04/25/07 1

DMAS Division of Health Care Services

Billing for Emergency and Non-Emergency Transportation ServicesWith Dates of Service October 31,

2009 and Before

2

Presentation Outline

Health Insurance Claim Form - 1500 Emergency Ground & Neonatal Ambulance Transportation Emergency Air Ambulance Transportation

Title XVIII (Medicare) Deductible and Coinsurance Invoice DMAS 30-R DMAS 31-R

Resources TrailBlazer Revs Line DMAS Website

Contact Information Questions

3

Health Insurance Claim Form CMS 1500

What’s Changed? We want to remind everyone that this is not a change in policy. Effective April 1, Cross Over claims will be processed using the correct

manner. Medicaid reimbursement for these services is less than 80% of the Medicare

payment level, Medicare crossover claims will be paid at $0.00 with the claims edit 364 (“Exceeds Medicaid Allowed Amount.”)

Use Font size 10 or larger Mail all Ground Ambulance claims to First Health, address at end of

presentation

Most Common Mistakes Using a 2-code system (One code for base rate and second code for mileage) Trying to bill using CPT/HCPCS mileage codes with:

• A0425• A0435• A0436

Block 10b, make sure and check yes for auto accidents Block 10c, make sure to mark for other accidents

4

Eligibility and Claims status information DMAS offers a web-based Internet option (ARS) to

access information regarding Medicaid or FAMIS eligibility, claims status, check status, service limits, prior authorization, and pharmacy prescriber identification. The website address the use to enroll for access to this system is http://virginia.fhsc.com. The Medical voice response system will provide the same information and can be accessed by calling 1-800-884-9730 or 1-800-772-9996. Both options are available at no cost to the provider.

5

Transportation for Managed Care Organizations (MCO)

The Virginia Medicaid Program includes enrolling eligible Medicaid recipients in Managed Care Organizations (MCO).

Eligible enrollees receive emergency air ambulance, emergency ground ambulance and non-emergency transportation services through the MCO.

Please contact the appropriate MCO for billing

instructions.

6

Billing on the CMS-1500

6

7

Printing

Must be RED OCR dropout ink or the exact match

Should be 10-pitch Pica type, 6 lines per inch vertical and 10 characters per inch horizontal

Claim has to match /line up with the original claim form

8

Printing

Print 100% of actual size Set page scaling to ‘none’ Margins must be exact DMAS will not reprocess claims

denied for scanning issues as a result of failure to follow the above instructions

9

TIMELY FILING

ALL CLAIMS MUST BE SUBMITTED AND PROCESSED WITHIN ONE YEAR FROM THE DATE OF SERVICE

EXCEPTIONSRetroactive/Delayed EligibilityDenied Claims

NO EXCEPTIONSAccident CasesOther Primary Insurance

10

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 (Attachments include: Run sheets, Call sheets, Pre-hospital Patient Care Report (PPCR)

11

Block 1

Enter an ‘X’ in the MEDICAID box for the Medicaid Program

MEDICAID

(Medicaid #)

Block 1

CHAMPUS

(Sponsor's SSN)

1. MEDICARE

(Medicare #)

MEDICAID CLAIM

2. PATIENT'S NAME (Last Name, First Name, Middle Initial)

12

TRICARE

1a. INSURED'S I.D. NUMBER (FOR PROGRAM IN ITEM 1)

Block 1a: Recipient ID Number

(Be sure to include all 12 digits)

123456789014

13

Block 2: Patient's Name

2. PATIENT'S NAME (Last name, First Name, Middle Initial)

Smith, Sam5. PATIENT'S ADDRESS (No., Street)

14

15

Is Patient’s Condition Related To Block- 10a,10b & 10c

10a - Mark box with appropriate ‘Yes’ or ‘No’

10b - If the condition is related to an auto accident, mark ‘Yes’ and place the postal code (i.e. VA, TN, WV) of the state in which the accident occurred.

10c - Mark box with appropriate ‘Yes’ or ‘No’

Block 10: Accident-Related

10. IS PATIENT'S CONDITION RELATED TO:

a. EMPLOYMENT? (CURRENT OR PREVIOUS)

b. AUTO ACCIDENT?

c. OTHER ACCIDENT?

YES NO

PLACE (State)

YES

YES

NO

NO

You MUST check YES or NO for a, b & c16

WV

Block 10d

You MUST use the word "ATTACHMENT"

if documents are attached to the HCFA form.

10d. RESERVED FOR LOCAL USE

ATTACHMENT

17

Block 11c - Insurance Plan Name or Program Name

c. INSURANCE PLAN NAME OR PROGRAM NAME

Other Insurance COPAY

18

19

Is There Another Health Benefit Plan?Block-11d

Providers should only check yes if there is another third party carrier

Block 11d - Is There Another Health Benefit Plan?

d. IS THERE ANOTHER HEALTH BENEFIT PLAN?

YES NO If yes, return to and complete item 9 a-d.

20

21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY

1.

2.

3.

4.

31100

Block 21: Diagnosis Codes

May enter up to 4 codes

Omit decimals (List of frequently used diagnosis codes are in the

Transportation Manual)

30130

21

22

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

23

TPL Information Block 24A

Qualifier ‘TPL’ will be used followed by dollars/cents amount whenever an actual payment is made by a third party carrier

No spaces between the qualifier and dollars and no $ symbol used

Decimal between dollars and cents is required to read paid amount correctly

Must be left justified

24

TPL Information Block 24A

DMAS will set COB code based on the information given in locator 11d.No, or nothing indicated-no other carrier-

old COB code 2No, or nothing indicated/system has other

insurance-claim will deny bill other insurance

No, or nothing indicated/‘TPL’ qualifier with payment in 24a red area-old COB code 3

25

TPL Information Block 24A

DMAS will set COB code based on the information given in locator 11d.Yes, but nothing in 24a red area-other

carrier billed and made no payment-old COB code 5

Yes, and ‘TPL’ qualifier with payment in 24a red area-other carrier billed and paid-old COB code 3

24. A.DATE(S) OF SERVICE

From ToMM DD YY MM DD YY

Block 24A: Dates of Service

03 01 06 03 01 061

2

Both FROM and TO datesmust be completed

Dates must be within same calendar month26

TPL27.08

B.Place

ofService

Block 24B: Place of Service

41

41- Ambulance – Land

Or

42- Ambulance – Air or Water

“Not both”

Medicaid accepts the same 2 digit CMS Place of Service codes as

Medicare.27

28

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

C.

EMG

Block 24C: EMG

Medicaid will accept a ‘Y’ in this Locator to indicate that the procedure was an

emergency 29

Y

D.

Block 24D: Procedure Codes

All Claims must have modifier 22

PROCEDURES, SERVICES, OR SUPPLIES(Explain Unusual Circumstances)

CPT/HCPCS MODIFIER

22A0225

30

DMAS Recognizes the

Following codes:

A0225A0427A0429A0430A0431

21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY

1.

2.

3.

4.

34431

Block 24E: Diagnosis Code

E.

DIAGNOSISPOINTER

1

2963

1,2

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.

31

F.

$ CHARGES

Block 24 F: Charges

Enter the usualand customary charges

32

500 00

G.DAYS

ORUNITS

Block 24G: Days or Units

31

Enter the number of “loaded miles” of transport.

The 31 is an example that shows loaded miles.

33

34

ID.QUALBlock-24I – Shaded Area

Qualifier ‘ZZ’ is to be used to indicate the taxonomy code-only when the NPI is used and only if necessary to adjudicate the claim.

35

If Taxonomy codes are usedBlock-24J

If needed the shaded red area will contain the Taxonomy codes

If Taxonomy codes are used in shaded area, NPI number must be provided in the open area.

Fill in only if Taxonomy codes are needed

Block 24I: ID. Qual.

& 24J: Rendering Provider ID #

36

ZZ3416A0800X

Or3416L0300X

3416A0800X is Air 3416L0300X is Land

Block 24I: ID. Qual.

& 24J: Rendering Provider ID #

37

I.ID.

QUAL

J.RENDERING

PROVIDER ID. #

NPI

ZZ Taxonomy # (if needed)

12345647890

26. PATIENT ACCOUNT NUMBER

Block 26: Patient’s Account Number

(Optional)

12345678918765

38

Can not exceed 17 alphanumeric digits

39

Total ChargeBlock 28

DMAS now requires this locator to be completed

Enter the total charges for the services in 24F lines 1-6.

28. TOTAL CHARGE

Block 28: Total Charges

40

$

29. AMOUNT PAID

Block 29: Amount Paid

(By Other Insurance)

41

$

42

30. Balance Due

Block 30: Amount Paid

(By Other Insurance)

42

$

31. SIGNATURE OF PHYSICIAN OR SUPPLIERINCLUDING DEGREES OR CREDENTIALS

(I certify that the statements on the reverseapply to this bill and are made a part thereof.)

SIGNED DATE

Block 31: Signature & Date

If there is a signature waiveron file, you may stamp, print,

or computer-generate the signature.43

44

Service Facility Location InformationBlock-32

Enter information for the location where services were rendered First line-Name Second line-Address Third line-City, State, 9 digit zip code

The zip code must reflect the office location where services were rendered

No punctuation in the address Space between city and state Include hyphen for the 9 digit zip code

45

Service Facility Location InformationBlock-32a-b

Leave Blank

Block 32: Service Facility Location Information

Your Local HospitalXXXX Anywhere St.

Your Town, ST 12345-1456

32. SERVICE FACILITY LOCATION INFORMATION

Leave Blank Leave Blanka. b.

46

47

Billing Provider Info & PH #-Block-33

Enter the information to identify the provider that is requesting to be paidFirst line-NameSecond line-AddressThird 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

48

Billing Provider Info & PH #-Block-33a-b

Enter the 10 digit NPI number of the service location in 33a.

Enter ‘ZZ’ qualifier with the taxonomy code if needed, when using the NPI in 33a (example – ZZ3416L0300Z)

Block 33: Billing Provider Info & PH #

Your Local HospitalXXXX Anywhere St.

Your Town, ST 12345-1456

33. BILLING PROVIDER INFO & PH #

ZZ3416L0300X (If needed)a. b.1234567890

(123) 456-7890

49

22. MEDICAID RESUBMISSIONCODE ORIGINAL REF. NO.

Block 22: Adjustments and Voids

1032 xxxxxxxxxxxxxxxxAdjustment

or

Resubmission Code

From OriginalRemittance

Void

Chap. V, Medicaid Transportation Manual has code list.

50

Block 22: Medicaid Resubmission Codes

Original Reference Number/ICN - Enter the claim reference number/ICN of the paid claim. This number may be obtained from the remittance voucher and is required to identify the claim to be adjusted. Only one claim can be adjusted on each CMS-1500 (08-05) submitted as an Adjustment Invoice. (Each line under Locator 24 is one claim.)

Medicaid Resubmission of Adjustment Codes

1023 Primary Carrier has made additional payment1024 Primary Carrier has denied payment1025 Accommodation charge corrected1026 Patient payment amount charged1027 Correcting service periods1028 Correcting procedure/service code1029 Correcting diagnosis code1030 Correcting charges1031 Correcting units/visits/studies/procedures1032 IC reconsideration of allowance, documented1033 Correcting admitting, referring, prescribing,

provider ID 1041 Incorrect Amount paid1053 Adjustment reason is in the Misc. Category

Medicaid Resubmission of Void Invoice Codes

1042 Original claim has multiple incorrect items1044 Wrong provider identification number1045 Wrong enrollee eligibility number1046 Primary carrier has paid DMAS maximum allowance1047 Duplicate carrier has paid full charge1048 Primary carrier has paid full charge1051 Enrollee is not my patient1052 Miscellaneous1060 Other insurance is available

51

52

More than One Emergency Air or Ground Claim with Same Day Service

Please complete second/third claim using the same billing instructions as the first. Please provide a cover letter explaining this claim is the second or third ambulance claim for the same day service. Please attach cover letter on top of second claim with attachments and mail to:

DMAS

Transportation Unit, Suite 1300

600 East Broad Street

Richmond, Virginia 23219

53

Mailing Address for Emergency Air Ambulance Claims

Emergency Air Ambulance Claims with Attachments

DMAS

Transportation Unit, Suite 1300

600 East Broad Street

Richmond, Virginia 23219

Note: All claims must have attachments that include ambulance Pre-hospital Patient Care Report (PPCR) that establish medical necessity for emergency air and ground service. Beginning and ending mileage must be included on PPCR.

54

Air Ambulance Claim Procedure and Claim Reconsideration

All air ambulance claims are reviewed for medical necessity of using an emergency air ambulance. Claims submitted that do not establish air ambulance medical necessity will be paid at DMAS emergency ground ambulance rates.

In certain cases, the air ambulance provider may not agree with claim being paid at ground rate. The air ambulance provider can request the claim be reconsidered if the original claim was missing attachments or other medical information. For reconsideration please write a brief description or explanation on why the claim needs to be reconsidered.

Please mail the letter, a new original CMS 1500 with attachment to:

DMASTransportation Unit, Suite 1300600 East Broad StreetRichmond, Virginia 23219

If reconsideration is denied, then please use the formal appeal process.

55

Mailing Address for Emergency Ground Ambulance Services

Emergency Ground and Neonatal Ambulance Claims with Attachments

DMAS-Transportation

P. O. Box 27447

Richmond, Virginia 23261-7447

Note: All claims must have attachments that include ambulance Pre-hospital Patient Care Report (PPCR) that establish medical necessity for emergency air and ground service. Beginning and ending mileage must be included on PPCR.

56

Billing on the DMAS 30 & 31

56

57

Title XVIII Common Mistakes

Locator 7 - Other Coverage Locator 8 - Type Coverage Locator 17- Charges to Medicare Locator 18- Allowed By Medicare Locator 19- Paid By Medicare Locator 20- Deductible Locator 21- Coinsurance Locator 22- Paid By Carrier Other Than Medicare Locator 23- Patient Pay Amount (LTC Only) Locator 7 - Other Coverage Locator 8 - Type Coverage Locator 17- Charges to Medicare Locator 18- Allowed By Medicare Locator 19- Paid By Medicare Locator 20- Deductible Locator 21- Coinsurance Locator 22- Paid By Carrier Other Than Medicare Locator 23- Patient Pay Amount (LTC Only)

58

CHANGES

Locator 01-Billing Provider Number Locator 06-Rendering Provider

Number Locator 08-Type of Coverage

Title XVIII- Block 01

01 Billing Provider Number

Enter the billing provider NPI number

59

Title XVIII- Block 06

06 Rendering Provider Number

Enter the rendering provider NPI number

60

61

Primary Carrier Information Other ThanMedicare

072 No Other Coverage

5 Billed No Coverage3 Billed and Paid

Title XVIII – Block 7

62

Type OfCoverageMedicare

B

Type Coverage Medicare- Mark type of coverage “B”.

6

08

Title XVIII – Block 08

63

Title XVIII- Block 17

Charges To Medicare

Block 17: Charges to Medicare- Enter the total charges submitted to Medicare.

17

64

Title XVIII- Block 18Allowed By Medicare

Block 18: Allowed by Medicare- Enter the amount of the charges allowed by Medicare.

18

65

Title XVIII- Block 19

Paid By Medicare

Block 19: Paid by Medicare- Enter the amount paid by Medicare (taken from the

EOB).

19

66

Title XVIII- Block 20

Deductible

Block 20: Deductible- Enter the amount of the deductible (taken from the Medicare EOB).

20

67

Title XVIII- Block 21

Co-Insurance

Block 21: Coinsurance - Enter the amount of the coinsurance (taken from the Medicare

EOB).

21

68

Title XVIII- Block 22

Paid By Carrier Other Than Medicare

Block 22: Paid by Carrier Other Than Medicare- Enter the payment received from the

primary carrier (other than Medicare). If Code 3 is marked in Block 7, enter an amount in this block.

(Do not include Medicare payments.)

22

69

Title XVIII- Block 23

Patient Pay Amt. LTC Only

Block 23: Patient Pay Amount, LTC Only-

Leave Blank.

23

70

TITLE XVIII- Adjustment InvoiceDMAS-31

Block 1 Adjustment/Void

Check the appropriate block Block 2 Billing Provider Number

Enter the NPI of the billing provider

Block 6 Rendering Provider NumberEnter the NPI of the rendering

provider Block 2A Reference Number

Enter the ICN number taken from the Remittance Voucher for the line of payment needing adjustment.

71

TITLE XVIII- Adjustment Invoice

Blocks 3-20 Refer to instructions for the DMAS-31 for the completion of these blocks.

Remarks This section of the invoice should be used to give a brief explanation of the change needed.

Signature Signature of the provider or agent and the date signed.

72

REMINDERS Xeroxed copies are still unacceptable Medicaid reimburses providers for the coinsurance and

deductible amounts on Medicare claims for Medicaid recipients who are dually eligible for Medicare and Medicaid. However, the amount paid by Medicaid in combination with the Medicare payment will not exceed the amount Medicaid would pay for the service if it were billed solely to Medicaid

Use the same CPT/HPCS codes that were billed to Medicare (this means using the two code system)

Make sure and attach Medicare EOB to 30-R & 31-R

73

LogistiCare Contact Telephone Number For A0428 Non-Emergency Ambulance Non-Emergency Services

LogistiCare’s Medicaid recipients toll-free reservation line: 1-866-386-8331

- This line is intended for recipients, facilities, and hospitals to schedule trips

All A0428 Medicaid Non-Emergency Ambulance trips must be “pre-authorized”, arranged, and paid for by LogistiCare.

74

Resources TrailBlazer – Federal Source for Medicaid and

Medicare Information Website: http://www.Trailblazerhealth.com/

Medicall Line (Eligibility) – 1-800-884-9730 or 1-800-772-9996

DMAS Internet - Providers are encouraged to monitor all Medicaid memorandums and the DMAS website for additional directions. Website: http://www.dmas.virginia.gov

75

Help Line

HELPLINE The “HELPLINE” is available to answer questions

Monday through Friday from 8:30 a.m. to 4:30 p.m., except state holidays. The “HELPLINE” numbers are:

1-804-786 -6273 Richmond area and out-of-state long distance

1-800-552-8627 All other areas (in-state, toll-free long distance)

Please remember that the “HELPLINE” is for provider use only. Please have your Medicaid Provider Number or your NPI number available when you call.

76

Questions?

77

THANK YOU