Upload
erno
View
27
Download
3
Tags:
Embed Size (px)
DESCRIPTION
Medicaid Eligibility Verification Options & CMS-1500 (08-05) Billing Guidelines. October – December 2008 www.dmas.virginia.gov Department of Medical Assistance Services. ************. - PowerPoint PPT Presentation
Citation preview
Medicaid Eligibility Verification Options &
CMS-1500 (08-05) Billing Guidelines
October – December 2008www.dmas.virginia.gov
Department of Medical Assistance Services
2
This presentation is to facilitate training of the subject matter This presentation is to facilitate training of the subject matter in Chapter V of the Virginia Medicaid in Chapter V of the Virginia Medicaid Psychiatric Services Manual..
This training contains only highlights of this manual and is This training contains only highlights of this manual and is not meant to substitute for or take the place of the not meant to substitute for or take the place of the Psychiatric Psychiatric Services Manual.Services Manual.
************
3
Objectives
Upon completion of this training you should be able to :
Correctly utilize Medicaid options to verify eligibility
Understand timely filing guidelines Properly submit Medicaid claims,
adjustments and voids
4
As a Participating Provider You 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 Virginia Medicaid. Bill any and all other third party carriers.
5
DOB: 05/09/1964 F CARD# 00001
DEPARTMENT OF MEDICAL ASSISTANCE SERVICESCOMMONWEALTH OF VIRGINIA
V I RG I N I A J. R E C I P I E N T
9 9 9 9 9 9 9 9 9 9 9 9
002286
6
Important Contacts MediCall ARS- Web-Based Medicaid Eligibility Provider Call Center Provider Enrollment
7
MediCall
800-884-9730800-772-9996804-965-9732804-965-9733
8
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
9
Automated Response System ARS Web-based eligibility verification option
Free of Charge. Information received in “real time”. Secure Fully HIPAA compliant
10
UAC Registration ProcessGo 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’
11
ARS –Users
Web Support Helpline- ARS Manual (User Guide)
800-241-8726http://virginia.fhsc.com
12
Provider Call Center
Claims, covered services, billing inquiries:
800-552-8627
804-786-62738:30am – 4:30pm (Monday-Friday)
11:00am – 4:30pm (Wednesday)
13
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
14
Electronic BillingElectronic Claims Coordinator
Mailing Address
First Health Services CorporationVirginia Operations
Electronic Claims Coordinator4300 Cox Road
Glen Allen, VA 23060 E-mail: [email protected]
Phone: (800) 924-6741
Fax: (804) 273-6797
15
Billing on the CMS-1500
16
MAIL CMS-1500 FORMS TO:
DEPARTMENT OF MEDICAL ASSISTANCE SERVICES
PRACTITIONERP. O. Box 27444
Richmond, Virginia 23261
17
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
18
TIMELY FILING Submit claims with documentation attached (to
the back of claim) explaining the reason for delayed submission
Printing Must be RED OCR dropout ink or the exact match Computer generated form must match/line up with
National Uniform Claim Committee standard Print 100% of actual size, set page scaling to
“none” 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
CMS-1500 CLAIM FORM:
Use ONLY the ORIGINAL
RED & WHITEWHITECMS-1500 (08-05) Invoice
Photocopies are not Acceptable
Computer generated claims must match NUCC uniform standards
MEDICAID
(Medicaid #)
Block 1
CHAMPUS
(Sponsor's SSN)
1. MEDICARE
(Medicare #)
TRICARE
21
1a. INSURED'S I.D. NUMBER (FOR PROGRAM IN ITEM 1)
Block 1a: Recipient ID Number
(Be sure to include all 12 digits)
123456789014
22
Block 2: Patient's Name
2. PATIENT'S NAME (Last name, First Name, Middle Initial)
Smith, Sam
23
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 & c24
Block 11d - Is There Another Health Benefit Plan?
d. IS THERE ANOTHER HEALTH BENEFIT PLAN?
DMAS does not require providers to complete Blocks 9 a-d
YES NO If yes, return to and complete item 9 a-d.
25
Providers must indicate YES for all patients who have any other insurance coverage. Regardless of whether payment is received from the primary carrier for service provided.
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY
1.
2.
3.
4.
3441
Block 21: Diagnosis Codes
May enter up to 4 codesOmit decimals
2963
26
23. PRIOR AUTHORIZATION NUMBER
Block 23: Prior Authorization Number - Conditional
27
28
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
29
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
30
TPL Information Block 24A DMAS will set COB code based on the information
given in locator 11d: No, or nothing indicated-no other carrier on file for
the recipient, Medicaid will pay primary No, or nothing indicated and system has other
insurance coverage on file - claim will deny bill other insurance
No, or nothing indicated and ‘TPL’ qualifier with payment listed in 24a red shaded area – Medicaid will coordinate benefits with other carrier
31
TPL Information Block 24A DMAS will set COB code based on the information given
in locator 11d: Yes, and ‘TPL’ qualifier with payment in 24a red
shaded area primary carrier billed and paid, Medicaid will coordinate benefits with the primary carrier
Yes, but nothing in 24a red shaded area and other carrier billed and made no payment. Providers must attach current documentation of non-payment from the other carrier. Copy of explanation of benefits denial or information documented on agency/group letterhead is acceptable documentation.
24. A.DATE(S) OF SERVICE
From ToMM DD YY MM DD YY
Block 24A: Dates of Service
09 01 08 09 01 08
09 01 08 09 16 08
1
2 Both FROM and TO dates
must be completedDates must be within same calendar month
TPL27.08
B.Place
ofService
Block 24B: Place of Service
11
11-Office location
21 – Inpatient
Medicaid accepts the same 2 digit CMS Place of Service codes as
Medicare.
Note: Type of Serviceis no longer required
33
34
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
C.
EMG
Block 24C: EMG
35
D.
Block 24D: Procedure Codes
PROCEDURES, SERVICES, OR SUPPLIES(Explain Unusual Circumstances)
CPT/HCPCS MODIFIER
T101690806
36
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY
1.
2.
3.
4.
34431
Block 24E: Diagnosis Code
E.
DIAGNOSISPOINTER
1
2963
1,2Enter 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. 37
F.$ CHARGES
Block 24 F: Charges
Enter the usualand customary charges
38
G.DAYS
ORUNITS
Block 24G: Days or Units
1
Enter the number of times or hours the procedure, service, or item was provided during the service period.
31
39
H.
Block 24H: EPSDT/Family Plan
1
EPSDTFamilyPlan
1-EPSDT
40
41
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).
DMAS requires Treatment Foster Care agencies to bill with an API.
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.
42
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.
Block 24I: ID. Qualifier& 24J: Rendering Provider ID #
I.ID.
QUAL
J.RENDERING
PROVIDER ID. #
NPI
1D
Atypical Provider Identifier43
0012345671
Block 24I: ID. Qualifier& 24J: Rendering Provider ID #
I.ID.
QUAL
J.RENDERING
PROVIDER ID. #
NPI 1234567890
ZZ Taxonomy (if needed)
44
National Provider Identifier
26. PATIENT ACCOUNT NUMBER
Block 26: Patient’s Account Number
12345678918765
Can not exceed 14 alphanumeric digits
45
28. TOTAL CHARGE
Block 28: Total Charges
$
46
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.47
48
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
49
Block 32
Block 32, cont’d.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
Block 32: Service Facility Location Information
32. SERVICE FACILITY LOCATION INFORMATION
a. b.NPI
50
51
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
52
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.
Block 33: Billing Provider Info & PH #
33. BILLING PROVIDER INFO & PH #
a. b.NPI
( )
53
22. MEDICAID RESUBMISSIONCODE ORIGINAL REF. NO.
Block 22: Adjustments and Voids
1032 xxxxxxxxxxxxxxxxAdjustment
or
Resubmission Code
From originalremittanc
eVoid
Chap. V, Psychiatric Services Manualhas resubmission code list. 54
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.
55
REMITTANCE VOUCHERSections of the Voucher
FINANCIAL TRANSACTION
EOB DESCRIPTION
ADJUSTMENT DESCRIPTION/REMARKS- STATUS DESCRIPTION
REMITTANCE SUMMARY- PROGRAM TOTALS
56
THANK YOUDepartment of Medical Assistance
Services
www.dmas.virginia.gov