Department of Medical Assistance Services

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Department of Medical Assistance Services

• Assisted Living Facility
• Medicaid Eligibility Verification Options
• And
• CMS-1500 (08-05) Billing Guidelines
• 2008
• www.dmas.virginia.gov

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OBJECTIVESThe participants should be able to

• Verify Medicaid eligibility
• Properly submit claims
• Understand timely filing guidelines
• Including submission of adjustment/voids
• Resolve rejected/denied claims
• Interpret Medicaid Remittance Advice

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As a Participating ProviderYou must -

• Determine the patient's identity.
• Verify the patient's age.
• Verify the patient's eligibility.
  
• Accept, as payment in full, the amount paid by
  Medicaid.

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Important Contacts

• Provider Enrollment
• MediCall
• ARS- Web-Based Medicaid Eligibility
• Provider Call Center
• Customer Service

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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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Electronic Fund Transfer- EFT

• To participate in the Electronic Funds Transfer
  (EFT), please contact
• First Health Provider Enrollment Unit
• [phone]
• The EFT enrollment form is also available
  for printing or downloading on the DMAS
  web-site
• www.dmas.virginia.gov

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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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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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Automated Response System (ARS)

• NPI Compliant ARS Web Site will allow
• Access to claims status for bills submitted using
  an NPI
• Access to claims status for bills submitted by a
  Group Practice
• Enhanced delegated administration capability
  provided by the User Administration Console (UAC)

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User Administration Console

• The UAC will
• Allow providers to manage their own ARS access
  for one or more users
• Allow the provider to assign a Delegated
  Administrator for its office or facility
• Enable access to the ARS for anyone in the
  providers office or facility with a business
  need to information on the providers behalf

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UAC Registration Process

• Go to https//virginia.fhsc.com
• 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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UAC Registration Process

• 3-Step Process
• Step One Request PIN (will be mailed)
• Step Two Register with a PIN
• Step Three Activate your user login ID and
  password
• After this process you will need to log onto the
  UAC, in order to assign your access privileges to
  the ARS, set up additional local administrators
  and assign roles and providers to administrators

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ARS Users

• Web Support Helpline-
• 800-241-8726

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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 Services
• Department of Medical Assistance Services
• 600 East Broad Street, Suite 1300
• Richmond, VA 23219

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

• DEPARTMENT OF MEDICAL
• ASSISTANCE SERVICESPRACTITIONERP. O. Box
  27444Richmond, Virginia 23261

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TIMELY FILING

• ALL CLAIMS MUST BE SUBMITTED AND PROCESSED
  WITHIN ONE YEAR FROM
• THE DATE OF SERVICE
• EXCEPTIONS 1. Retroactive
  Eligibility/Delayed Enrollment 2. Previously
  rejected or denied claims
• Submit claims with documentation attached
  explaining the reason for delayed submission.

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CMS-1500 FORM
Use ONLY the original
RED
WHITE
and
Invoice
Photocopies are not
acceptable!
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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)
123456789014
(Be sure to include all 12 digits)
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Block 2 Patient's Name
2. PATIENT'S NAME (Last name, First Name, Middle
Initial)
Smith, Sam
5. PATIENT'S ADDRESS (No., Street)
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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 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
Please indicate NO for recipients who have
no other insurance coverage. DMAS does not
require providers to complete Blocks 9 a-d.
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Block 21 Diagnosis Codes
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY
3139
1.
3.
2963
2.
4.
May enter up to 4 codes
Omit decimals
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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 Dates of Service
24. A.
DATE(S) OF SERVICE
From
To
MM DD YY
MM DD YY
07
07
12
01
12
01
1
12
01
07
12
31
07
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
Note Type of Service is no longer required
B.
Place
of
Service
12
12- Patients Home
Medicaid accepts the same 2 digit CMS Place of
Service codes as Medicare.
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32
Block 24D Procedure Codes
D.
PROCEDURES, SERVICES, OR SUPPLIES
(Explain Unusual Circumstances)
CPT/HCPCS
MODIFIER
T1020

T1020 U1
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Assisted Living Services

• Regular
• T1020 (no modifier)
• 3.00/day
• Not to exceed 90.00 monthly
• Intensive
• T1020 (U1 modifier required)
• 6.00/day
• Not to exceed 180.00 monthly

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Block 24E Diagnosis Code
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY
3139
1.
3.
2963
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 days service was provided during
the billing 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
  Medicaid provider number or Atypical Provider
  Identifier (API).
• Qualifier ZZ is to be used to indicate the
  taxonomy code.
• Taxonomy code should only be listed if required
  with the NPI to adjudicate the claim.

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Rendering Provider ID Block-24J

• The shaded red area will contain the current
  Medicaid provider number/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
J. RENDERING PROVIDER ID.
I. ID. QUAL
Medicaid Provider Identification Number OR API
1D
NPI
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Block 24I ID. Qualifier 24J Rendering
Provider ID
I. ID. QUAL
J. RENDERING PROVIDER ID.
1D
001234567
NPI
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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
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Block 26 Patients Account Number
26. PATIENT ACCOUNT NUMBER
xxxxxxxxxxxxxxxxx
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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 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 32Block 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 Medicaid PIN
  (during Dual Use) or 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 Medicaid PIN
  (during Dual Use) or 1D qualifier with the API
  in 33b

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Block 33 Billing Provider Info PH
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
xxxxxxxxxxxxxxx
Adjustment or
From original
Void Resubmission
remittance
Code
(See Assisted Living Manual, Chapter V
instructions for list of Adj./Void codes)
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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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THANK YOU

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