Department of Medical Assistance Services

1
Department of Medical Assistance Services

• Eligibility Verification Options and
• CMS-1500 Billing Guidelines
• For
• Intellectual Disabilities (Mental Retardation)
  Waiver

www.dmas.virginia.gov July 2009
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This presentation is to facilitate training of
the subject matter in Chapter V of the Virginia
Medicaid Mental Retardation Community Services
Manual. This training contains only highlights
of this manual and is not meant to substitute for
or take the place of the Mental Retardation
Community Services Manual. Providers are
responsible for reviewing and adhering to the
Mental Retardation Community Services Manual
requirements.
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Agenda
1. Medicaid Eligibility Verification Options
2. Patient Pay Information
3. Important Contacts
4. Excluded Individuals/Entities
5. CMS-1500 Billing Guidelines
6. Adjustments/Voids
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As a Participating Provider You 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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Important Contacts

• MediCall
• ARS- Web-Based Medicaid Eligibility
• Provider Call Center
• Provider Enrollment
• Electronic Claims Coordinator

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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 05/09/1994 F
CARD 00001
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MediCall/Automated Response System (ARS)

• Available 24 hours a day, 7 days a week
• Medicaid Eligibility Verification
• Claims Status
• Patient Pay Information
• Prior Authorization Information
• Primary Payer Information
• Medallion Participation
• Managed Care Organization Assignment

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MediCall

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

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Automated Response System (ARS)

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

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ARS Registration Process

• https//uac.fhsc.com/uac/pages/unsecured/common/h
  ome.jsf
• Select the ARS tab on FHSC ARS Home Page
• Choose User Administration
• Follow the on-screen instructions for help with
  registration, this is a 3-step process to
  request, register and activate a new account
• Answer the initial Who are you? question by
  selecting I do not have a User ID and need to be
  a Delegated Administrator

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ARS Users

• ARS Users Guide
• http//www.dmas.virginia.gov/prclaims_billing.htm
  
• Web Support Helpline-
• 800-241-8726

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Patient Pay Information

• Effective March 1, 2009, the local department of
  social services (LDSS) will enter data regarding
  the individuals patient pay obligation into the
  Medicaid Management Information System (MMIS) at
  the time action is taken on a case
• Result of application for long term care services
• Time of the annual redetermination of eligibility
• Change in the enrollees situation is reported

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Patient Pay Information

• It is anticipated that patient pay information
  for all long term care enrollees will be in the
  MMIS by December 2009.
• MMIS patient pay information is available via
  MediCall and ARS.
• Providers responsible for collecting the patient
  pay amount should review the information prior to
  billing each month.

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ARS Patient Pay Information
Patient Pay Information
Begin-End (Date Time Period)
Patient Pay
Status
V
05/01/2009 - 05/31/2009
658.00
05/01/2009 - 05/31/2009
488.00
A
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Provider Helpline

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

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Duplicate Remittance Advice

• Effective July 1, 2009, DMAS will process and
  send requests for duplicate provider remittance
  advices via secure email.
• A processing fee will be applied to all paper
  requests for duplicate remittance advices,
  effective July 1, 2009.
• The requests should be directed to the Provider
  Helpline.

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Provider Enrollment

• New provider enrollment, Electronic Fund
  Transfer (EFT) 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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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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Excluded Individuals/Entities

• The U.S. Department of Health and Human Services
  Office of Inspector General (HHS-OIG) has the
  authority to exclude individuals and entities
  from participation in Medicare, Medicaid and all
  Federal healthcare programs
• HHS-OIG excluded individuals or entities are
  prohibited from being reimbursed by DMAS for any
  items or services that they have furnished,
  ordered or prescribed

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Excluded Individuals/Entities

• This ban includes payment for administrative and
  management services not directly related to
  patient care
• Providers are required to identify excluded
  individuals and entities
• This ensures that DMAS is not paying any excluded
  individuals or entities for services rendered

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Excluded Individuals/Entities

• No payment can be made for any items or services
  ordered or prescribed by an excluded physician
  when the furnishing party either knew or should
  have known of the exclusion
• Medicaid providers may be subject overpayment
  liability and civil monetary penalties when they
  do not abide by this Federal Regulation

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How to Ensure Program Integrity

• Screen all employees and contractors to determine
  whether they have been excluded
• Search HS-OIG List of Excluded Individuals/Entitie
  s (LEIE) website monthly
• Immediately report to DMAS any exclusion
  information discovered

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Reporting

• Discoveries are to be sent in writing to the
  address below and should include the
• individual or business name
• provider identification number
• State action, if any, has been taken
• DMAS
• Attn Program Integrity/Exclusions
• 600 E. Broad St. Ste 1300
• Richmond, VA 23219

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Accessing the LEIE

• HHS-OIG maintains the LEIE
• Provides information about parties excluded from
  participation in Medicare, Medicaid and all other
  Federal healthcare programs
• The online database is located at
• http//www.oig.hhs.gov/fraud/exclusions.asp

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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/Delayed Eligibility
• Denied Claims
• NO EXCEPTIONS
• Other Primary Insurance

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TIMELY FILING

• Submit claims with documentation attached (to the
  back of claim) explaining the reason for delayed
  submission

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CMS-1500 CLAIM FORM
Use ONLY the ORIGINAL RED WHITE Invoice Photo
copies are not Acceptable Computer generated
claims must match NUBC uniform standards
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Block 1
TRICARE
MEDICAID
CHAMPUS
1. MEDICARE
(Medicare )
(Medicaid )
(Sponsor's SSN)
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31
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
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33
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 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
DMAS does not require providers to complete
Blocks 9 a-d. Please indicate NO for recipients
who have no other insurance coverage.
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Block 21 Diagnosis Codes (Current ICD.9 Code)
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY
3180
1.
3.
2.
4.
May enter up to 4 codes
Omit decimals
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ICD-9 Diagnosis Codes

• All claims submitted to DMAS will require a
  current ICD-9 diagnosis code for payment
  processing.
• Some 3-digit diagnosis codes are valid
• 317 (mild mental retardation) is a valid
  3-digit DX code
• 319 (mental retardation) is a valid
  3-digit DX code

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ICD-9 Diagnosis Codes

• If the current year ICD-9 book indicates the
  diagnosis code requires 4-5 digits, the code
  listed on the claim submission must include 4-5
  digits
• 318 (other specified mental retardation) requires
  an additional 4th digit to be a valid diagnosis
  code 3180, 3181 or 3182
• Claims submitted without a valid diagnosis code
  will be denied

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Block 23 Prior Authorization Number
(Conditional)
23. PRIOR AUTHORIZATION NUMBER
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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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Block 24A Shaded Red AreaTPL Information
Billing Scenarios

• No other insurance
• Check NO in Locator 11d or leave blank
• Primary Carrier pays covered service
• Provider receives Explanation of Benefits (EOB)
• Check YES in Locator 11d
• Document primary payment information in the
  shaded red area of 24A on claim form
• DMAS does not require an attached copy of the EOB
  when provider receives payment from primary
  carrier

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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
09
09
05
01
05
01
1
05
01
09
05
16
09
2
Both FROM and TO dates
must be completed
Dates must be within same calendar month
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TPL Billing Scenarios

• Primary carrier does not pay
• Payment applied to deductible/claim denied
• Provider receives EOB
• Check YES in Locator 11d
• Attach copy of EOB showing non-payment to the
  back of the DMAS claim form
• Do not document any information in the shaded red
  area of 24A

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TPL Billing Scenarios

• Primary carrier does not pay
• Service not covered
• Check YES in Locator 11d
• Attach EOB documenting that services are not
  covered or, attach letter verifying the service
  is not covered
• Do not document any information in the shaded red
  area of 24A

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TPL Billing Scenarios

• Primary carrier does not pay
• Carrier will not enroll provider
• Check YES in Locator 11d
• Attach letter documenting the primary carrier
  will not enroll the provider
• Do not document any information in the shaded red
  area of 24A

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TPL Billing Scenarios

• Primary carrier does not pay
• Policy is no longer active/coverage terminated
• Check YES in Locator 11d
• Attach EOB verifying that the policy is not
  active or, attach letter verifying the policy is
  not active
• Advise patient/guardian to contact Local DSS with
  policy termination documentation/information

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Block 24B Place of Service
Note Type of Service is no longer required
B.
Place
of
Service
11-Office location 12- Patients Home
11
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
• If there was no emergency leave blank

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Block 24C EMG
C. EMG
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
97535

T1017 U3
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Block 24E Diagnosis Code
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY
3180
1.
3.
4019
2.
4.
E.
DIAGNOSIS
POINTER
1
Enter the 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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ID.QUAL Block-24I

• Qualifier 1D is to be used in the red shaded
  area for claims being submitted using the
  Atypical Provider Identifier (API).
• OR-
• Qualifier ZZ is to be used to indicate the
  taxonomy code - only when the National Provider
  Identifier is used and only if necessary to
  adjudicate the claim.

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DMAS Service Types May Require A Taxonomy Code
on Claims
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Rendering Provider ID Block-24J

• The shaded red area will contain the API
• OR
• The open area will contain the NPI of the
  provider rendering the service

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Block 24I ID. Qualifier 24J Rendering
Provider ID
I. ID. QUAL
J. RENDERING PROVIDER ID.
1D
0001234567
NPI
Atypical Provider Identifier
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Block 24I ID. Qualifier 24J Rendering
Provider ID
I. ID. QUAL
J. RENDERING PROVIDER ID.
ZZ
Taxonomy (if needed)
1234567890
NPI
National Provider Identifier
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Block 26 Patients Account Number
26. PATIENT ACCOUNT NUMBER
12345678918765
Can not exceed 14 alphanumeric digits
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Block 28 Total Charges
28. TOTAL CHARGE

Please list the total all charges in Block 28.
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Block 29 Amount Paid

• Patient pay amount is taken from services billed
  in Block 24A line 1
• If multiple services are provided on the same
  date of service, another form must be completed.
  Only one line per claim form can be submitted if
  patient pay is to be considered in the processing
  of this service.

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Block 29 Amount Paid (Personal and Waiver
Services ONLY)
29. AMOUNT PAID

Enter the Patient Pay amount as indicated on the
DMAS-225, MediCall or Automated Response System
(ARS).
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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 32Service Facility Location Information

• Enter information for the location where services
  were rendered
• 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 code

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Block 32, contd.Service Facility Location
Information

• Providers with multiple offices/locations - the
  zip code must reflect the office/ location where
  services were rendered
• Enter the 10 digit NPI number of the service
  location in 32a.
• OR
• Enter 1D qualifier with the API in 32b

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Block 32 Service Facility Location Information
32. SERVICE FACILITY LOCATION INFORMATION
a.
b.
NPI
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Block 33 Billing Provider Info PH -

• 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.
• OR
• Enter 1D qualifier with the API in 33b

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Block 33 Billing Provider Info Phone
33. BILLING PROVIDER INFO PH
( )
a.
b.
NPI
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Block 22 Adjustments and Voids
22. MEDICAID RESUBMISSION
CODE
ORIGINAL REF. NO.
1032
xxxxxxxxxxxxxxxx
From Original
Adjustment or
Void
Remittance Advice
Resubmission Code
Chapter V, Mental Retardation Community Services
Manual has resubmission code list.
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THANK YOU

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