Department of Medical Assistance Services

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Department of Medical Assistance Services
Physicians-101 Virginia Medicaid Programs,
Eligibility Verification Options and Billing
for Physicians Services April-May
2005 www.dmas.virginia.gov
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As A Participating ProviderYou Must-

• Determine the patients identity.
• Verify the patients age.
• Verify the patients eligibility.
• Accept, as payment in full, the amount paid by
  Virginia Medicaid.
• Bill any and all other third-party carriers.

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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
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Medicaid Verification Options

• MediCall
• ARS- Web-Based Medicaid Eligibility

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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 SystemARS

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

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ARS- Information Available

• Medicaid client eligibility/benefit verification
• Service limit information
• Claim status
• Prior authorization
• Provider check log

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Automated Response System- Registration

• Registration
• virginia.fhsc.com
• Questions concerning registration process
• Web Support Helpline 800-241-8726

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ARS User Guide Available

• Located on the DMAS web-site under Provider
  Services section
• General information on ARS eligibility
  verification
• Instructions on the using the system
• FAQ(frequently asked questions) section

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Copay Indicators

• Code A
• Under 21- No copay exists
• Code B
• Long Term Care, Home or Community Based Waiver
  Services, Hospice-No copay
• Code C
• All other clients collect all applicable copays

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Copay Exemptions

• Enrollees in managed care may not have copays
• Pregnancy related/family planning services
• Emergency services
• Exception-CMM with a pharmacy restriction

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Copay Amounts

• Inpatient hospital 100.00 per admission
• Outpatient hospital clinic 3.00 per visit
• Clinic visit 1.00 per visit
• Physician office visit 1.00 per visit
• Other physician visit 3.00 per visit
• Eye examination 1.00 per examination

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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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Billing Inquiries
Customer Service Department of Medical
Assistance Services 600 East Broad Street, Suite
1300 Richmond, VA 23219
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Provider Enrollment

• New provider numbers 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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Requests for DMAS Forms and Manuals

• DMAS Order DeskCOMMONWEALTH MARTIN1700
  Venable StreetRichmond, Virginia 23222

Phone [phone] Emaildmas_at_cms-mpc.com
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Electronic Billing

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

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DMAS Website

• Current, most up-to-date information on Virginia
  Medicaid programs
• Provider memos available for review
• Access to Medicaid manuals
• Top 50 Common Error Reason Codes with Resolutions
• Numeric Insurance Code List
• Primary Carrier Coverage Code List

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DMAS Website

• Financial Reason Code Description List
• State and Local Hospital (SLH) Program Balance
  Statement
• Virginia Medicaid Error Code Crosswalk Listing
• Hospital DRG Rates for Fiscal Year 2005
• 2004 Medicaid/FAMIS-PLUS Handbook

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Medicaid Programs
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Medicaid Programs

• Medicaid Fee-for-Service
• No Primary Care Physician (PCP)
• No mandatory referral from the PCP.

• Medallion
• Primary Care Physician who directs all care.
• PCP referral required for all non-emergency
  services.

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Medallion II HMO ID Cards

• Issued by the Managed Care Organizations
• Client will have both HMO and Medicaid cards
• Eligibility verification is a REQUIREMENT
• Each verification option will give the HMO
  enrollment information if applicable

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Medallion II HMO ID Cards

• The Anthem card for Medicaid clients indicates
  Anthem Healthkeepers Plus (Plus identifies the
  Medicaid plan).
• The Optima Card for Medicaid clients indicates
  Optima Family Care (Family Care identifies the
  Medicaid plan).
• Virginia Premier only has a contract for Medicaid
  HMO- anyone presenting a VAPremier Card is a
  Medicaid client.

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Medallion II HMO ID Cards

• The Southern Health Services card for Medicaid
  clients indicates CareNet.
• Unicare Health Plan of Virginia is for Medicaid
  clients.

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Virginia Medicaid HMO Contacts
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Client Medical Management CMM

• Mandatory Primary Care Physician and Pharmacist
  who directs all care
• Responsibilities
• coordinating routine medical care
• making referrals to specialists as necessary
• arrange 24 hour coverage when not available
• explain to recipients all procedures to follow
  when office is closed or there is an urgent or
  emergency situation

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Designated Physicians CMM

• A Medicaid enrolled physician who is not the PCP
  will be reimbursed only
• in a medical emergency/delay in tx may cause
  death, lasting injury or harm
• on written referral from PCP using the
  Practitioner Referral Form (DMAS-70), includes
  covering physicians
• covered services excluded from CMM program
  requirements

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Medicaid Programs

• FAMIS
• Medical program for children under 19.
• First 30 days coverage in the FAMIS
  fee-for-service program.
• Mandatory Managed Care Organization (where
  available) after initial 30 days.

• Aliens
• Emergency medical treatment only
• Eligibility requests should be sent to the local
  DSS
• Emergency Medical Certification form required for
  claim submission

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ALIENS

• Section 1903v of the Social Security Act requires
  Medicaid to cover emergency services for
  specified aliens when the services are provided
  in an emergency room or inpatient hospital
  setting.
• Hospital outpatient follow-up visits or physician
  office visits are not included in the covered
  services.

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Aliens

• To be covered, the services must meet
  emergency treatment criteria and are
• limited to
• Emergency room care
• Physician services
• Inpatient hospitalization not to exceed limits
  established for other Medicaid recipients
• Ambulance service to the emergency room
• Inpatient and outpatient pharmacy services
  related to the emergency treatment

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State and Local Hospital SLH

• Covered Services
• Acute care inpatient hospital services (excluding
  rehab and free-standing psychiatric hospitals)
• Acute care outpatient services.
• Ambulatory surgical services.
• Department of Health Clinic Services.
• SLH claims should be submitted with the Medicaid
  provider number.

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Temporary Detention Order TDO

• ALL TDO claims must have the TDO form attached to
  the front of the claim.
• Claims submitted without the TDO form will be
  returned to the provider
• The TDO form must be signed by the law
  enforcement officer and dated to be valid.
• TDO is the payer of last resort. SLH is the
  exception, paying primary over TDO.

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Temporary Detention Orders TDO

• Mail all TDO claims to
• Department of Medical Assistance Services
• TDO- Payment Processing Unit
• 600 East Broad Street, Suite 1300
• Richmond, VA 23219

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Medicaid Benefit Package
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Qualified Medicare Beneficiaries QMB

• Eligible only for payment of Medicare premiums,
  deductibles, and coinsurance.
• Medicaid will consider the Medicare deductibles
  and coinsurance for benefits.
• If Medicare does not cover the service, the
  service cannot be billed to Medicaid.

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Qualified Medicare Beneficiaries- QMB
Extended

• This group is eligible for Medicaid coverage of
  premiums, deductibles, and coinsurance plus all
  other Medicaid-covered services.
• Medicaid will consider the Medicare deductibles
  and coinsurance for benefits.
• Clients are also eligible for all Medicaid
  covered services.

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Medicaid Benefit Programs

• Special Low-Income Beneficiaries -This group is
  only eligible for Medicaid coverage of the
  Medicare Part B premium only.
• Breast and Cervical Cancer Prevention and
  Treatment Act- women who were certified through
  the Breast and Cervical Cancer Early Detection
  Program. This group is eligible for the full
  range of Medicaid services.
• Family Planning Waiver Services-This group is
  eligible for Medicaid family planning related
  services only.

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Clarification of Family Planning Waiver

• Any woman enrolled as a Medically Indigent
  pregnant woman, who received a pregnancy related
  service paid by Medicaid on or after 10/01/03 is
  automatically eligible for the waiver at the end
  of her Medicaid coverage.
• The Medicaid client should visit her local DSS to
  ensure she has been enrolled.
• Eligible clients are enrolled for up to 24 months
  following the end of pregnancy.

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Clarification of Family Planning Waiver

• The Family Planning Waiver provides coverage for
  only the following services
• Annual gynecological exams
• Family planning education and counseling
• Over-the-counter birth control supplies and
  prescription birth control supplies approved by
  the Federal Food and Drug Administration (FDA).

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Clarification of Family Planning Waiver

• Family Planning Waiver covered services, contd.
• Sterilizations (excluding hysterectomies) and the
  required hospitalization
• Testing for sexually transmitted diseases (STDs)
  during the first family planning visit

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Clarification of Family Planning Waiver

• Family Planning Waiver services are reimbursed on
  a fee-for-service basis.
• Please refer to the 11/05/04 Medicaid Memo for
  specific billing guidelines.
• Because Family Planning Waiver clients receive a
  limited benefit package, it is important to
  access each Medicaid participants eligibility
  and service limit status prior to providing
  services.

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Billing on the CMS-1500
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MAIL CMS-1500 FORMS TO

• DEPARTMENT OF MEDICAL ASSISTANCE
• SERVICES
• PRACTITIONER
• P. O. Box 27444
• 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 Eligibility
• Delayed Eligibility
• Denied Claims
• NO EXCEPTIONS
• Accident Cases
• Other Primary Insurance

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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

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Block 1 Check Medicaid
MEDICAID
CHAMPUS
1. MEDICARE
(Medicare )
(Medicaid )
(Sponsor's SSN)
2. PATIENT'S NAME (Last Name, First Name, Middle
Initial)
CHECK MEDICAID BLOCK ONLY
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Block 1a Recipient ID Number
1a. INSURED'S I.D. NUMBER (FOR PROGRAM
IN ITEM 1)
123456789 01 4
(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)
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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?
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 you attach anything to the HCFA form.
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Blocks 17 and 17a- Conditional
17. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE
17- Name of the Recipients PCP
(primary care physician) 17a- PCPs 9-digit
Medicaid provider ID
17a. ID NUMBER OF REFERRING PHYSICIAN
(Medicaid 7-digit provider ID)
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Block 19- Conditional Use
19. RESERVED FOR LOCAL USE
Clinical Laboratory Improvement Amendment (CLIA)
Number of the physician office laboratory (POL)
performing the service.
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Block 21 Diagnosis Codes
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY
3441
1.
3.
2963
2.
4.
May enter up to 4 codes
Omit decimals
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Block 23 Prior Authorization Number - Conditional
23. PRIOR AUTHORIZATION NUMBER
If service requires prior authorization, enter
the nine digit PA number assigned by WVMI.
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Block 24A Dates of Service
24. A
DATE(S) OF SERVICE
From
To
MM DD YY
MM DD YY
05
05
03
01
03
01
1
03
05
01
31
05
03
2
Both FROM and TO dates
must be completed
Dates must be within same calendar month
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Block 24B Place of Service Block 24C Type of
Service
B
C
Type
Place
of
of
Service
Service
11-Office location 21- Inpatient
11
1
1- Medical Care
Medicaid accepts the same Place of Service and
Type of Service as Medicare.
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Block 24D Procedure Codes
D
PROCEDURES, SERVICES, OR SUPPLIES
(Explain Unusual Circumstances)
CPT/HCPCS
MODIFIER
99213
22
99254
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Block 24E Diagnosis Code
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY
34431
1.
3.
2963
2.
4.
E
DIAGNOSIS
CODE
1
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
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Block 24 F Charges
F
CHARGES
Enter the usual
and customary charges
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Block 24G Days or Units
G
DAYS
OR
Enter the number of times or hours the procedure,
service, or item was provided during the service
period.
UNITS
1
31
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24J COB Other Insurance 24K Other Insurance
Paid
J
K
RESERVED FOR
LOCAL USE
COB
Attach denial from other carrier
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Block 26 Patients Account Number (Optional)
26. PATIENT ACCOUNT NUMBER
12345678918765432
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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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Block 33 Provider ID and Address
33. PHYSICIAN'S, SUPPLIER'S BILLING NAME,
ADDRESS, ZIP CODE
PHONE
123456789
PIN
GRP
Be sure to put the MEDICAID
9-digit ID number!
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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 Physicians Manual has code
list.
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Medicaid Claims Correction vs. Appeals

• Claims submitted to VA Medicaid which have been
  denied for these claim issues do not meet our
  definition of an appeal
• Claim form not completed correctly
• Incorrect procedure/diagnosis codes
• Additional information required and not submitted
  with claim
• Authorization not listed or incorrect
• Provider should correct the information and
  resubmit as a brand new claim.

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Medicaid Claims Correction VS. Appeals

• Claims submitted to Medicaid which have been
  denied for
• Service not covered by Medicaid
• Authorization denied or service not authorized
  within specified Medicaid guidelines
• Service denied as not being medically necessary
• Repayment of identified overpayments
• Services denied for these reasons can be
  appealed.

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Medicaid Appeal Guidelines

• Service specific Medicaid appeal guidelines can
  be found the Physicians Manual Chapter II and IV.

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Medicaid Error Codes

• Resolutions

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1 Error Code 0482 Authorization by Medallion
PCP Not Indicated

• Probable Cause
• Client is in the Medallion Program and the PCP
  number is not listed or is incorrect
• Correction
• Make sure that the claim form has the correct PCP
  referral number listed in Locator 17A of the
  CMS-1500

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2 Error Code 0450Service Not Authorized for
Alien.

• Probable Cause
• Provider is billing services for specified aliens
  with no authorization
• Correction
• Emergency claims for non-resident aliens must be
  submitted with a copy of the Emergency Medical
  Certification Form.

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3 Error Code 0015Primary Carrier Pay Missing
or Invalid

• Probable Cause
• Claim was submitted with primary carrier
  information but no payment amount was indicated
  on the claim
• Correction
• Claims submitted with COB code 3 in Locator 24J
  must have the amount paid by the primary carrier
  in Locator 24K

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4 Error Code 308Payment Request Filed After 1
Yr Limit Not Justified

• Probable cause
• Dates of service were over a year old and
  provider did not include any justification
• Correction
• Claims for service rendered that exceed the 12
  month timely filing requirements (12 months past
  the date of service) must have documentation
  attached to waive timely filing

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4 Error Code 308 Payment Request Filed After
1 Yr Limit Not Justified

• Correction (contd)
• Enter the word attachment in Block 10d and a
  modifier 22 in Block 24D of the CMS-1500

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4 Error Code 308 Payment Request Filed After
1 Yr Limit Not Justified

• Correction (contd)
• Include
• Remit or documentation from DMAS showing the
  claim was originally denied or rejected with the
  timely filing limit
• Letter from the case worker at Social Services
  both signed and dated verifying retroactive
  eligibility

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5 Error Code 1270One Service unit per 36
months for the same provider

• Probable Cause
• Provider submitted code that is only allowed once
  every 36 months.
• Correction
• Claim needs to be resubmitted with the correct
  procedure code.

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Additional Error Codes

• 0014- Billed Amount Missing or Invalid
• 0110- Diagnosis Code Does Not Agree with Age
• 0159- Provider Disagrees with Authorization
• 0202- Duplicate- Different Provider, Same DOS
• 0301- Duplicate Payment- Same Provider, Same DOS

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Additional Error Codes

• 0302- Duplicate of History - Same Provider, Same
  DOS
• 0352- Only Paid Payment Requests Can be
  Adjusted/Voided
• 0967- HCPCS/Diagnosis Restriction
• 1108- Contraindicated Audit - Same Provider /Date
  of Service
• 1471- Same as 0302

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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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Before you FLY Please complete and turn in your
evaluation form
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THANK YOU

• Department of Medical Assistance Services
• www.dmas.virginia.gov