Intellectual Disability Community Waiver

1www.vita.virginia.gov

Eligibility Verification and Direct Data Entry Billing Requirements

February 2013

www.dmas.virginia.gov 1

Department of Medical Assistance Services

Intellectual Disability Community Waiver

www.vita.virginia.gov

• This presentation is to facilitate training of the subject matter in the Virginia Medicaid manuals.

This training contains only highlights of the manual and is not meant to substitute for or take the place of the manual.

Providers are responsible for reviewing and adhering to all Medicaid manual requirements.

3

Agenda• DMAS Web Portal• Eligibility Verification Options• Patient Pay Information• Important Contacts• Direct Data Entry Billing

Guidelines• Timely Filing

www.vita.virginia.govwww.dmas.virginia.gov 3


4

DMAS Web Portal



• Current, most up-to-date information on Virginia Medicaid programs:– Provider Memos Available for Review– Access to Medicaid Manuals– Provider Forms– Provider Profile Maintenance– Automated Response System– Direct Data Entry (DDE)

https://www.virginiamedicaid.dmas.virginia.gov/wps/portal

https://www.virginiamedicaid.dmas.virginia.gov/wps/portal

5

DMAS Web Portal• Current, most up-to-date information on

Virginia Medicaid programs:– Provider Memos Available for Review– Access to Medicaid Manuals– Provider Forms– Provider Profile Maintenance– Automated Response System– Direct Data Entry (DDE)



• https://www.virginiamedicaid.dmas.virginia.gov/wps/portal

6

As a participating Provider You Must

• Determine the patients identity.• Verify the patient’s age.• Verify the patient’s eligibility• Accept, as payment in full the amount paid

by Virginia Medicaid.• Bill any and all other third party carriers.



7

COMMONWEALTH OF VIRGINIADEPARTMENT OF MEDICAL ASSISTANCE SERVICES

002286

9 9 9 9 9 9 9 9 9 9 9 9V I RG I N I A J. R E C I P I E N T

DOB: 05/09/1994 F CARD# 00001

8www.vita.virginia.govwww.dmas.virginia.gov 8


Medicaid Eligibility Verification Options

MediCall/Automated Response System

(ARS)



MediCall/Automated Response System (ARS)

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



MediCall

800 - 884 - 9730800 - 772 - 9996800 - 965 - 9732800 - 965 - 9733



Automated Response System (ARS)• Web based eligibility verification

option–Free of Charge–Information received in “real time”

–Secure–Fully HIPPA compliant



ARS Registration Process• First Time Users

– Go to https://www.virginiamedicaid.dmas.virginia.gov/wps/portal/Webregistration

– Establish an user ID and password– By registering you are acknowledging

yourself as a staff member with administrative rights for the organization

https://www.virginiamedicaid.dmas.virginia.gov/wps/portal/Webregistration

https://www.virginiamedicaid.dmas.virginia.gov/wps/portal/Webregistration



ARS Web Support Call Center• Questions regarding new user registration,

temporary password or password resets, call:

1-866-352-0496 Available 8 am – 5 pm

Monday – Friday (No Holidays)

14

Patient Pay Information• The local department of social services (LDSS) will

enter data regarding the individual’s 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 re-determination of eligibility– Change in the enrollee’s situation is reported

• Medicaid 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.



Patient Pay Information

Begin-End(Date Time Period) Patient Pay Status

06/01/2012- 06/30/2012

06/01/2012 - 06/30/2012

658.00

488.00 A

V

ARS Patient Pay Information

15

16

Provider Call Center



Claims, covered services, billing inquiries:

800-552-8627 804-786-6273

8:30am – 4:30pm (Monday-Friday)11:00am – 4:30pm (Wednesday)

17

Provider Enrollment



New provider enrollment, Electronic Fund Transfer (EFT) or change of address:

Xerox– PEU P. O. Box 26803 Richmond, VA 23261 888-829-5373 804-270-5105 804-270-7027 - Fax



Direct Data Entry



Accessing DDE• Once registered for the Web Portal, the

Primary Account Holder (PAH) and Organization Administrator (OrgAdmin) will automatically have access to DDE

• Other users identified as Authorized Staff, will need to be assigned a new role called Authorized Staff-Claims to have access to DDE



Direct Data Entry (DDE) of Claims• DDE allows the submission of professional

claims by entering the information at the required locators as detailed in the billing instructions within the User Guide– http://www.virginiamedicaid.dmas.virginia.gov– Under Provider Resources tab select Claims

Direct Data Entry (DDE)– Provides access to DDE User Guide, Tutorial

and FAQs

http://www.virginiamedicaid.dmas.virginia.gov/

21

Direct Data Entry (DDE) of Claims



• Through the DDE process providers will have the ability to – create a new initial claim– create templates – request an adjustment or void

22

Accessing the Claims DDE• https://www.virginiamedicaid.dmas.virginia.gov



• Upon successful login, you will be directed to the secure Provider Welcome Page• Navigational tabs will direct you to Claims DDE and Automated Response System functions

https://www.virginiamedicaid.dmas.virginia.gov/



Claims Menu-Access



Claims Main Page

• DDE functions can be accessed here

25

Create New Professional Claim



26

Void/Replacement Claim

26

• Is this a void/replacement (adjustment) of a paid claim: System defaults to ‘No’ and requires no Claim

Resubmission Information fields related to a prior claim

If ‘Yes’ is selected, the system requires Claim Resubmission Information fields be entered as well as the original paid claim except areas changing for adjustment.

• Claim Resubmission Information section has the following required fields: Resubmission Type Code (required) Select the 4 digit

code identifying the reason for adjusting or voiding an individual claim



Resubmission Type Options- Adjustments• 1023- Primary carrier

has made additional payment

• 1024- Primary carrier denied payment

• 1025- Accommodation charge correction

• 1026- Patient payment amount changed

• 1027- Correcting service periods

• 1028- Correcting procedure/service code

• 1029- Correcting diagnosis code

• 1030- Correcting charges• 1031- Correcting units/

visits/studies/procedures• 1032-IC reconsideration of

documented allowance• 1033- Correcting

admitting/referring/ prescribing Provider Identification Number

29

Resubmission Type Options – Voids



• 1042- Original claim has multiple incorrect items

• 1044- Wrong provider identification number

• 1045- Wrong enrollee eligibility number

• 1046- Primary carrier paid DMAS max allowance

• 1047- Duplicate payment was made

• 1048- Primary carrier has paid full charge

• 1051- Enrollee not my patient

• 1052-Miscellaneous• 1060- Other insurance

available

Submitter Information

• Submitter ID- this field defaults to the User ID used to login into the portal

30

Patient and Insured Information

31

• Patient's Last Name (REQUIRED) – Enter the Last Name of the member receiving the service.

• First Name (REQUIRED) – Enter the First Name of the member receiving the service.

• MI (optional) – Enter the member's middle initial.

• Insured's I.D. Number (REQUIRED) – Enter the 12 digit Virginia Medicaid Identification number for the member receiving the service.

• Is Patient's Condition Related To: (REQUIRED)• Related Cause 1– Select whether or not the member’s

condition is the result of an employment accident.• Drop down options:

– Not Related To Employment– Related To Employment

• Related Cause 2– Select whether or not the member’s condition is related to an auto accident.

• Dropdown options:– Not Related To An Auto Accident– Related To An Auto Accident

• If ‘Related to an Auto Accident’, the system requires you to enter the state where the auto accident occurred.

• Related Cause 3– Select whether or not the member’s condition is related to an accident other than auto or employment.

• Drop down options:– No Accident– Accident

• Is there another Health Benefit Plan? (REQUIRED) – This field always defaults to ‘No’ but if other third party coverage exists, select ‘Yes’ and enter Other Coverage Information.

• If ‘Yes’ is entered and other insurance pays this must be listed as Supplemental Data

• If ‘Yes’ is entered and other insurance does not pay standard TPL guidelines must be followed– Attachments must be indicated in Service

Location section

Physician or Supplier Information

This is notrequired

35

CLIA #

• Date of Current (optional/situational) – Select the reason from drop down options and enter the date in the format MM/DD/YYYY– Illness(First Symptom)-Waiver services providers will enter

the date care began from the DMAS-93 (PA Letter)• Diagnosis or Nature of illness or Injury

(REQUIRED) – Enter the appropriate diagnosis code, which describes the nature of the illness or injury for which the service was rendered. You have to enter at least one diagnosis code out of four.

• Service Authorization # (optional/situational) - Enter the Service Authorization Number for approved services that require a service authorization.

Service Line ItemClick on ‘Add Service Line Item’Button to add additional Line items

After entering informationYou must Save, Reset, or Cancel

37

Note: Taxonomy Code isentered here if applicable

• Service Date Begin (REQUIRED) – Enter the date on which the service was first rendered. Format is MM/DD/YYYY

• Service Date End (REQUIRED) – Enter the date on which the service was last rendered. Format is MM/DD/YYYY.

• Place of Service (REQUIRED) – Select the two digit code which best describes where the services were rendered.– 12 – Home

• Procedure Code (REQUIRED) – Enter the code that describes the procedure rendered or the service provided.

• Modifiers (optional/situational) – Enter the appropriate modifiers if applicable.

• Diagnosis Pointers (REQUIRED) – Select the diagnosis pointer related to the date of service and the procedure performed for the primary diagnosis. The system requires you to enter at least one diagnosis pointer value out of four.– Drop down options:

• 1• 2• 3• 4

Saved Service Line Items

After entering informationYou must Save, Delete, or Cancel

Click on Service Line Item to view

40

Save/Reset/Cancel• After entering information in identified

sections, you will have the following options: Save- saves the data as part of your DDE

claim Reset- clears the data entered allowing you to

start again Cancel- will exit or close the current data field

• Data will be required to be saved to be included as part of the DDE claim submission

• After saving the data, each line item will be displayed

• Additional information can be entered by selecting the ‘Add’ link

• To correct or delete a saved line item, you must first select the line to be amended by clicking on it

• After selecting the saved line item, you will have the following options: Correcting the information and

save by clicking the Save link Remove the entry from the claim

by clicking on the Delete link Keep the original data as listed by

clicking on the Cancel link

Service Location and Attachments

44

• The Amount Paid field is for Personal Care and Waiver services only– Enter the patient pay amount that is due from

the patient.– NOTE: The patient pay amount is taken from

services billed. – Providers rendering more than one service will

need to send another DDE submission for charges not subject to the Patient Pay.

Patient Pay Amount

• If the claim has any attachments, you must select ‘Yes’ and enter the following information: Patient Account Number (required) –

Enter up to 20 alphanumeric characters Date of Service (required) – Enter from

date of service the attachment applies to in the MM/DD/YYYY format

Sequence Number (required) – Enter the provider generated sequence number – maximum of 5 digits

• A ‘Claim Submitted’ confirmation page will be generated by the system

• Print the Claim Submitted page • Staple documents to a copy of the

confirmation page and mail to DMAS• Attachment “documentation” must be

received by Xerox (DMAS Fiscal Agent) within 21 days of the DDE submission or claim will deny

• NOTE: Confirmation page must be the first page of the mailed submitted documents

• Mailing Address – Claims Submission page and required documents should be mailed within 21 days to:

Department of Medical Assistance ServicesP. O. Box 27444

Richmond, VA 23261-7444

Service Facility Location Information

49

Billing Provider Information

• This section details information about the provider requesting payment for services rendered.

• Billing Provider Information section has both required and optional/situational fields 50

Claim Submitted Page

51

• You will not be able to access the Claim Submitted page anywhere else on the Portal

• It is strongly recommended you always save a file copy or print this page for your records by clicking on the ‘Print Submission Page’

• Claim Information- review the following: ICN – Displays the ICN number of the

submitted claim Attachment Control Number (ACN) – Displays

the ACN number if the ATTACHMENT option has been selected for this claim

Date of Service Provider # Member ID Member Name Total Charge Submitted Date/Time (this information will be

accepted as Proof of Timely Filing)

Create a Professional Template CMS 1500

54

• Templates are a mechanism for the user to establish a baseline claim that can be reused as needed.

• They can :– be used to eliminate the need for having to

rekey static data with every submission (i.e. billing provider information).

– be established for common submissions (i.e. infant well care, immunizations, etc)

– be stored for reuse

55

• To establish a template for a professional claim, select Create Professional Template from the Claims drop down menu.

• You will be transferred to the Create New Professional Template page for template creation 56

Template Name

57

• All the fields utilized in the Create Professional Template will be the same as the fields in the Create Professional Claim Except for the buttons below

• From this template page you can

– save the template by clicking on ‘Save Template’ button

– reset all the entered fields by clicking on the ‘Reset’ button or;

– navigate to the ‘Create New Professional Template’ page by clicking on the ‘Cancel’ button.

58

• When saving the template, the system only validates the format of the data entered.

• After clicking 'Save Template' button, the system displays a successful save message by directing you to the ’Save Template‘ portlet.

59

Save Template

• From this Save Template page you can– navigate to the ’Claims Main Page’ in order to

access other claims options by clicking on the 'Claims Main Page’ button or;

– create a new professional template by clicking on the 'Create Another Template' button.

60

View/Manage/DeleteTemplates

61

6262

View/Edit/Delete Template

• Once a selection is made, you will be transferred to the request page

6363

View/Edit/Delete Request Page

6464

View/Edit/Delete Template –Search Results

6565

• Results that match the search criteria entered, will be displayed in the ‘Search Results’ section

• Clicking on the individual search result record will direct you to the response page containing detailed information for the selected template

• Except for the buttons above, all of the fields in the Template Response page will be the same as the fields in Create Professional Claim

6666

• After clicking on the ‘Delete Template’ button, the system deletes the template and displays a successful deletion message by directing you to the ‘Template Deleted’ portlet shown above

DDE Tips

• Recommend using 6.0 or higher Internet Explorer

• Web-based cursor must be placed in correct location

• Templates limited to 100• Be as specific as possible when naming

templates-they are to be shared• Data entry only-no edits• When adjustments and/or voids of

claims are required, you must wait until the next business day to submit this information

67

DDE Tips• Print or save confirmation-Claim Submitted

Page• You will not receive prompts to submit

required Supplemental Data• Don’t worry about capitalization,

punctuation, or symbols (except for TPL Supplemental Data)

• 3 year limit for adjustments and voids• Claims for Medallion II members enrolled in

Managed Care Organizations will continue to be submitted to the MCO’s according to their guidelines 68

69

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– Accidents

70

TIMELY FILING• Claims documentation can be submitted

with DDE• Provider must indicate documentation will

be submitted during the data entry claims process

• Documentation should be attached to the claims confirmation page and mailed to the DMAS fiscal agent – Xerox State Health Plans



Thank You

Documents

Intellectual Disability Community Waiver