective/end dates
• Client liability

• Units/
• How you are reimbursed
• Status
• Used/balance units and dollars

44
Claims processing
45
MMIS

• The federal government requires DHS to process
  Medicaid claims through the automated claim
  processing system which is MMIS.
• This system is a combination of people and
  computers working together to process claims.
• This system performs daily edits for presence and
  validity of data.
• DHS staff only reviews claims that MMIS cannot
  make a payment decision based on the information
  submitted on the claim and other system related
  data (i.e. eligibility).

46
Claims Processing

• Paper claims submitted by mail go to the DHS
  Office of Document Management (ODM) Imaging Unit.
  
• ODM processes hardcopy claims using Optical
  Character Recognition (OCR) scanning.
• Make sure your claim form meets OCR
  specifications.
• A Remittance Advice (RA) listing all claims
  adjudicated is mailed to the provider (with
  payment if appropriate).
• NOTE Effective August 1, 2009, only red forms
  will be acceptable.

47
Claim processing times

• 80 of the departments claim volume is
  electronic.
• Electronic claims process in real-time and
  usually adjudicate the week in which they are
  submitted.
• Paper claims may take up to three weeks for
  processing.
• DMAP pays providers on a weekly Friday cycle.
• Electronic fund transfers are processed on
  Wednesdays in the week following the Friday
  claims cycle.
• Less than two percent of claims suspend. Once
  they suspend, DMAP works them within 14 days.

48
Prior to submitting a paper claim

• Verify eligibility to assure the client is
  eligible on the date of service for the services
  provided.
• Bill third-party resources first, DHS is the last
  payer.
• Check the provider number to verify the claim
  will be submitted for the correct provider.

49
A few tips!

• When submitting handwritten claim forms, you must
  use blue or black ink, never use red ink.
• Make sure your hand writing is legible and
  clearly indicates zeros (0) versus Os, fives
  (5) versus Ss, ones (1) versus Ls, and eights
  (8) versus Bs.
• If possible, submit no more than one line of
  services per claim form.
• Do not use liquid whiteout.
• Check your printer alignment.

50
Form suppliers

• The UB-04 form is not supplied by DHS.
• Forms are available by contacting one of the
  following
• Local business forms suppliers
• Standard Register Company, Forms Division
  (800-755-6405)

51
Introducing the UB-04
52
(No Transcript)
53
The UB-04 claim form

• Not sure if you are using the correct form?
• The bottom left corner will say UB-04 CMS-1450.

54
Top section
Required for SNF and PHEC claims
Required for SNF claims
Red Required
Yellow Optional
55
Box 1 - optional
Nursing Facility PO Box
Anytown, OR 97

• Billing Provider Information
• Enter the name and address of the Nursing
  Facility that is requesting to be paid for the
  services rendered.

56
Box 3a - optional
X123400

• Patient Account Number
• Enter your residents account number here.
• This box allows up to twelve characters.
• This number will appear on your Remittance
  Advice (RA).

57
Box 4 - required
Type of Bill
Enter the
three-digit numeric code to identify
the type of facility, type of care provided,
and frequency of services you are billing for.
651
ICF SNF Swing Description
651 211 181 Admit through discharge.
652 212 182 First claim.
653 213 183 Continuing claim.
654 214 184 Last claim.
Will use SNF type of bill at a later date.
58
Box 6 - required
120108 123108

• Statement Covers Period
• Enter the beginning and ending dates of
  services covered by this claim.
• From date is the date services began.
• Through date is the last paid date for the
  service period, or last paid day before
  discharge.

59
Statement covers period - notes

• If billing for an entire month and there is no
  break in service or change in level of care, the
  through date will be the last day of the month.
• When a resident is discharged, the through date
  must be one day prior to the day of discharge.
• Example Admitted 12/01/08
  
  Discharged 12/15/08
  Through date will be
  12/14/08 (it will read 12/01/08 thru 12/14/08).
• NOTE Submit a new UB-04 each time there is a
  break in service.

60
Box 7-required for SNF claims only
XOVR

• Crossover Indicator
• NOTE This field is not used at this time,
  but will be required at a later date.
• Enter XOVR to indicate the claim is a
  Medicare or a Medicare Managed Care crossover
  claim.
• Leave this blank for ICF claims.

61
Box 8b - required
Resident, Your

• Patient Name
• Enter the residents name exactly as it is
  printed on the Medical Care Identification.
• Use the clients last name first.
• Do not use nicknames.

62
Box 12 - required
120108

• Admission Date
• Enter the original admission date.

63
Box 13 - required
10

• Admission Hour
• Enter the hour of admission in military time.
• Example
  
  01 100 a.m.
  
  10 1000 a.m.
  
  14 200 p.m.
  23
  1100 p.m.

64
Box 16 - optional
15

• Discharge Hour
• Required if the resident discharged on the last
  day of the Statement Covers Period.
• Enter the discharge hour in military time.
• Example
  01
  100 a.m.
  10 1000
  a.m.
  14 200
  p.m.
  23 1100 p.m.

65
Box 17 - required
30

• Discharge Status
• NOTE The last day in the statement covers
  period will not be paid if using any other code.
  
• Enter resident discharge status.
• Enter 30 on nursing facility claims.

66
Box 31 - optional

• Occurrence
• Enter the two-digit code to indicate the type
  of occurrence and the date of the occurrence
  01
  Auto accident
  
  04 Employment related accident
  
• Pursue all prior resources first.
• DHS is the payer of last resort.

67
Box 35 - required for SNF claims only
70 112808 010209

• NOTE This field is not used at this time, but
  will be required at a later date.
• Occurrence Span
• Enter 70 occurrence code.
• Enter the date the resident was admitted to the
  hospital
• Enter the date the resident discharged from the
  hospital.
• To receive coinsurance payment, or the 20-day
  post hospital extended care (PHEC) benefit, this
  box must be completed.

68
Box 39 40 - required for SNF claims only
A1 695 00
A2 95 00

• Value Codes
• NOTE This field is not used at this time, but
  will be required at a later date.
• Box 39
• Enter value code A1 to identify Medicare Part
  A or Part B deductible, and the amount.
• Box 40
• Enter value code A2 to identify Medicare Part
  A or Part B coinsurance, and the amount.

69
Middle section
Red Required
70
Box 42 - required

• Revenue Center Codes
• Enter a three-digit revenue center code which
  most accurately describes the service provided.
• Enter 001 in line 23 to indicate claim total
  charges.

0100 0001
71
Revenue center codes
Type of care Revenue code Level of care Description
ICF/LTC 100 01 Basic
ICF/LTC 100 02 Pediatric
ICF/LTC 100 03 Complex medical add-on
ICF/LTC 100 04 Enhanced care
ICF/LTC 100 05 Outlier
ICF/LTC 100 06 Out-of-state NF
Swing bed 101 N/A Hospital swing bed (short stay)
20 day PHEC 101 N/A Post hospital extended care
SNF 022 N/A Medicare (no coinsurance days)
SNF 022 N/A Medicare (with coinsurance days
NOTE Revenue center codes 101 and 022 are not
used at this time, but will be required at a
later date.
72
Box 44 - do not use

• Leave this box blank.
• If anything is entered here, the claim will deny,
  suspend, or pay at an incorrect amount.

Leave blank
73
Box 46 - required

• Service Units
• Enter the number of days for each revenue
  center code listed.
• One day equals one unit of service.
• The total number of units must match the total
  number of days in the statement covers period
  listed in box 6 unless using a discharge day.

31
74
Box 47 - required

• Total Charges
• Enter the total usual and customary charge for
  each related revenue center code listed.
• Do not list credits.
• Do not use dashes.

4,200 00
75
Total - required
4,200 00

• Total Charges
• Enter the total amount billed.
• Add the charges as indicated from column 47.
• Do not list credits.
• Do not use dashes.
• Each claim form is a separate document, and is
  to be totaled as such.

76
Bottom section
Red Required
Yellow Optional
77
Box 50 - optional
Primary payer Secondary payer
Tertiary payer

• Payer Name
• Enter the names of up to three payer
  organizations in order.
• Example
  
  If Medicare is primary, enter on line A.
  If another Third
  Party payer is secondary, enter on line B.
  If Medicaid
  is tertiary payer, enter on line C.

78
Box 54 - optional

• Prior Payments
• Enter the total amount paid by other third
  party resources.
• Do not include
• Write-offs.
• DHS previously paid amounts.
• Copayments.
• Client liability.
• Use this box if a resident has long-term care
  insurance.

79
Box 56 - required

• National Provider Identifier (NPI)
• Enter your ten-digit NPI.

80
Box 57 - required

• Provider Number
• Enter your six or nine-digit (DHS issued)
  provider number.
• Do not list other payer provider numbers.
• Correspond the placement number as outlined in
  box 50 instructions.

81
Box 60 - required
X X X X

• Insureds Unique ID
• Enter the residents eight-character prime
  identification number (clearly enter letters
  versus numbers).
• Enter the number exactly as it appears on the
  Medical Care Identification.
• Correspond the placement as outlined in box 50
  instructions.

82
Box 66 - required
2989

• Diagnosis Code
• Enter the primary diagnosis code of the
  resident by using a valid ICD-9-CM code carried
  out to its highest degree of specificity.
• The diagnosis code must be the reason chiefly
  responsible for the service being provided.
• You may enter up to five codes if necessary
  listing them in boxes 67 - 67D.
• Do not use the decimal point.

83
Box 69 - required
2989

• Admit DX
• Enter the admitting diagnosis of the resident
  by using a valid ICD-9-CM code carried out to
  its highest degree of specificity.
• Do not use the decimal point.
• This can be the same as the primary diagnosis.

84
Box 78 - optional

• Other Physician ID
• This box is only required when the resident
  has a Primary Care Manager (PCM).
• Enter the ten-digit NPI of the PCM.
• Enter the six or nine-digit (DHS issued)
  provider number of the PCM.

85
Box 80 - optional
NC

• Third Party Resource
• If the resident has other medical coverage,
  enter the appropriate two-digit third party
  resource (TPR) explanation code.
• A code must be listed when the other insurance
  did not make a payment, and always when the
  recipient has more than one other insurance
  carrier.

86
Single carrier TPR codes
UD Service under deductible
NC Service not covered by insurance policy
PN Patient not covered by insurance policy
IC Insurance coverage canceled/terminated
IL Insurance lapsed or not in effect on date of service
IP Insurance payment went to policyholder
PP Insurance payment went to patient
NA Service not authorized or prior authorized by insurance
NE Service not considered emergency by insurance
NP Service not provided by primary care provider/facility
Single carrier TPR codes continued on next slide
87
Single carrier TPR codes
MB Maximum benefits used for diagnosis/condition
RI Requested information not received by insurance from patient
RP Requested information not received by insurance from policyholder
MV Motor Vehicle Accident Fund (MVAF) maximum benefits exhausted
AP Insurance mandated under administrative/court order through an absent parent and not paid within 30 days
OT Other (if above codes do not apply, include detailed explanation of why there was no payment from insurance)




88
Multiple carrier TPR codes
MP Primary insurance paid secondary paid
SU Primary insurance paid secondary under deductible
MU Primary and secondary under deductible
PU Primary insurance under deductible secondary paid
SS Primary insurance paid secondary service not covered
SC Primary insurance paid secondary patient not covered
ST Primary insurance paid secondary canceled/terminated
SL Primary insurance paid secondary lapsed or not in effect
SP Primary insurance paid secondary payment went to patient

Multiple carrier TPR codes continued on next two
slides
89
Multiple carrier TPR codes
SH Primary insurance paid secondary payment went to policyholder
SA Primary insurance paid secondary denied service not authorized
SE Primary insurance paid secondary denied service not considered emergency
SF Primary insurance paid secondary denied service not provided by primary care provider/facility
SM Primary insurance paid secondary denied maximum benefits used for diagnosis/condition
SI Primary insurance paid secondary denied requested information not received from policyholder




Multiple carrier TPR codes continued on next slide
90
Multiple carrier TPR codes
SR Primary insurance paid secondary denied requested information not received from patient
MC Service not covered by primary or secondary insurance
MO Other (if above codes do not apply, include detailed explanation of why there was no payment from insurances)







91
X123400
Nursing Facility PO
Box Anytown, OR 97
651
120108 120108
Resident, Your
120108 10 15 30
C O M P L E T E D
E X A M P L E
100

31 4,200 00

0001


4,200 00

Medicaid


XXXX
2989
2989
NC
92
Billing Cycles

• Monthly
• Bill on a monthly basis for residents that are
  identified as still a patient (Patient status
  code 30, as identified in box 17).
• Claims must be submitted on or after the 1st day
  of the month following the month in which
  services have been provided.
• Partial
• Bill for a partial month if the resident is
  discharged or if the resident expires before the
  end of the month.
• Paid
• Can adjust if necessary.
• Denied
• Rebill at any time.
• Suspended
• Wait for DHS to complete the review.

93
Break in service

• Any time a resident is out of the facility past
  midnight and is expected to return, it is
  considered a break in service.
• Each time there is a break in service, you must
  submit a separate UB-04 claim form.
• 12/01/08 resident is admitted to a basic level of
  care (separate UB-04).
• 12/05/08 resident goes to hospital and is
  expected to return.
• 12/06/08 resident returns from hospital at the
  basic level of care and remains at the facility
  through the end of the month (separate UB-04).
• Notify the local SPD office so the residents
  Plan of Care can be updated.

94
Things to remember

• Do not enter residents liability on the UB-04.
• Liability is automatically deducted from your
  total billed amount.
• Do not include the residents level of care on
  the UB-04.
• SPD enters the maximum daily amounts in MMIS.
• Contact your local SPD office for questions
  concerning level of care.

95
SNF crossovers (XOVR)

• NOTE This field is not used at this time, but
  will be required at a later date.
• Before billing DHS for coinsurance, you must bill
  the primary payer responsible for Medicare Part A
  benefit.
• DHS will pay coinsurance for days 21 through 100.
• Dont forget required boxes on the UB-04
• Box 7 enter XOVR.
• Box 35 enter occurrence span of the date the
  resident was admitted to the hospital, and the
  date the resident discharged from the hospital.
• Box 39 enter the appropriate value code and
  amount of coinsurance.
• Box 54 enter the amount Medicare paid.

96
Web portal institutional claims
97
Institutional claims

• From the main menu select Claims.
• Select Institutional from the drop-down menu.

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• There are six sections that will display.
• Institutional Claim
• TPL
• Medicare Information
• Detail
• Hard Copy Attachments
• Claim Status Information
• There are six additional sections that do not
  display.

Additional sections
located here.
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Institutional claim - section 1 - required

• Required fields are
• Client ID
• Claim type
• Type of bill
• From date
• To date

• Enter SPDs required information and as much
  information as possible to process your claim.
• The left side includes billing information.
• The right side includes service information.

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Additional sections
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Additional sections

• A navigation menu allows access to additional
  sections that do not appear on the main page.
• Additional sections are
• Diagnosis
• Condition
• Payer
• Procedure
• Occurrence/Span
• Value
• Click on the item to navigate a section.

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Diagnosis - additional section - required

• Allows entry of up to ten diagnoses.
• Click Add to activate the diagnosis section for
  each diagnosis to be entered.
• Enter the Diagnosis (to find a diagnosis code,
  use the Search feature).
• Enter the Sequence (diagnosis code pointer)
  number.

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Condition - additional section - do not use

• NOTE You may skip this section, it is not
  required for Nursing Facilities.
• Allows entry of one or multiple conditions (i.e.,
  disabled beneficiary, private room medically
  necessary).
• Click Add to activate the condition section for
  each condition to be entered.

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Payer - additional section - optional

• NOTE Ignore Medicare information for now, but
  this section may be used at a later date.
• This section allows entry of the names of the
  payer organizations being billed (A. Medicare, B.
  Other, C. Medicaid).
• Payers are to be entered in order of primary,
  secondary, and tertiary.
• Click Add to activate the Payer panel for each
  payer to be entered.

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Procedure - additional section - do not use

• NOTE You may skip this section, it is not
  required for Nursing Facilities.
• Allows entry of the 4-digit principal procedure
  code.
• The procedure code is used to describe the
  procedure performed for definitive treatment
  rather than for diagnostic or exploratory
  purposes.
• Click Add to activate the procedure section for
  each procedure to be entered.

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Occurrence/Span - additional section - optional

• Required fields are
• Sequence
• Occurrence code
• From date

• Allows entry of the occurrence code (auto
  accident, employment related accident, qualifying
  hospital stay) relating to the billing period.
• Click Add to activate the Occurrence/Span
  section.
• Use only one day for the From and To Date.

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Value - additional section - optional

• NOTE You may skip this section, it is not used
  at this time, but may be used at a later date.
• Allows entry of the value code and related dollar
  or unit amounts to identify data of a monetary
  nature (most common semi-private rate).
• Click Add to activate the Value section.
• Enter the Value (to find a value code, use the
  Search feature).

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TPL - section 2 - optional

• If a third party payer was billed, enter that
  information in this section.
• Click Add to activate.
• Enter as much information as necessary.
• If a third-party did not make a payment or made a
  partial payment, the appropriate HIPAA Adjustment
  Reason Codes (ARC) must be entered.

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Medicare information - section 3 - optional

• NOTE You may skip this section, it is not used
  at this time, but may be used at a later date.
• This section is only completed when the client
  has Medicare.
• All fields are required.

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Detail - section 4 - required

• Required fields are
• From and To Dates of Service
• Units
• Charges
• Revenue code
• Medicare fields (if applicable)

• Allows entry of up to 999 detail lines.
• Click Add to activate the section for each
  service you are billing.

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Claim status information - section 6

• Claim status information displays at the bottom
  of all claims.
• No data displays before the claim has been
  submitted.
• Click Submit.

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Completed institutional claim example. The
buttons at the bottom provides further action if
necessary.
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Claim status information - section 7

• Once the claim is submitted, this section
  indicates whether a claim is paid, suspended or
  denied.
• Provides the Internal Control Number (ICN) of the
  claim.
• Date the claim paid or denied.
• DHS allowed amount.
• Click on the coversheet button if submitting
  supporting documentation.

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HIPAA Adjustment Reasons

• The HIPAA Adjustment Reasons section appears once
  the claim is submitted, and provides explanation
  of benefit (EOB) information.
• This section populates with explanations/reasons
  specific to the claim.

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Web portal claim search
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Claims search section

• Select Claims from the main menu.
• 2. Select Search.
• Enter any of the fields necessary (ICN, client
  ID, date of services, claim type, status, or date
  paid) to conduct your search.
• 4. Click on Search.

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Claims search results

• To view the entire claim, click on the line item.
• The claim will appear identical to the completed
  claim example shown previously.

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Claim actions
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Paid claim - adjust

• The adjust button allows modification of
  information within the claim, and then resubmits
  the claim to DHS.
• Modify and update data as necessary.
• Click on Adjust.

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Paid claim - void

• The void button cancels an entire claim that was
  previously submitted and paid.
• Click on Void.
• Any amount previously paid by DHS will be
  recouped.
• Be extremely cautious when using the Void
  button. You will not receive a warning.

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Paid claim - copy claim

• The copy claim button makes an exact duplicate of
  the existing claim.
• Once copied, claims data can be updated, and the
  claim can be submitted as a new claim.
• Click Copy Claim.
• Update information as needed.
• Click Submit.

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Denied claim - re-submit

• The re-submit button allows modification of
  information within the claim, and then resubmits
  the claim to DHS.
• Enter new data in appropriate fields.
• Click Re-submit.

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Questions?
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Remittance Advice (RA)
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About the RA

• DHS mails the paper Remittance Advice (RA) to the
  provider.
• The RA tells about payment or other claims
  actions made by DHS.
• You will continue to receive the paper RA until
  you specifically request DHS to stop sending the
  paper RA to you.
• You can also obtain claim status and payment
  information through Automated Voice Response, the
  Provider Web Portal, or the 835 transaction
  (Electronic Remittance Advice) typically because
  the electronic version of the RA is requested.

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How it works for claim submissions
Claim received
Claim processes through the
Medicaid
Management Information System (MMIS)
Meets payment criteria
Does not meet payment criteria
A Remittance Advice is generated
Claim Paid
Claim Partial Paid
Claim Denied
Claim in Process
Do not resubmit claim. If needed,
complete a DMAP Individual Adjustment Request
form (DMAP 1036) or adjust the claim via the Web
portal.
If needed, correct claim and resubmit, on paper,
the Web portal or EDI.
No action needed. Wait for DHS resolution.
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RA information

• Claim information is broken out by
• Internal Control Number (ICN)
• Type of claim
• Claim status
• The RA now includes additional information
• Banner message
• Third Party Liability (TPL) information (if
  applicable)
• Financial Transactions
• Remittance Advice Summary
• Explanation of Benefit (EOB) Descriptions

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Order of RA information

• Information will appear on the RA (as applicable)
  in this order
• Banner messages Messages from DHS.
• Claims By type of bill and ICN - Paid, denied,
  in process, adjustments.
• TPL information For each client, in order of
  ICN.
• Financial transactions Non-claim-specific
  payouts to or refunds from providers accounts
  receivable information.
• Summary Of all activity reported on the RA.
• EOB Code Descriptions For all the Explanation
  of Benefit (EOB) codes listed in the RA.
• Check the page headings to find the information
  youre looking for!

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RA page headings

• Every page of the RA contains the following
  header information
• The report number.
• RA number.
• The title of the RA section Check this section!
• Date of the RA.
• Provider name and address.
• DHS provider number (Payee ID), National Provider
  Identifier (NPI), Check or Electronic Fund
  Transfer (EFT) number, and the date the RA was
  generated.

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Page 1 - Banner message
Messages from DHS appear on
this page, separated by asterisks ().
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Claim information

• After the banner message page, claim information
  is divided in sections by the type of bill that
  is submitted
• Institutional claims Medicare Crossover Part A,
  Long Term Care (LTC).
• Claim information will be in order of Internal
  Control Number (ICN).
• Each type of bill section is further divided by
  claim status (paid, denied, in process, and/or
  adjustments).

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Internal Control Number (ICN)

• The first two digits of a claims ICN is the
  region code, which tells how the claim
  originated.
• This also tells you the order you will see the
  claims appear on your RA.

• Because claim information is sorted by ICN, the
  claim information on your RA will be sorted by
  the claim origin within each type of bill, in
  this order
• 1. Paper claims
• 2. EDI claims
• 3. Web claims

Region Code Region Code Description
10 Paper Claims With No Attachments
11 Paper Claims With Attachments
20 Electronic Claims With No Attachments
21 Electronic Claims With Attachments
22 Internet Claims With No Attachments
23 Internet Claims With Attachments
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LTC - claims paid
134
LTC - claims denied
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LTC - claims in process
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LTC - claim adjustment
The top ICN is the original claim. The bottom ICN
is the adjustment (adjustments have an ICN
beginning with 5).
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Long Term Care - financial transactions

1. Transitional payments will display in the
   Non-Claim Specific Payouts section.
2. Provider payments (e.g., refunds) will display in
   this section.
3. The Accounts Receivable (A/R) section shows
   recoupment information. (You will receive RAs
   with A/R information until there is a total
   balance of zero in this section).

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Summary information


This page is a summary of all actions described
in the RA. 1. Current weeks totals. 2.
Year-to-Date totals.
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Explanation of benefit
The last section of the RA is a list of the EOBs
used throughout the RA (in EOB order) and
descriptions.
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Common EOB code descriptions
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EOB code descriptions

• The EOB message explains the outcome of the claim
  that was submitted for payment processing.
• The EOB itemizes the reason for reducing or
  rejecting payment on your claim.
• By reading the explanation and following the
  instructions listed in the EOB, you will be able
  to correct the error in a timely manner.
• The following pages lists common billing Header
  errors, and common billing Detail errors, in
  EOB numeric order, and Helpful Tips to assist
  you in identifying and correcting common errors
  that most providers make.

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Common errors

• EOB 0015
• Service is a duplicate of a previously
  processed/paid service.
• The services billed match a claim in history.
• This appears when the date range, revenue center
  code, and diagnosis code are an exact match of a
  previously processed/paid claim.
• Look for previous RAs to determine if the service
  has been previously processed and/or paid.
• If applicable, correct any incorrect data and
  resubmit the claim.

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Common errors

• EOB 0028
• Recipients name and number disagree and DMAP
  cannot resolve.
• The client name and ID number that was entered on
  your claim mismatch.
• If you have determined that both the name and
  number entered is correct, contact DMAP Provider
  Services, or the Senior and Peoples with
  Disabilities branch for assistance.
• Correct the name or ID number and resubmit the
  claim.

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Common errors

• EOB 0032
• Recipient number missing.
• The client ID number is missing on your claim.
• Correct and resubmit the claim.
• EOB 0044
• Claim form inconsistent with provider type.
• The services were billed on the incorrect claim
  form. Submit the claim on the UB-04 claim form
  or Institutional billing format on the provider
  Web portal.

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Common errors

• EOB 0054
• 1st diagnosis code is missing or invalid.
• The 1st diagnosis code entered on your claim is
  missing or invalid.
• Check the diagnosis field on your claim to verify
  that a diagnosis code is listed.
• If a diagnosis code is listed, check the
  diagnosis to determine if it is a valid
  diagnosis.
• Correct and resubmit the claim.

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Common errors

• EOB 0065
• Over 31 days billed. Bill no more than one
  calendar month on a claim.
• A claim was billed for more than one calendar
  month.
• Only bill for one calendar month.
• If necessary, correct and resubmit the claim.

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Common errors

• EOB 0091
• Non-covered service.
• The revenue center code billed is not covered for
  the benefit plan on the date of service.
• If applicable, correct the revenue center code
  and resubmit.
• If the revenue center code is correct, contact
  DMAP Provider Services for clarification.

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Common errors

• EOB 0145
• The recipient number listed is not in our
  records.
• The client ID number is invalid.
• Verify the client ID number that was entered on
  your claim.
• If the number entered is correct, contact DMAP
  Provider Services, or the Senior and Peoples with
  Disabilities branch for assistance.
• If the ID number can be corrected, resubmit the
  claim.

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Common errors

• EOB 0161
• The sum of days billed does not equal reported
  period covered.
• The date range you are submitting does not match
  the sum of days as reported with the revenue
  center code.
• Correct the date range, or the units that
  correspond with the revenue center code and
  resubmit the claim.

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Common errors

• EOB 0244
  Number of
  visits or units of service is missing or invalid.
  
• The number of units that correspond with the
  revenue center code is zero or blank.
• Correct as appropriate and resubmit the claim.

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Common errors

• EOB 1116
• No pricing segment is on file.
• The dates of service on the claim span multiple
  benefit plan segment dates for this client.
• The clients benefit plan changed sometime during
  the month.
• The claim cannot be submitted with two different
  date ranges under two different benefit plans.
• If applicable, submit two separate claims, one
  with one benefit plan date range, and the second
  claim with the other benefit plan date range.
  

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Common errors

• EOB 3138
• Missing/invalid type of bill.
• The type of bill on the claim is missing or
  invalid.
• Add or correct the type of bill and resubmit the
  claim.

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Informational only

• Some EOBs are informational or have suspended for
  DHS review only. No action is needed from the
  provider.
• 0038 Our records do not show client certified
  for billed level of care.
• 0052 Provider ineligible to perform this
  procedure or type of service.
• 0067 Total amount billed exceeds amount
  authorized.
• 0193 Revenue center code restriction.
• 1043 Claim indicates recipient expired.
• 1114 Taxonomy code invalid.
• 1124 Cannot prioritize clients programs.
• 9013 Provider and submitter mismatched.

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Resources
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Reminders for successful billing

• Make sure you have the most current information
  that is in effect for the date of service being
  billed.
• Verify client eligibility on the date the service
  is provided.
• Bill electronically, it saves you time, you get
  paid faster, less chance the claims will suspend.
• If billing on paper, use commercially available
  red forms.
• Read the explanation of benefit codes on your
  remittance advice, they will tell you what the
  error is.
• Sign up for Electronic Funds Transfer (EFT) and
  receive your payments via direct deposit.

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Need help?

• For assistance reading RAs or to request a
  re-print, contact
• DMAP Provider Services
• 800-336-6016
• dmap.providerservices_at_state.or.us
• Team.Provider-ACCESS_at_state.or.us
• For questions specific to Long Term Care
  Facilities, contact
  
  Vivien VanHatten at 503-945-6528, or
  
  
  Rose Laurente at 503-945-5779,
  or
• David Allm at 503-945-6407 (program and policy)
  
• To view claim status on the Web
• Provider Web Portal https//www.or-medicaid.gov

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Thank You!