Provider Billing Instructions - KYMMISuatweb.kymmis.com/kymmis/pdf/billingInstr/01Hospital... · 2006-09-22 · Provider Billing Instructions For Hospital Services Provider Type –

Commonwealth of Kentucky KyHealth Choices

Provider Billing Instructions

For Hospital Services

Provider Type – 01

Version 1.5 September 22, 2006

Revision History Document

Version Date Name Comments

1.0 10/14/2005 EDS Initial creation of DRAFT Home Health Services Provider Type – 34

1.2 01/19/2006 EDS Updated Provider Rep list 1.3 02/16/2006 Carolyn Stearman Updated with revisions requested by

Commonwealth. 1.4 03/28/2006 Lize Deane Updated with revisions requested by

Commonwealth. 1.5 04/5/2006 Tammy Delk Updated with revisions requested by

Commonwealth. 1.6 09/18/2006 Ann Murray Replaced Provider Representative table.

Printed 9/18/2006 Provider Type-01 Page i

TABLE OF CONTENTS

NUMBER DESCRIPTION PAGE

1 General ................................................................................................................................................. 1 1.1 Member Eligibility.......................................................................................................................... 1 1.2 Plastic Swipe KYHealth Card ....................................................................................................... 2 1.3 Member Eligibility Categories ....................................................................................................... 3

1.3.1 Lock-In ............................................................................................................................. 3 1.3.2 KenPAC ........................................................................................................................... 3 1.3.3 QMB and SLMB............................................................................................................... 3 1.3.4 Managed Care Partnerships............................................................................................ 3 1.3.5 KCHIP .............................................................................................................................. 3 1.3.6 Presumptive Eligibility...................................................................................................... 4 1.3.7 Breast & Cervical Cancer Program.................................................................................. 5

1.4 Verification of Member Eligibility................................................................................................... 6 1.4.1 Obtaining Eligibility and Benefit Information .................................................................... 6

2 General Billing Instructions ............................................................................................................... 9 2.1 General Instructions...................................................................................................................... 9 2.2 Imaging ......................................................................................................................................... 9 2.3 Optical Character Recognition...................................................................................................... 9

3 Electronic Data Interchange (EDI) ................................................................................................... 11 3.1 Means Of Electronic Submission................................................................................................ 11

3.1.1 Soft Media...................................................................................................................... 11 3.1.2 Hard Media .................................................................................................................... 11

3.2 How To Get Started .................................................................................................................... 11 3.3 Format and Testing..................................................................................................................... 11 3.4 ECS Help .................................................................................................................................... 11

4 Additional Information and Forms .................................................................................................. 13 4.1 Claims with Service Dates Over One Year Old .......................................................................... 13 4.2 Retroactive Eligibility (Back-Dated) Card.................................................................................... 13 4.3 Unacceptable Documentation..................................................................................................... 13 4.4 Third Party Coverage Information............................................................................................... 14

4.4.1 (Excluding Medicare) ..................................................................................................... 14 4.4.2 Documentation That May Prevent A Claim From Denying............................................ 14 4.4.3 For Accident And Work Related Claims ........................................................................ 15

4.5 Provider Inquiry Form ................................................................................................................. 17 4.6 Prior Authorization Information ................................................................................................... 19 4.7 Adjustments And Claim Credit Request ..................................................................................... 20 4.8 Cash Refund Documentation Form ............................................................................................ 22 4.9 Return To Provider Letter ........................................................................................................... 24 4.10 Provider Representative List....................................................................................................... 26

4.10.1 Phone Numbers and Assigned Counties....................................................................... 26 5 HIPAA Information for Billing .......................................................................................................... 29 6 Completion of UB-92 Claim Form.................................................................................................... 33

6.1 UB-92 Billing Instructions............................................................................................................ 33 6.2 Special Billing Instructions .......................................................................................................... 43

6.2.1 DRG............................................................................................................................... 43 6.2.2 Outpatient Services Provided ........................................................................................ 44 6.2.3 Instructions On Submitting a Two-Page UB-92............................................................. 44

Printed 9/18/2006 Provider Type-01 Page ii

6.3 Medicaid Payment for Claims ..................................................................................................... 45 6.3.1 With Non-Covered Days Involving A Third Party........................................................... 45

7 Medicare Deductibles and Coinsurance......................................................................................... 47 7.1 Professional Fees ....................................................................................................................... 47

7.1.1 CMS 1500 (12/90) Billing Instructions for Part B ........................................................... 49 7.2 Resubmission Of Medicare/Medicaid Part B Claims.................................................................. 52

8 Forms Requirements ........................................................................................................................ 53 8.1 Completion of Hysterectomy Consent Form, (MAP-251) ........................................................... 59

8.1.1 Purpose.......................................................................................................................... 59 8.1.2 General Instructions....................................................................................................... 59 8.1.3 Detailed Instructions for Completion of the Form .......................................................... 59

8.2 Completion of Certification of Conditions Met (MAP-346).......................................................... 60 8.3 Completion of Other Hospitalization Statement (MAP-383) ....................................................... 62 8.4 Completion of Other Services Statement (MAP-397)................................................................. 63

9 Appendix A ........................................................................................................................................ 65 9.1 Internal Control Number (ICN).................................................................................................... 65

10 Appendix B ........................................................................................................................................ 66 10.1 Inpatient Revenue Codes ........................................................................................................... 66 10.2 Incremental Nursing Revenue Codes......................................................................................... 75

10.2.1 All Inclusive Accommodation, Appropriate Type Of Bills............................................... 75 11 Appendix C ........................................................................................................................................ 76

11.1 Outpatient Revenue Codes ........................................................................................................ 76 12 Appendix D ........................................................................................................................................ 82

12.1 Inpatient and Outpatient Professional Component..................................................................... 82 13 Appendix E......................................................................................................................................... 83

13.1 Outpatient Drugs......................................................................................................................... 83 14 Appendix F......................................................................................................................................... 84

14.1 Remittance Advice...................................................................................................................... 84 14.1.1 Examples Of Pages In Remittance Advice.................................................................... 85

14.2 Title ............................................................................................................................................. 86 14.3 Paid Claims Page ....................................................................................................................... 89 14.4 Denied Claims Page ................................................................................................................... 91 14.5 Claims In Process Page ............................................................................................................. 93 14.6 Returned Claim........................................................................................................................... 95 14.7 Adjusted Claims Page ................................................................................................................ 97 14.8 Accounts Receivable Summary Page ...................................................................................... 100 14.9 Summary Of Benefits Page ...................................................................................................... 107

15 Appendix G ...................................................................................................................................... 110 15.1 Remittance Advice Location Codes (LOC CD)......................................................................... 110

16 Appendix H ...................................................................................................................................... 111 16.1 Remittance Advice Reason Code (ADJ RSN CD or RSN CD) ................................................ 111

17 Appendix I ........................................................................................................................................ 113 17.1 Remittance Advice Status Code (ST CD)................................................................................. 113

1 General

Printed 9/18/2006 Provider Type-01 Page 1

1 General

1.1 Member Eligibility KY Members must apply for Medicaid eligibility through their Department for Community Based Services (DCBS) local office. If you have any questions or concerns, you must contact the KY Administrative Agent (KMAA), which is First Health Services Corporation, at 1-800-635-2570, 8:00 a.m. – 6:00 p.m. Eastern Time, Monday through Friday, except Holidays and select the prompt for Member Eligibility.

The primary identification for Medicaid eligible members is the KYHealth Card. It is a permanent plastic card issued when the Member becomes eligible for Medicaid coverage. The name of the member and the Member Identification number is the only data displayed on the card. The provider has the responsibility to check identification and eligibility of each member before providing services.

NOTE: Payment cannot be made for services provided to ineligible members,

and/or,

Possession of a Member Identification card does not guarantee payment for all medical services.

The following is an example of the KYHealth Card:

1 General


1.2 Plastic Swipe KYHealth Card

Through a vendor of your choice, the magnetic strip can be swiped to obtain eligibility information.

Member Name

First, Middle Initial (if available), Last

10 DIGIT Member Identification Number

Magnetic Strip

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1.3 Member Eligibility Categories

1.3.1 Lock-In KY Medicaid monitors utilization patterns of Medicaid members to ensure that benefits received are at an appropriate frequency and are medically necessary given the condition presented by the member. Referrals regarding suspected over-utilization are investigated by the Department. In those cases where improper utilization can be documented, the member is "locked-in" or assigned to one physician to serve as case manager and/or one pharmacy for supply of prescription drugs. The lock-in member is thereafter limited to use the services of these providers except in cases of emergency or appropriate referrals by the physician case manager. Providers who are not designated as lock-in case managers or pharmacies do not receive payment for services provided unless a medical emergency is documented or an appropriate referral has been made.

1.3.2 KenPAC Kentucky Patient Access Care (KenPAC) is a patient care system which provides Medicaid members with a primary care provider. The primary care provider is responsible for providing or arranging for the member’s primary care and for referral of other medical services. Similar to "lock-in" members, a service provided to a KenPAC member by a medical provider other than the assigned primary care provider is not covered unless an appropriate referral has been made by the KenPAC PCP. Some categories of medical service are exempt from the KenPAC referral requirement. A complete list of these is listed in 907 KAR 1:320. Some of the physician-provided services which do not require a KenPAC referral include a mental health service (if provided by a psychiatrist), a vision service, a maternity care service, an EPSDT service, a family planning service, or a newborn care service.

1.3.3 QMB and SLMB Qualified Medicare Beneficiaries (QMBs) and Specified Low-Income Medicare Beneficiaries (SLMBs) are Medicare eligible members who also qualify for limited Medicaid assistance. The QMB eligible individual is issued a medical card with a designation indicating the individual is eligible for either QMB and Medicaid benefits or QMB benefits only. QMB benefits entitle the individual to Medicaid coverage of Part A & Part B Medicare premiums, co-pays, and deductibles. An individual who qualifies for SLMB benefits is not eligible for Medicaid benefits other than coverage of their monthly Medicare premium.

1.3.4 Managed Care Partnerships Passport is a Medicaid health care plan serving Medicaid members living in the following counties: Breckinridge, Bullitt, Carroll, Grayson, Hardin, Henry, Jefferson, Larue, Marion, Meade, Nelson, Oldham, Shelby, Spencer, Trimble, and Washington.

Although medical benefits for individuals whose care is managed by Passport mimic those of KY Medicaid, some billing procedures may differ. A physician having questions regarding Passport coverage should contact Passport Provider Services at 1-800-578-0775.

1.3.5 KCHIP The KY Children's Health Insurance Program (KCHIP) is for children through the age of 18 years who have no other type of insurance and whose family meets specified income criteria. Based upon household income, these children are issued a regular Medicaid card. Children

1 General


having KCHIP III category eligibility are covered for all Medicaid covered services except non-emergency transportation and EPSDT special services.

1.3.6 Presumptive Eligibility Presumptive Eligibility (PE) is a program offering pregnant women temporary medical coverage for prenatal care. A treating physician may issue an Identification Notice to a woman once pregnancy is confirmed. Presumptive eligibility expires 90 days from the date the Identification Notice is issued This short-term program is only intended to allow a woman to have access to prenatal care while she is completing the application process for full Medicaid benefits.

1.3.6.1 Presumptive Eligibility Definitions Presumptive Eligibility (PE) is designed to provide coverage for ambulatory prenatal services when these services are provided by approved health care providers.

A. SERVICES COVERED UNDER PE

• Office visits to a Primary Care Provider (see list below) and/or Health Department,

• Anesthesia Services;

• Surgical Services;

• Termination of Pregnancy;

• Laboratory Services;

• Diagnostic radiology services (including ultrasound);

• General dental services;

• Emergency room services;

• Transportation services(emergency and non-emergency); and,

• Prescription drugs (including prenatal vitamins).

B. DEFINITION OF “PRIMARY CARE PROVIDER” – Any health care provider who is enrolled as a KY Medicaid provider, in one of the following programs:

• Physician/osteopaths practicing in the following medical specialties: --Family Practice --Obstetrics/Gynecology --General Practice --Pediatrics --Internal Medicine;

• Physician Assistants;

• Nurse Practitioners/ARNP’s;

• Nurse Midwives;

• Rural Health Clinics;

• Primary Care Centers; and,

• Public Health Departments.

1 General


C. SERVICES NOT COVERED UNDER PE

• Office visits or other procedures performed by a specialist physician (those practicing in a specialty other than those listed in Section B above), even if that visit/procedure is determined by a qualified PE primary care provider to be medically necessary;

• Inpatient hospital services, including labor, delivery and newborn nursery services;

• Mental health/substance abuse services;

• Any other service not specifically listed in Section A as being covered under PE; and,

• Any services provided by a health care provider who is not recognized by the Department for Medicaid Services (DMS) as a participating provider.

1.3.7 Breast & Cervical Cancer Program Breast and Cervical Cancer Program (BCCP) offers Medicaid coverage to individuals who have a confirmed cancerous or pre-cancerous condition of the breast or cervix. In order to qualify for Medicaid eligibility under this program, an individual must be under age 65 and have no other insurance coverage. Eligible individuals receive an Identification Notice. The length of coverage extends through the required treatment period for the breast of cervical cancer condition. Those members receiving Medicaid through the Breast and Cervical Cancer Program are entitled to full Medicaid services.

1 General


1.4 Verification of Member Eligibility This section discusses:

• Methods for verifying eligibility;

• How to verify eligibility through an automated 800 number function;

• How to use other proofs to determine eligibility; and,

• What to do when a proof of eligibility is not available.

1.4.1 Obtaining Eligibility and Benefit Information Eligibility and benefit information is available to providers via the following:

• Voice Response Eligibility Verification (VREV) available 24 hours/7 days a week at 1-800-807-1301;

• Access KYHealth-Net at http://www.chfs.ky.gov/dms/kyhealth.htm; and,

• Contacting the First Health Services Corporation, the fiscal agent for KMAA, Call Center Customer Representative at 1-800-635-2570 Monday through Friday 8:00 a.m. – 6:00 p.m., except Holidays.

1.4.1.1 Voice Response Eligibility Verification (VREV) EDS maintains a Voice Response Eligibility Verification (VREV) system that provides member eligibility verification, third party liability (TPL) information, KenPAC, Lock-in, Managed Care, PRO review, Card Issuance, Co-pay, provider check write, and claim status information.

The VREV system generally processes calls in the following sequence:

1. Greet the caller and prompt for mandatory provider ID.

2. Prompt the caller to select the type of inquiry desired (eligibility, check amount, claim status, or etc.).

3. Prompt the caller for the dates of service (enter four digit year, for example, MMDDCCYY).

4. Respond by providing the appropriate information for the requested inquiry.

5. Prompt for another inquiry.

6. Conclude the call.

This system provides a fast-path mode that permits a provider to take a short path to information. By simply keying the appropriate responses to prompts such as provider ID or Member Identification number as soon as each prompt begins. This greatly increases the speed of the inquiry. The number of inquiries is limited to 5 per call. The VREV spells the member name and announces the dates of service to ensure accuracy of responses. The check amount data is accessed through the VREV voice menu. The provider file is accessed to obtain up to the last three (3) processing check dates and check amounts.

The telephone number (for use by touch-tone phones only) for the VREV is 1-800-807-1301. If you have a rotary telephone, the VREV is not available.

1 General


1.4.1.2 VREV Conversion Chart If you have the Member name and Date of Birth, dial 1-800-807-1301, then choose from the following prompts:

1# to access VREV

Enter the eight digit Medicaid provider ID number followed by the #

1# for Eligibility Verification

5# for Standard Eligibility Verification

2# to access using the Member’s First Name and Last Name

Enter first 5 digits of LAST NAME: *22*72*63*91*62# (*B*R*O*W*N#)

1# to Confirm the LAST NAME

2# to Change the LAST NAME

Enter first 4 digits of FIRST NAME: *51*21*62*32# (J*A*N*E#)

1# to Confirm the LAST NAME

2# to Change the LAST NAME

Using the following conversion chart for the letters of the alphabet, with a * before each letter and a # after the last character of the name:

A 21 H 42 O 63 V 83

B 22 I 43 P 71 W 91

C 23 J 51 Q 11 X 92

D 31 K 52 R 72 Y 93

E 32 L 53 S 73 Z 12

F 33 M 61 T 81 SP *

G 41 N 62 U 82 END #

1# to verify eligibility by the member’s social security number (SSN)

2# to verify eligibility by the member’s DATE OF BIRTH

Enter the Member’s DATE OF BIRTH: MMDDCCYY#

Enter 1# = Male or 2# = Female,

Enter the FROM DATE OF SERVICE#

Enter the TO DATE OF SERVICE#

Or Enter # for today’s date

The system gives the entire name and member Medicaid identification number as well as stating if the member is eligible or ineligible for the DATE OF SERVICE requested.

1 General


1.4.1.3 KYHealth-Net Online Member Verification

KYHEALTH-NET ONLINE ACCESS CAN BE OBTAINED AT:

http://www.chfs.ky.gov/dms/

Click on KYHEALTH-NET

This web-based system is designed to allow Medicaid Providers instant access to pertinent member information. A User Manual is available for downloading and is designed to assist you in navigating through the system. If at any time you have suggestions, comments, or questions, please contact us through the assistance email address located at the bottom of each primary web page ([email protected]).

Please keep in mind information contained on the KYHealth-Net is highly confidential and access should be strictly limited to those with valid reasons. It is the responsibility of the provider and the system administrator to ensure all persons with access understand the appropriate use of this data. We highly recommend the creation and implementation of guidelines within your office outlining appropriate and inappropriate uses of this data.

2 General Billing Instructions



2.1 General Instructions The Department for Medicaid Services is mandated by the Centers for Medicare and Medicaid Services (CMS) to use the UB92 form for the reimbursement of services. You may bill on paper or electronically.

2.2 Imaging All paper claims are imaged. Imaging is taking a picture of the claim and using that picture during claims processing. The major objectives of the imaging technology are: increased accuracy in claims processing; improved customer and provider service; and, reduced storage requirements. This state of the art technology streamlines Medicaid claims processing and provide efficient tools for claim resolution, inquiries, and attendant claim related matters. Considerable gains in productivity and data accuracy are achieved with the EDS Imaging Solution implemented. Listed are a few guidelines for original claims, as well as claims that are being resubmitted, to ensure accurate readability:

• USE BLACK INK ONLY;

• Do not use glue;

• Do not use more than one staple per claim;

• Press hard to guarantee strong print density if claim is not typed or computer generated;

• Do not use white-out or shiny correction tape; and,

• Do not send attachments smaller than the accompanying claim form.

2.3 Optical Character Recognition Optical Character Recognition (OCR) eliminates human intervention by sending the information on the claim directly to the processing system, bypassing data entry. OCR is used for computer generated or typed claims only. Information obtained mechanically during the imaging stage does not have to be manually typed, thus reducing claim processing time. Information on the claim must be contained within the fields in order for the text to be properly read by the scanner.



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3 Electronic Data Interchange (EDI)



Healthcare organizations have traditionally conducted business by trading information on preprinted paper forms. The variety and volume of paper-based exchanges has grown. This has forced healthcare organizations to seek more efficient ways of communicating. Electronic Data Interchange (EDI) is structured business-to-business communications using electronic media rather than paper.

3.1 Means Of Electronic Submission EDS processes electronic transactions on either soft or hard media as defined below.

3.1.1 Soft Media • Asynchronous Modem transmission • Mainframe Communications (contact the EDS EDI Technical Support Help Desk for

constraints)

3.1.2 Hard Media • CD • 3 1/2 inch diskette

3.2 How To Get Started All Trading Partners are encouraged to utilize EDI rather than paper claims submission. To become a business-to-business EDI Trading Partner contact the EDS Electronic Data Interchange Technical Support Help Desk at:

EDS P.O. Box 2016 Frankfort, KY 40602-2016 1-800-205-4696

Help Desk hours are between 7:00 a.m. and 6:00 p.m. Monday through Friday except holidays.

3.3 Format and Testing All EDI Trading Partners must test successfully with EDS and have Department for Medicaid Services (DMS) approved agreements to bill electronically before submitting production transactions. Contact the EDI Technical Support Help Desk at the phone number listed above for specific testing instructions and requirements.

3.4 ECS Help If you are already billing electronically, or have questions of a technical communications nature contact the EDI Technical Support Help Desk at 1-800-205-4696. Help Desk hours are 7:00 a.m. to 6:00 p.m. Monday through Friday except holidays.




4 Additional Information and Forms



4.1 Claims with Service Dates Over One Year Old In accordance with federal regulations, claims must be received by Medicaid within 12 months from the date of service or six months from the Medicare payment date, whichever is later. “Received” is defined in 42 CFR 447.45 (d) (5) as, “The date the agency received the claim as indicated by its date stamp on the claim.”

For KY, the date received is included in the Internal Control Number (ICN). The ICN is a unique number assigned to each incoming claim and the claim’s related documents during the data preparation process.

To consider claims 12 months past the date of service for processing, the provider must attach documentation showing timely receipt by DMS or EDS and documentation showing subsequent billing efforts, if any.

To process claims beyond the 12 month limit, you must attach to each claim form involved, a copy of a Claims in Process, Paid Claims, or Denied Claims section from your Remittance Statement no more than 12 months old, which verifies that the original claim was received within 12 months of the service date.

Additional documentation that may be attached to your claims for processing for possible payment is:

• A screen print from KYHealth-Net verifying eligibility issuance date and eligibility dates must be attached behind the claim.

• A screen print from KYHealth-Net to verify timely filing within each 12 months from date of service, such as the appropriate section of the Remittance Advice or from the Main Menu’s Claims Inquiry selection; and,

• A copy of the Medicare Explanation of Medicare Benefits received 12 months after service date, but less than six months after the Medicare adjudication date.

4.2 Retroactive Eligibility (Back-Dated) Card Aged claims for Members whose eligibility for medical assistance or a specific service is determined retroactively may be considered for payment if filed within one year from the issuance date noted on the Member Identification card. A copy of the Member’s Identification card covering the services dates must be attached behind the claim. Claim submission must be within 12 months of the issuance date. Paper Cards are obsolete as of July 1, 2005. Providers who are billing for services prior to this date attach a copy of the paper card to the claim. After July 1, 2005 a copy of the KYHealth-Net card issuance screen is acceptable documentation.

4.3 Unacceptable Documentation Copies of previously submitted claim forms, providers’ in-house records of claims submitted, or letters detailing filing dates are not acceptable documentation of timely billing. Attachments must prove the claim was received “timely” by EDS.



4.4 Third Party Coverage Information

4.4.1 (Excluding Medicare) When a claim is received for a Member whose eligibility file indicates other health insurance is active and applicable for the dates of services and no payment from other sources is entered on the Medicaid claim form, the claim is automatically denied unless documentation is attached.

4.4.2 Documentation That May Prevent A Claim From Denying

4.4.2.1 For Other Insurance The following forms of documentation prevent your claim from denying for other health insurance when attached to the claim.

1. Remittance statement from the insurance carrier that includes:

a. Member name; b. Date(s) of service; c. Billed information that matches the billed information on the claim submitted to Medicaid;

and, d. An indication of denial or the billed amount was applied to the deductible.

NOTE: Rejections from insurance carriers stating “additional information necessary to process claim” is not acceptable.

2. Letter from the insurance carrier that includes:

a. Member name; b. Date(s) of service(s); c. Termination or effective date of coverage (if applicable); d. Statement of benefits available (if applicable); and, e. Signature of insurance representative or the letter must be on the insurance company’s

letterhead.

3. Letter from a provider that states they have contacted the insurance company via telephone. The letter must include the following information:

a. Member name; b. Date(s) of service; c. Name of insurance carrier; d. Name of insurance representative spoken to and the phone number of the insurance

carrier or notation indicating a voice automated response system was reached; e. Termination or effective date of coverage; and, f. Statement of benefits available (if applicable).

4. A copy of a prior remittance statement from an insurance company may be considered an acceptable form of documentation if it is:

a. For the same Member;

b. For the same or related service being billed on the claim; and,

c. The date of service specified on the remittance advice is no more than six months prior to the claim’s date of service.



NOTE: If the remittance statement does not provide a date of service, the denial may only be acceptable by EDS if the date of the remittance statement is no more than six months from the claim’s date of service.

5. Letter from an employer that includes:

a. Member name;

b. Date of insurance or employee termination or effective date (if applicable); and,

c. Employer letterhead or signature of company representative.

6. No response within 120 days from the insurance carrier

a. When the other health insurance has not responded to a provider’s billing within 120 days from the date of filing a claim, a provider may complete a TPL Lead Form. Write “no response in 120 days” on either the TPL Lead Form or the claim form, attach it to the claim and submit it to EDS. EDS overrides the other health insurance edits and forward a copy of the TPL Lead form to the TPL Unit. The TPL staff contact the insurance carrier to see why they have not paid their portion of liability.

4.4.3 For Accident And Work Related Claims For claims related to an accident or work related incident, the provider should pursue information relating to the event. If an employer, individual, or an insurance carrier is a liable party, but the liability has not been determined, you may submit your claim to EDS with an attached letter containing any relevant information, that is, names of attorneys, other involved parties and/or the Member’s employer to:

EDS P.O. Box 2107 ATTN: TPL Unit Frankfort, KY 40602-2107



EDS EDS Corporation Attention: TPL Unit P.O. Box 2107 Frankfort, KY 40602

THIRD PARTY LIABILITY LEAD FORM

Provider Name: _________________________ Provider #: ________________ Member Name: ________________________ Member #: _______________ Address: ______________________________ Date of Birth: ______________ From Date of Service: ____________________ To Date of Service: _________ Date of Admission: ______________________ Date of Discharge: __________ Insurance Carrier Name: ________________________________________________ Address: ____________________________________________________________ Policy Number: __________________ Start Date: _________ End Date: __________ Date Claim was Filed with Insurance Carrier: ________________________________ Please check the one that applies: ______ No Response in Over 120 Days ______ Policy Termination Date: __________ ______ Other: Please explain in the space provided below

____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________

____________________________________________________________________ Contact Name: _________________________ Contact Telephone #: ____________ Signature: _____________________________ Date: _________________________



4.5 Provider Inquiry Form Provider Inquiry Forms may be used for any unique questions concerning claim status, paid or denied claims, and billing concerns. The mailing address for the Provider Inquiry form is:

EDS Corporation P.O. Box 2100 Provider Services Frankfort, KY 40602-2100

Please keep the following points in mind when using this form:

• Send the two-part completed form to EDS. The yellow copy is returned to you with a response;

• When resubmitting a corrected claim, do not attach a Provider Inquiry Form;

• A toll free EDS number 1-800-807-1232 is available in lieu of using this form; and,

• To check claim status, call the EDS Voice Response on 1-800-807-1301.



PROVIDER INQUIRY FORM EDS P.O. Box 2100 Please remit both copiesFrankfort, KY 40602-2100 of the Inquiry Form to EDS1. Provider ID 3. Member Name (first, last) 2. Provider Name and Address 4. Medical Assistance Number 5. Billed Amount 6. Claim Service Date 7. RA 8. Internal Control Number 9. Provider’s Message 10. Signature Date

EDS Response: ______This claim has been resubmitted for possible payment. ______EDS can find no record of receipt of this claim as indicated above. Please resubmit. ______This claim paid on __________________in the amount of ______________________________ ______This claim was denied on ________________with EOB code____________________________ ______This claim denied on _______________with EOB 00294 “KenPAC Member. Referring provider

ID is missing or is not the KenPAC primary physician/clinic ID for the date(s) of service.” ______This claim denied on _______________with EOB 00295 “KenPAC Member. Billing and/or

referring provider ID is not the KenPAC primary physician/clinic for date(s) of service.” ______This claim denied on _______________with EOB 00467 “Member has other medical coverage.

Bill other insurance first or attach documentation of denial from the insurance carrier.” ______Aged claim. Please see attached documentation concerning services submitted past the 12

month filing limit. Other: ______________________________________________________________________________ ____________________________________________________________________________________ Signature Date



4.6 Prior Authorization Information • The prior authorization process does NOT verify anything except medical necessity.

• The process does not verify eligibility.

• The process does not verify age.

• The prior authorization letter does not guarantee payment. It only indicates that the service is approved based on medical necessity.

• If the Member loses KyHealth Choices or if the member ages out of the program eligibility, services are not reimbursed even though they have been authorized based on medical necessity and a prior authorization letter had been issued.

• Services should only be post authorized in case of:

• Retro-active Member eligibility

• Retro-active provider number

• Providers should always completely review prior to providing services or billing.

If you determine that the services you are providing require prior authorization (based upon Department for Medicaid Services policies and regulations or from the Fee Schedule for your procedure/revenue code), you may contact:

SHPS 9200 Shelbyville Road, Suite 100 Louisville, KY 40222 Telephone: 1-800-292-2392 Fax: 1-800-807-7840 Hours: 8:00 a.m. through 6:00 p.m.

Or you may access the KYHealth Net website to obtain blank Prior Authorization forms.

http://www.chfs.ky.gov/dms/kyhealth

http://www.chfs.ky.gov/dms/kyhealth



4.7 Adjustments And Claim Credit Request An adjustment is a change to be made to a “PAID” claim. The mailing address for the Adjustment Request form is:

EDS Corporation P.O. Box 2108 Frankfort, KY 40602-2108 Attn: Financial Services

Please keep the following points in mind when filing an adjustment request:

• Attach a copy of the corrected claim and the paid remittance advice page to your adjustment form. For a Medicaid/Medicare crossover, attach an EOMB (Explanation of Medicare Benefits) with the claim;

• Do not send refunds on claims for which an adjustment has been filed; • Be specific. Explain exactly what is to be changed on the claim; and, • Claims showing paid zero dollar amounts are considered paid claims by Medicaid. If the

paid amount of zero is incorrect, the claim requires an adjustment.



EDS

ADJUSTMENT AND CLAIM CREDIT REQUEST FORM MAIL TO: EDS CORPORATION

P.O. BOX 2108 FRANKFORT, KY 40602-2108 1-800-807-1232

ATTN: FINANCIAL SERVICES NOTE: A CLAIM CREDIT VOIDS THE CLAIM ICN FROM THE SYSTEM -- A “NEW DAY” CLAIM MAY BE SUBMITTED, IF NECESSARY. THIS FORM WILL BE RETURNED TO YOU IF THE REQUIRED INFORMATION AND DOCUMENTATION FOR PROCESSING ARE NOT PRESENT. PLEASE ATTACH A CORRECTED CLAIM AND REMITTANCE ADVICE TO ADJUST A CLAIM.

CHECK APPROPRIATE BOX: CLAIM CLAIM ADJUSTMENT CREDIT

1. Original Internal Control Number (ICN)

2. Member Name 3. Member Medicaid Number

4. Provider Name and Address

5. Provider 6. From Date of Service

7. To Date of Service

8. Original Billed Amount

9. Original Paid Amount

10. Remittance Advice Date

11. Please specify WHAT is to be adjusted on the claim. You must explain in detail in order for an adjustment specialist to understand what needs to be accomplished by adjusting the claim. 12. Please specify the REASON for the adjustment or claim credit request. 13. Signature 14. Date



4.8 Cash Refund Documentation Form The Cash Refund Documentation Form is used when refunding money to Medicaid. The mailing address for the Cash Refund Form is:

EDS Corporation P.O. Box 2108 Frankfort, KY 40602-2108 Attn: Financial Services

Please keep the following points in mind when refunding:

• Attach to the Cash Refund Documentation Form a check for the refund amount made payable to the KY State Treasurer.

• Attach applicable documentation, such as a copy of the remittance advice showing the claim for which a refund is being issued.



EDS Mail To: EDS P.O. Box 2108 Frankfort, KY 40602-2108 ATTN: Financial Services

CASH REFUND DOCUMENTATION 1. Check Number 2. Check Amount 3. Provider Name/ID /Address 4. Member Name 5. Member Number 6. From Date of Service 7. To Date of Service 8. RA Date 9. Internal Control Number (If several ICNs, attach RAs)

Research for Refund: (Check appropriate blank) a. Payment from other source - Check the category and list name (attach copy of EOB) Health Insurance Auto Insurance Medicare Paid Other b. Billed in error c. Duplicate payment (attach a copy of both RAs) If RAs are paid to two different providers, specify to which provider ID the check is to be applied.

d. Processing error OR overpayment (explain why) e. Paid to wrong provider f. Money has been requested - date of the letter (attach a copy of letter requesting money) g. Other Contact Name Phone



4.9 Return To Provider Letter Claims and attached documentation received by EDS are screened for required information (listed below). If the required information is not complete, the claim is returned to the provider with a “Return to Provider Letter” attached explaining why the claim is being returned.

A claim is returned before processing if the following information is missing:

• Provider ID;

• Original provider or authorized representative signature;

• Member Identification number;

• Member first and last names; and,

• EOMB for Medicare/Medicaid crossover claims.

Other reasons for return may include:

• Illegible claim date of service or other pertinent data.

• Claim lines completed exceed the limit. and,

• Unable to image.



EDS

RETURN TO PROVIDER LETTER Date: _______ - _______ - _______ Dear Provider, The attached claim is being returned for the following reason(s). These items require correction before the claim can be processed. _________________________________________________________________________________________________ 01) ___ PROVIDER NUMBER – A valid 8-digit provider number must be on the claim form in the appropriate field.

___ Missing ___ Not a valid provider number _________________________________________________________________________________________________ 02) ___ PROVIDER SIGNATURE – All claims require an original signature in the provider signature block.

The Provider signature cannot be stamped or typed on the claim. ___ Missing ___ Typed signature not valid ___ Stamped signature not valid.

_________________________________________________________________________________________________ 03) ___ Detail lines exceed the limit for claim type. _________________________________________________________________________________________________ 04) ___ UNABLE TO IMAGE OR KEY – Claim form/EOMB must be legible. Highlighted forms cannot be accepted. Please resubmit on a

new form. ___ Print too light ___ Print too dark ___ Highlighted data fields ___ Not legible ___ Dark copy _________________________________________________________________________________________________ 05) ___ Medicaid does not make payment when Medicare has paid the amount in full. _________________________________________________________________________________________________ 06) ___ The Member’s Medicaid Identification number is missing _________________________________________________________________________________________________ 07) ___ Medicare EOMB does not match the claim

___Dates of Service _____Member Number ____Charges ____ Balance due in Block 30 _________________________________________________________________________________________________ 08) __Other Reason- ________________________________________________________________________________________________ _________________________________________________________________________________________________ _______ Claims are being returned to you for correction for the reasons noted above.

Helpful Hints When Billing for Services Provided to a Medicaid Member

• The Member’s Medicaid Identification number on the CMS must be entered Field 9A • The Member’s Medicaid Identification number on the UB92 must be entered in Block 60 • Medicare numbers are not valid Medicaid numbers • Please refer to your billing manual if you have any concerns about billing the Medicaid program correctly.

Please make the necessary corrections and resubmit for processing. If you have any questions, please feel free to contact our Provider Relations Group, 8:00 a.m. until 6:00 p.m. eastern time, at 1-800-807-1232, Monday through Friday, except Holidays. If you are interested in billing Medicaid electronically, please contact the EDS helpdesk at 1-800-205-4696 7:00 a.m. to 6:00 p.m. eastern time, Monday through Friday except holidays. Initials of clerk ____________ Provider Name ____________________________________________________________________________________ Provider Number _______________________________ Reason Code __________



4.10 Provider Representative List

4.10.1 Phone Numbers and Assigned Counties VICKY HICKS

502-209-3050

MICHELLE GOINS

502-209-3071

STAYCE TOWLES

502-209-3052

BRENDA ORBERSON

502-209-3053

JANET SPERRY

502-209-3051

ASSIGNED COUNTIES

ASSIGNED COUNTIES

ASSIGNED COUNTIES

ASSIGNED COUNTIES

ASSIGNED COUNTIES

ANDERSON BOONE BATH ADAIR BALLARD

BOURBON CARROLL BELL ALLEN BRECKINRIDGE

CAMPBELL GALLATIN BOYD BARREN BULLITT

CLARK GRANT BRACKEN BOYLE BUTLER

FAYETTE HENRY BREATHITT CASEY CALDWELL

FRANKLIN JEFFERSON CARTER CLINTON CALLOWAY

GARRARD OLDHAM CLAY CUMBERLAND CARLISLE

HARRISON OWEN ELLIOTT EDMONSON CHRISTIAN

JESSAMINE SHELBY ESTILL GREEN CRITTENDEN

KENTON SPENCER FLEMING HART DAVIESS

MADISON TRIMBLE FLOYD LARUE FULTON

MERCER GREENUP LINCOLN GRAVES

PENDLETON HARLAN MARION GRAYSON

SCOTT JACKSON MCCREARY HANCOCK

WOODFORD JOHNSON METCALFE HARDIN

KNOTT MONROE HENDERSON

KNOX PULASKI HICKMAN

LAUREL ROCKCASTLE HOPKINS

LAWRENCE RUSSELL LIVINGSTON

LEE SIMPSON LOGAN

LESLIE TAYLOR LYON

LETCHER WARREN MARSHALL

LEWIS WAYNE MCCRACKEN

MAGOFFIN MCLEAN

MARTIN MEADE

MASON MUHLENBERG

MENIFEE NELSON



MONTGOMERY OHIO

MORGAN TODD

NICHOLAS TRIGG

OWSLEY UNION

PERRY WASHINGTON

PIKE WEBSTER

POWELL

ROBERTSON

ROWAN

WHITLEY

WOLFE

PROVIDER RELATIONS 1-800-807-1232




5 HIPAA Information for Billing



The Health Insurance Portability and Accountability Act (HIPAA)

Information for Billing

Standard Transaction Formats for Billing KY Medicaid To simplify the electronic exchange of financial and administrative health care transactions, the Health Insurance Portability and Accountability Act (HIPAA) transactions standards require all health plans, health care clearinghouses and health care providers to use or accept the following electronic transactions. Prior to the passage of HIPAA in 1996, Congress determined that to improve the efficiency and effectiveness of the health care system and decrease administrative burdens on providers (that is, medical practices, hospitals, and health care plans) it was necessary to have national standards for the electronic exchange of health care transactions. The following formats replace the hundreds of proprietary and local formats used throughout the health insurance industry. The transaction standards took effect for KY Medicaid on October 16, 2003:

Code Sets The regulation also requires the use of standardized procedure/diagnosis coding to represent the data to be transmitted. Code Sets include at a minimum:

1. Current Procedure Terminology (CPT-4);

2. International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM);

3. HCFA Common Procedure Coding System (HCPCS);

4. ADA Codes on Dental Procedures and Nomenclature, 2nd Edition (CDT-2); and,

5. Revenue Codes

NOTE: Please be aware that no Medicaid local codes are accepted after October 16, 2003.



HIPAA Transaction Standards The HIPAA transactions and code set standards are rules to standardize the electronic exchange of patient-identifiable, health-related information. They are based on electronic data interchange (EDI) standards, which allow the electronic exchange of information from computer to computer without human involvement. These standards apply to nine types of administrative and financial health care transactions used by payers, physicians and other providers, including claims submission, claims status reporting, referral certification and authorization, and coordination of benefits.

HIPAA EDI Transactions Health Care Eligibility Inquiry and Response (270 & 271) Health Care Claim Status Inquiry / Response (276 & 277) Unsolicited (277) Health Care Service Review (278) Health Care Claim (837 & NCPDP Standard) Health Care Claim Payment and Remittance Advice (835) NOTE: The standard transaction for the Coordination of Benefits using the 837 is not HIPAA mandated and therefore not currently a requirement for HIPAA compliance.

Health Care Eligibility Inquiry and Response (270 & 271) A provider uses the 270-benefit inquiry transaction to inquire about Medicaid eligibility for a Member. Effective October 16, 2003 this replaces the Medicaid Eligibility Verification Systems (MEVS) transaction. It can also be used to check benefits, deductibles, and copays of the patient's health plan and verify that the patient is on file and currently covered by the plan. The 271 is a response from KY Medicaid to the inquiry. The response is conditional. It is not a guarantee of payment.

Health Care Claim Status Inquiry and Response (276 & 277) A provider uses the 276 claim status inquiry to ask about the status of processing for a particular claim or claims that remain outstanding within its accounts receivable system. The 277 is the response from KY Medicaid.

Unsolicited (277) KY Medicaid is using this transaction to transmit the status of a suspended or pended claim back to the provider.



Health Care Service Review (278) This transaction is used to transmit referral information between providers and between provider and payer. Note: A referral from provider to provider is one of the most attractive transactions for providers.

Health Care Claims (837 & NCPDP Standard) Effective October 16, 2003 health care claims for pharmaceuticals use the NCPDP v5.1 standard to bill KY Medicaid. Other claims use the X12 837 format. There are separate Implementation Guides (the official standard) for institutional claims, professional and dental claims. The 837 replaces electronic versions of the uniform billing claim and the CMS 1500. It can carry HMO medical encounter accounting information as well as billing claims. A key consideration for coordination with payer claim systems is a requirement for systems to retain all of the information received on the claim.

Health Care Claim Payment and Remittance Advice (835) The Payment and Remittance Advice transaction is frequently used in separate functions. In the payment role, it is a payment order directing a bank to effect payment to a provider; in this role, the remittance advice is primarily payment reference information to enable the provider's systems to match up the payment with claims paid. Payments are frequently made in aggregate to cover several claims. In the electronic remittance advice role, it explains payment, partial payment, or denial, item by item for each claim. The remittance advice is intended to support automatic reconciliation of claims in provider accounts receivable systems and is one of the most attractive transactions from a provider's viewpoint.

Implementation Guides for the Standards The implementation guides for the ASC X12N standards may be obtained from: Washington Publishing Company 806 W. Diamond Ave., Suite 400 Gaithersburg, MD, 20878 Telephone: 1-301-949-9740 FAX: 1-301-949-9742. These guides are also available at no cost through the Washington Publishing Company on the Internet at http://www.wpc-edi.com/hipaa/. The implementation guide for retail pharmacy standards is available from: National Council for Prescription Drug Programs 4201 North 24th Street, Suite 365 Phoenix, AZ, 85016 Telephone: 1-602-957-9105 FAX: 1-602-955-0749. It is also available from the NCPDP’s website at http://www.ncpdp.org.

Medicaid Companion Guides EDS and the Department have prepared companion guides for Medicaid Services. The companion guide specifies unique data fields necessary to correctly submit standard



transactions for KY Medicaid processing. They are used in conjunction with the implementation guides. Companion guides are available on KY Medicaid’s website located at http://chs.ky.gov/dms.

Attachments At this time, claims requiring attachments must still be billed via paper. Each claim is processed separately; therefore, each individual claim needs the required or supporting documentation. Attachments are handled in the same manner as the current process standard for KY Medicaid.

EOB/Adjustment Reason/Remark Codes The EOB/Adjustment reason/remark codes change to HIPAA compliant codes. These codes are included on ASC X12N835 electronic remit and/or paper remittance advice. The purpose of the EOB/Adjustment Reason/Remark Codes is to communicate the status and disposition of the claim to the provider.

EDS Technical Support All Trading Partners are encouraged to utilize EDI rather than paper claims submission. To become a business-to-business EDI Trading Partner, contact the EDS Electronic Data Interchange Technical Support Help Desk at 1-800-205-4696 between the hours of 8:00 a.m. and 6:00 p.m. Monday through Friday except holidays. If you have a general HIPAA question, please call 1-800 807-1232 between the hours of 8:00 a.m. to 6:00 p.m. EST Monday through Friday except holidays.

Additional Resources HRSA HIPAA Website http://www.bphc.hrsa.gov/hipaa/

DHHS Administrative Simplification Website http://aspe.os.dhhs.gov/admnsimp/

Centers for Medicare and Medicaid Services (CMS) http://cms.hhs.gov/hipaa/http://www.cms.gov/hipaa

Southern HIPAA Administrative Regional Process (SHARP) workgroup http://www.sharpworkgroup.com/

Workgroup for Electronic Data Interchange’s (WEDI) Strategic National Implementation Process (SNIP) http://snip.wedi.org

Washington Publishing Company (Implementation Guides) http://www.wpc-edi.com

6 Completion of UB-92 Claim Form



6.1 UB-92 Billing Instructions Following are form locator numbers and form locator instructions for billing hospital services on the UB-92 billing form. Only the instructions for form locators required for EDS processing or for Medicaid Program information are included. Instructions for Form Locators not used by EDS or the Medicaid Program can be found in the UB-92 Training Manual. The UB-92 Training Manual may be obtained from the address listed below. You may also obtain the UB-92 billing forms from the address listed below.

Kentucky Hospital Association P.O. Box 24163 Louisville, KY 40224 Telephone: 1-502-426-6220

The original UB-92 billing form must be sent to:

EDS P.O. Box 2106 Frankfort, KY 40602-2106



UB-92 Claim Form WE CARE HOSPITAL 2 3 PATIENT CONTROL NO. 4 TYPE

OF BILL

123 HAPPY ST 123456 111 ANYTOWN, KY 40000

1 5 FED TAX NO

6 STATEMENT COVERS PERIOD FROM THROUGH

7 COV’D. 8 N-C D. 9 C-I D. 10 L-R D. 11

01012003 01052003 4 12 PATIENT NAME 13 PATIENT ADDRESS 14 BIRTHDATE 15 SEX 16 MS ADMISSION 21 D HR 22 STAT 23 MEDICAL RECORD NO. CONDITION CODES 31 17 DATE 18 HR 19 TYPE 20 SRC 24 25 26 27 28 29 30

0101 05 01 C1 2003 32 OCCURRENCE 33 OCCURRENCE 34 OCCURRENCE 35 OCCURRENCE 36 OCCURRENCE SPAN 37

CODE DATE CODE DATE CODE DATE CODE DATE CODE FROM THROUGH A 11 01012003 B

C 39 VALUE CODES 40 VALUE CODES 41 VALUE CODES CODE AMOUNT CODE AMOUNT CODE AMOUNT

a b c d 42 REV. CD. 43 DESCRIPTION 44 HCPCS/RATES 45 SERV. DATE 46 SERV. UNITS 47 TOTAL CHARGES 48 NON-COVERED

CHARGES 49

120 ROOM CHARGES 4 2000 00 250 PHARMACY 98 688 42 001 TOTAL 2688 42 50 PAYER 51 PROVIDER NO. 52 REL 53 ASG

INFO BEN 54 PRIOR PAYMENTS 55 EST. AMOUNT DUE 56 KENPAC ID (IF APPLICABLE)

KY MEDICAID 01000000 57 DUE FROM PATIENT

58 INSURED’S NAME 59 P. REL 60 CERT.-SSN-HIC.-ID NO. 61 GROUP NAME 62 INSURANCE GROUP NO. JANE DOE 4000000000 63 TREATMENT AUTHORIZATION CODES 64 ESC 65 EMPLOYER NAME 66 EMPLOYER LOCATION 01234567 67 PRIN. DIAG. CD. OTHER DIAG. CODES 76 ADM. DIAG. CD. 77 E-CODE 78 68 CODE 69 CODE 70 CODE 71 CODE 72 CODE 73 CODE 74 CODE 75 CODE

123.4 123.4 79 P.C. 80 PRINCIPAL PROCEDURE 81 OTHER PROCEDURE OTHER PROCEDURE 82 ATTENDING PHYS.ID CODE DATE CODE DATE CODE DATE C123456 DR. DAN A B OTHER PROCEDURE OTHER PROCEDURE OTHER PROCEDURE 83 OTHER PHYS. ID CODE DATE CODE DATE CODE DATE A C D E 84 REMARKS OTHER PHYS. ID B 85 PROVIDER REPRESENTATIVE 86 DATE X Hand Written Signature

01/31/2003

UB-92 HCFA-1450 OCR/ORIGINAL I CERTIFY THE CERTIFICATIONS ON THE REVERSE APPLY TO THIS BILL AND ARE MADE A PART HEREOF.



FORM LOCATOR NUMBER

FORM LOCATOR NAME AND DESCRIPTION

1 Provider Name, Address and Telephone Enter the complete name, address, and telephone number

(including area code) of the facility. 3 Patient Control Number Enter the patient control number. The first 20 digits

(alpha/numeric) will appear on the remittance advice as the invoice number.

4 Type of Bill Enter the appropriate code to indicate the type of bill. 1st Digit (Type of Facility) 1 = Hospital

2nd Digit (Bill Classification) 1 = Inpatient (including Medicare

Part A) 2 = Inpatient (Medicare Part B only) 3 = Outpatient 4 = Non-patient

3rd Digit (Frequency) 0 = Non-payment 1 = Admit through discharge 2 = Interim, first claim 3 = Interim, continuing claim 4 = Interim, final claim

Example: TOB 131 has been established and must be used to identify outpatient services.

For dates of service 4/1/03 and after; the TOB must be 111 for inpatient claims except for critical access, rehabilitation and psychiatric hospitals. For newborn claims TOB 110 is to be used.

6 Statement Covers Period

FROM: Enter the beginning date of the billing period covered by this invoice in numeric format (MMDDYY).

THROUGH: Enter the last date of the billing period covered by this invoice in numeric format (MMDDYY).



FORM LOCATOR NUMBER


Do not include days prior to when the Member’s Medicaid eligibility period began. The “FROM” date is the date of the admission if the Member was eligible for the Medicaid benefits upon admission. If the Member was not eligible on the date of admission, the “FROM” date is the effective date of eligibility. The “THROUGH” date is the last covered day of the hospital stay.

7 Covered Days (Medicaid Only) Enter the total number of covered days from Form Locator 6.

Data entered in Form Locator 7 must agree with accommodation units in Form Locator 46. Covered days are not required for Medicare crossover claims for coinsurance days or life reserve days. Such days are shown in Form Locators 9 and 10, respectfully.

9 Coinsurance Days (CID) (Medicare Crossover Claims) Enter the number of coinsurance days billed to the Medicaid

Program during this billing period. Attach EOMB. 10 Lifetime Reserve Days (LRD) (Medicare Crossover Claims) Enter the Lifetime Reserve days the patient has elected to use for

this billing period. Attach EOMB. 17 Admission Date Enter the date on which the Member was admitted to the facility

in numeric format (MMDDYY). 18 Admission Hour Enter the code for the time of admission to the facility. Admission

hour is required for both inpatient and outpatient services. CODE STRUCTURE: CODE TIME A.M. CODE TIME P.M. 00 12:00 - 12:59 midnight 12 12:00 - 12:59 noon 01 01:00 - 01:59 13 01:00 - 01:59 02 02:00 - 02:59 14 02:00 - 02:59 03 03:00 - 03:59 15 03:00 - 03:59 04 04:00 - 04:59 16 04:00 - 04:59 05 05:00 - 05:59 17 05:00 - 05:59 06 06:00 - 06:59 18 06:00 - 06:59 07 07:00 - 07:59 19 07:00 - 07:59



FORM LOCATOR NUMBER


08 08:00 - 08:59 20 08:00 - 08:59 09 09:00 - 09:59 21 09:00 - 09:59 10 10:00 - 10:59 22 10:00 - 10:59 11 11:00 - 11:59 23 11:00 - 11:59

19 Admission Type (Hospital Inpatient Claims Only) Enter the appropriate type of admission:

1 = Emergency 3 = Elective 2 = Urgent 4 = Newborn

22 Patient Status Code Enter the appropriate two-digit patient status code indicating the disposition of the patient as of the “through” date in Form Locator 6. Status Codes Accepted by KY Medicaid 01 Discharged to Home or Self Care (Routine Discharge) 02 Discharged or Transferred to Acute Hospital 03 Discharged or Transferred to Skilled Nursing Facility

(SNF) or NF 04 Discharged or Transferred to Intermediate Care

Facility (ICF) 05 Discharged or Transferred to Another Type of

Institution 06 Discharged or Transferred to Home Under Care of

Organized Home Health Service Organization 07 Left Against Medical Advice 10 Discharged or Transferred to Mental Health Center or

Mental Hospital 20 Expired 30 Still a Resident

24-30 Condition Codes Peer Review Organization (PRO) Indicator Enter the appropriate indicator, which describes the

determination of the PRO/Utilization Review Committee. C1 = Approved as Billed

C2 = Automatic Approval as Billed Based on Focus Review C3 = Partial Approval*



FORM LOCATOR NUMBER


If the PRO authorized a portion of the Member’s hospital stay, the approved date(s) must be shown in Form Locator 36, Occurrence Span. These dates should be the same as the dates of service in Form Locator 6.

The condition codes are also included in the UB-92 Training Manual. Information regarding the Peer Review Organization is located in the Reference Index.

32-35 Occurrence Codes and Dates Enter the appropriate code(s) and date(s) defining a significant

event relating to this bill. Reference the UB-92 Training Manual for additional codes.

Accident Related Codes: 01 = Auto Accident 02 = No Fault Insurance Involved - Including Accident or Other 03 = Accident - Tort Liability 04 = Accident - Employment Related 05 = Other Accident - Not described by the other codes

Discharge Code and Date: Enter “42” and the actual discharge date when the “THROUGH”

date in Form Locator 6 is not the actual discharge date and Form Locator 4 indicates “Final Bill.”

36 Occurrence Span Code and Dates Enter occurrence span code “MO” and the first and last days

approved by the PRO/UR when condition code C3 (partial approval) has been entered in Form Locators 24 - 30.

39-41 Value Codes Enter the appropriate value code(s) for Medicare/Medicaid

crossover claims. A1 = Deductible Payer A

Enter the amount as shown on the EOMB to be applied to the Member’s deductible amount due. Attach EOMB. A2 = Coinsurance Payer A Enter the amount as shown on the EOMB to be applied toward Member’s coinsurance amount due. Attach EOMB B1 = Deductible Payer B Enter the amount as shown on the EOMB to be applied to the Member’s deductible amount due. Attach EOMB.



FORM LOCATOR NUMBER


B2 = Coinsurance Payer B Enter the amount as shown on the EOMB to be applied toward Member’s coinsurance amount due. Attach EOMB.

42 Revenue Codes Enter the three digit revenue code identifying specific

accommodation and ancillary services. A list of revenue codes covered by Medicaid is located in Appendix B of this manual.

It is extremely important that the ancillary services reported on the UB-92 billing form be submitted by using the correct Revenue Codes. All approved Revenue Codes are listed in Appendix B of this manual. Incorrect billing of ancillary services or failure to correct any remarks may ultimately affect the instate provider’s prospective payment rate.

NOTE: Total charge 001 must be the final entry in this column.

43 Description Enter the standard abbreviation assigned to each revenue code. 44 CPT/RATES All outpatient claims require a CPT-4 procedure code for every

revenue code with the exclusions of revenue codes 250-261, 634, 635, 636 pharmacy, 270-275 medical/surgical supplies. Effective September 1, 2002 the Revenue Code 450 will require the use of one of the following CPT code to determine the level of care. 99281 Level 1 99282 Level 2 99283 Level 2 99284 Level 3 99285 Level 3 99291 Level 3 99292 Level 3 Revenue Code 451 will not require a CPT code.

45 Detail Date of Service Effective 8/1/05 all out patient claims require a detail date of service.



46 Unit Enter the quantitative measure of services provided per revenue

code. Revenue Code 762 –Observation Room is measured as one unit is equal to 23 hours or less.

47

Total Charges Enter the total charges relating to each revenue code for the billing period. The detailed revenue code amounts must equal the entry “total charges.”

48 Non-Covered Charges Enter the charges from Form Locator 47 that are non-payable by Medicaid.

50 Payer Identification Enter the names of payer organizations from which the provider

expects payment. For Medicaid, use KY Medicaid. All other liable payers, including Medicare, must be billed first.*

* Medicaid is payer of last resort. 51 Provider ID Enter the eight-digit KY Medicaid provider ID for the payer shown

in Form Locator 50 on the corresponding line (A, B, or C). 54 Prior Payments Enter the amount the facility has received toward payment of the

claim. Third party payment should be entered in this area. Do not enter Medicare payment amounts in this area.

56 Unlabeled Form Locator - KenPAC ID KenPAC provider’s number is required for KenPAC Members.

Enter the eight-digit Medicaid provider ID of the referring KenPAC provider on the same or corresponding line as KY Medicaid in Form Locator 50. Note: When billing a revenue code 450, KenPAC is not required.

58 Insured’s Name Enter the Member’s name in Form Locators 58 A, B, and C that

relates to KY Medicaid the payer in Form Locators 50 A, B, and C. Enter the Member’s name exactly as it appears on the Member Identification card in last name, first name, and middle initial format.



60 Identification Number Enter the Member Identification number in Form Locators 60 A,

B, and C that relates to the Member’s name in Form Locators 58 A, B, and C. Enter the ten-(10) digit Member Identification number exactly as it appears on the Member Identification card.

63

Treatment Authorization Number Enter the treatment authorization number assigned by the PRO/UR designating that the treatment covered by the bill is authorized by the PRO/UR.

67 Principal Diagnosis Code Enter the ICD-9-CM Vol. 1 and 2 code describing the principal

diagnosis. 68-75 Other Diagnosis Code Enter the ICD-9-CM Vol. 1 and 2 codes that co-exist at the time

the service is provided. 76 Admitting Diagnosis (Inpatient Only) Enter the ICD-9-CM diagnosis code describing the admitting

diagnosis. 80 Principal Procedure Code and Date Enter the ICD-9-CM (Vol.3) procedure code that identifies the

principal obstetrical or surgical procedure performed during the billing period. Enter the date the procedure was performed in numeric format (MMDDYY).

81 Other Procedure Code(s) and Date(s) Enter the ICD-9-CM (Vol.3) procedure codes identifying the

procedures, other than the principal obstetrical surgical procedure, performed during the billing period. Enter the date the procedures were performed in numeric format (MMDDYY).

82 Attending Physician ID Enter the unique physician identification number (UPIN) followed

by the last name, first name, and middle initial of the attending physician. If the physician does not have a UPIN number, enter the appropriate license number.

85 Provider Certification and Signature The actual signature of the provider’s authorized representative is

required. Stamped or typed signatures are not accepted.



86 Date Bill Submitted Enter the date in numeric format (MMDDYY) the UB-92 billing

form was completed and signed.



6.2 Special Billing Instructions

6.2.1 DRG Effective April 1, 2003, DRG’s were implemented for inpatient claims. For any outpatient services that are provided 72 hours before an inpatient admission, the outpatient service is then put on the inpatient claim. In the event that an outpatient service is provided and inpatient admission is required within 72 hours and the diagnoses are different, there is both an outpatient claim and an inpatient claim.

Beginning August 1, 2003, outpatient claims will require CPT-4 procedure codes except for pharmacy and medical/surgical supplies. The following revenue codes pay a flat rate.

REVENUE CODE SERVICE

360 SURGERY

450 ER

790 LITHOTRIPSY

481 CARDIAC CATH

350-352 CT SCAN

610-612 MRI

402 ULTRASOUND

762 OBSERVATION

If there are two flat rate procedures done on the same day, reimbursement is for both procedures. Example: MRI and CT.

If there is a flat rate procedure and a cost of charge procedure done on the same day, reimbursement is only for the flat rate procedure. Example: MRI and lab

If there are multiple surgeries on the same day, KY Medicaid pays the highest surgery whether it is a groupable surgery or a surgery paid by percent of charges.

In the event there is a series bill (example physical therapy) and the member has an MRI in the middle of the month (the 15th), the claim will then have to be split billed. There will be three claims.

• 1st claim will indicate the PT from the 1st-14th. Claim pays cost to charge ratio.

• 2nd claim will have the 15th PT and the MRI. Claim is paid at a flat rate for the MRI and PT will be bundled in the payment.

• 3rd claim with indicate the 16th – 30th. Claim is paid at cost to charge ratio.

The ER methodology implemented on September 1, 2002 will not change.



6.2.2 Outpatient Services Provided

6.2.2.1 Prior to Admission as Inpatient Effective for services provided on and after June 1, 1991, KY Medicaid requires that all outpatient services provided prior to the inpatient admission be submitted on a separate UB-92 billing form from the inpatient services. This policy change has created problems involving Medicaid Members who have only Medicare Part B, as this billing procedure is not utilized by Medicare. Medicare requires all charges, both inpatient and outpatient, be submitted on one claim as an inpatient service. As a result, the provider and the beneficiary/Member are left with charges being denied by both Medicare and Medicaid.

To eliminate this problem, KY Medicaid has implemented Type of Bill 134, along with special system edits that identify those claims and permit them to be processed. Hospital providers utilize this Type of Bill when charges (i.e., emergency room, drugs, supplies, etc.) for services are denied because Medicare considers them to be inpatient services, and the individual does not have Medicare Part A coverage, but is eligible for Medicaid benefits. Type of Bill 134 is effective for services provided on and after June 1, 1991.

The facility must enter the phrase “outpatient charges not covered by Medicare” in Form Locator 84 on the UB-92 billing form when billing the Medicaid Program. This notation helps identify the reason services were submitted without the usual EOMB.

6.2.3 Instructions On Submitting a Two-Page UB-92 Some billing situations may require two UB-92 billing forms to incorporate all revenue codes. Indicate the 001 revenue code (Total Charge) as the last entry only on the second UB-92 billing form. Only 45 detail lines are accepted for processing a two page UB 92.

Indicate on the first UB-92 billing form “1 of 2, Continued” to further clarify. Please attach and mail the two UB-92 billing forms together.

Contact EDS Provider Relations at 1-800-807-1232 for further assistance.



6.3 Medicaid Payment for Claims

6.3.1 With Non-Covered Days Involving A Third Party Admissions involving a payment from a third party payer must be submitted with an itemized or summarized bill attached to the UB-92 billing form for admissions which contain non-covered Medicaid days.

The first 14 covered days of the admission are indicated in Form Locator 6, with the total days of 14 shown in Form Locator 7. The discharge day is indicated in Form Locator 32, by using Occurrence Code 42 and entering the date of discharge. The charges submitted to KY Medicaid for payment would be those charges incurred within the Statement Covers Period.

Claims meeting the requirements for KY Medicaid payment are paid in the following manner if a third party payment is identified on the claim:

• The amount paid by the third party shall be applied to any non-covered days or services and any remaining monies shall reduce KY Medicaid payment;

• If the third party payment exceeds the Medicaid allowed amount, the resulting KY Medicaid payment shall be ZERO;

• Members cannot be billed for any difference in covered charges and the KY Medicaid payment amount. All providers have the choice of determining if this type of service shall be billed to the Medicaid Program; and,

• If KY Medicaid is billed for the service, the Medicaid guidelines shall be followed. Providers shall accept Medicaid payment as payment in full.

Detailed below are sample Medicaid payment methodologies for in-state and out-of-state inpatient hospital services. These payment formulas can be used to determine the amount due on any inpatient admission greater than fourteen days with third party involvement.

EXAMPLE 1 - Pricing example for in-state hospitals using a per diem rate:

Step 1 $ 470.33 Medicaid Per Diem Rate X 14 Days Payable $6,584.62 Medicaid Maximum Payment

Step 2 $36,592.11 Total charges for 24 day stay (entire stay) -25,150.67 Billed charges for covered period $11,441.44 TPL Balance -11,913.10 Amount received from other source -471.66 TPL balance. If this amount is negative, Medicaid payment is reduced. If the amount is positive, Medicaid payment is not reduced

Step 3 $6,584.62 Amount Payable -471.66 TPL Balance $6,112.96 Amount due from Medicaid Program

EXAMPLE 2 - Pricing example for out-of-state hospitals using percentage of charges:

Step 1 $20,550.00 Billed charges for 14 days covered period - 200.00 Non-covered charges



$20,350.00 Covered charges for days payable x 75% Reimbursement rate $15,262.50 Medicaid Maximum payment

Step 2 $36,000.00 Total charges for total stay (20 days) -20,550.00 Total charges for covered stay $15,450.00 -19,000.00 Amount received from other sources $-3,550.00 TPL Balance. If this amount is negative, Medicaid payment is reduced. If the amount is positive, Medicaid payment is not reduced.

Step 3 $15,262.50 Medicaid maximum payment - 3,550.00 TPL balance $11,712.50 Amount due from Medicaid if paid using percentage as rate.

Step 4 The computed payment is compared against the maximum rate for in-state hospitals of comparable bed size using payment formula for instate hospitals . Final Medicaid payment will be to lower of the two formulas.

NOTE: If there is no third party involvement only Step 1 is necessary under either payment formula.

If the claim for a Member is payable by a third party resource which was not pursued by the provider, the claim shall be denied. Along with a third party insurance company denial explanation, the name and address of the insurance company, name of the policy holder, and policy number are indicated on the remittance statement. The provider shall pursue payment with the third party resource before billing Medicaid again. Itemized statements shall be stamped “MEDICAID ASSIGNED” when they are forwarded to insurance companies, attorneys, Members, etc.

7 Medicare Deductibles and Coinsurance



Billing for Medicare Part A deductible or coinsurance days, Medicare Part B deductible or coinsurance, and Title XIX services must be on separate claim forms. If the Member was covered by Medicare Part A, Medicare Part B, and Medicaid, three separate claims must be submitted for payment for the three types of benefits. A Medicare Explanation of Medicare Benefits (EOMB) must be attached to each UB-92.

Medicaid PRO certification is not required on Medicare deductible and coinsurance claims as certification is determined using Medicare guidelines. If all Medicare benefits are exhausted and Title XIX days are being billed, Medicaid PRO certification for Medicaid days is required.

Effective for claims processed on and after October 12, 1991, AdminaStar™ of Kentucky, formerly the Medicare Division of Blue Cross/Blue Shield, Louisville, KY, began transmitting Medicare Part A claims directly to the Medicaid Program via tape. If a claim does not appear on your Medicaid remittance advice within 30 days of the Medicare adjudication date, a paper UB-92 with the corresponding EOMB should be submitted to the Medicaid Program.

Effective for claims processed on and after September 13, 1991, AdminaStar™ of Kentucky, formerly the Medicare Division of Blue Cross/Blue Shield, Lexington, KY, began transmitting Medicare Part B claims covering hospital-based physicians (i.e., emergency room physician, anesthesiologist, cardiologist, etc.) directly to the Medicaid Program via tape. If a claim does not appear on your Medicaid remittance advice within 30 days of the Medicare adjudication date, a paper CMS 1500 (12/90) with the corresponding EOMB must be submitted to the Medicaid Program for processing in accordance with billing instructions contained in this manual.

Providers utilizing a Medicare fiscal intermediary other than the above listed will continue to submit all Medicare cross-over claims using the appropriate billing form and corresponding EOMB attached to each claim.

7.1 Professional Fees Effective September 1, 2002 professional fees are billed on a CMS 1500 (12/90) under the attending physician’s individual provider ID for Emergency Room Services provided. Professional Fees are not required to have Medicare as primary. The following instructions are for Medicare deductible and coinsurance and for professional fees. Please read carefully to see what applies to your situation.



HEALTH INSURANCE CLAIM FORM 1. MEDICARE MEDICAID CHAMPUS CHAM PVA GROUP FECA OTHER

HEALTH PLAN BLK LUNG

24. A DATE(S) OF SERVICE

FROM TO DD YY MM DD YY

B C D E

Place of

Service

Type of

Service PROCEDURES, SERVICES, OR SUPPLIES

(Explain Unusual Circumstances)

F G H I J K

DIAGNOSISCODE $ CHARGES

MM DAYS

ORUNITS

EPSDT FAMILY PLAN CPT/HCPCS MODIFIER

PLEASE DO NOTSTAPLE IN THIS AREA

(Medicare #) (Medicaid #) (Sponsor’s SSN) (VA File #) (SSN or ID) (SSN) (ID)

1a. INSURED’S I.D. NUMBER

(FOR PROGRAM IN ITEM 1)

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

CITY STATE

ZIP CODE TELEPHONE (Include Area Code) ( )

9. OTHER INSURED’S NAME (Last Name, First Name, Middle Initial)

a. OTHER INSURED’S POLICY OR GROUP NUMBER

b. OTHER INSURED’S DATE OF BIRTH SEX MM DD YY

M F c. EMPLOYER’S NAME OR SCHOOL

d. INSURANCE PLAN NAME OR PROGRAM NAME

READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM 12. PATIENT’S OR AUTHORIZED PERSON’S SIGNATURE I authorize the release of any medical or other information

necessaryto process this claim. I also request payment of governme nt benefits either to myself or to the party who accepts assignm entbelow. SIGNED DATE

17. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE

14. DATE OF CURRENT: MM DD YY ILLNESS (First symptom) OR

INJURY (Accident) OR PREGNANCY (LMP)

19. RESERVED FOR LOCAL USE

17a. I.D. NUMBER REFERRING PHYSICIAN

15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESSGIVE FIRST DATE MM DD YY

21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. (RELATE ITEMS 1, 2 , 3 OR 4 TO ITEM 24E BY LINE)

25. FEDERAL TAX I.D. NUMBER SSN EIN 26. PATIENT’S ACCOUNT NO.

x YES NO

27. ACCEPT ASSIGNMENT?

CITY STATE

ZIP CODE TELEPHONE (INCLUDE AREA CODE)

( ) 11. INSURED’S POLICY GROUP OR FECA NUMBER

a. INSURED’S DATE OF BIRTH MM DD YY SEX

M F

b. EMPLOYER’S NAME OR SCHOOL NAME

c. INSURANCE PLAN NAME OR PROGRAM NAME

d. IS THERE ANOTHER HEALTH BENEFIT PLAN? YES NO

If yes , return to and complete item 9 a - d.

13. INSURED’S OR AUTHORIZED PERSON’S SIGNATURE I authorize payment of medical benefits to the undersigned physicia n or supplier forservices described below.

SIGNED

16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATIONMM DD YY MM DD YY

FROM TO

18. HOSPITALIZATION DATES RELATED TO CURRENT SEVICESMM DD YY MM DD YY

FROM TO 20. OUTSIDE LAB? $ CHAR GES

YES NO

22. MEDICAID RESUBMISSION CODE OR IGINAL REF. NO.

3. PATIENT’S BIRTH DATE SEXMM DD YY M F

6. PATIENT RELATIONSHIP TO INSURED

Self Spouse Child Other

8. PATIENT STATUS

Single Married O ther

Employed Full -Time Part -TimeStudent Student

4. INSURED’S NAME (Last Name, First Name, Middle Initial)

7. INSURED’S ADDRESS (No., Street)

EMG COB RESERVED FORLOCAL USE

23. PRIOR AUTHORIZATION NUMBER

10d. RESERVED FOR LOCAL USE

31. SIGNATURE OF PHYSICIAN OR SUPPLIER INCLUDING DEGREES OR CREDENTIALS

SIGNED DATE

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

32. NAME AND ADDRESS OF FACILITY WHERE SERVICES WERERENDERED (If other than home or office)

33. PHYSICIAN’S, SUPPLIER’S BILLING NAME, ADDRESS, ZIP CODE& PHONE#

PIN# 64000000 GRP# 65000000

28. TOTAL CHARGE 29. AMOUNT PAID 30. BALANCE DUE

$ $ $

3. 24.

5. PATIENT’S ADDRESS (No., Street) Doe, John

10. IS PATIENT’S CONDITION RELATED TO:

IF APPLICABLEa. EMPLOYMENT? (CURRENT OR PREVIOUS)

YES NO

b. AUTO ACCIDENT? PLACE (State )

YES NO

c. OTHER ACCIDENT?

YES NO

(2 d

igits

)

(1 d

igit

only

)

(If Applicable)

May use up to 20 digits

Doctors Place100 Easy St. Anytown, KY 40601

Medicaid Straight

x

1234567890

v222

12 17 03 99211

25 00

2-16-05

1 25 00 111

John Ball

KENPAC if applicable

PRIOR AUTHORIZATION if applicable



7.1.1 CMS 1500 (12/90) Billing Instructions for Part B The Medicare Part B cross-over claims covering hospital-based physician services (i.e.,emergency room physician, anesthesiologist, cardiologist, etc.) are transmitted to KY Medicaid via tape. If a claim covering the Part B deductible or coinsurance amount does not appear on the Medicaid Remittance Advice within 30 days of the Medicare adjudication date, a paper CMS 1500 (12/90) with the corresponding EOMB should be submitted to Medicaid utilizing the billing instructions listed below.

NOTE: Only those fields required for billing Medicaid are completed. Specific billing requirements are indicated within the claim form Field description. FIELD NUMBER FIELD NAME AND DESCRIPTION 1 Insurance Identification Indicator

Check the “Medicare” and “Medicaid” blocks when billing a claim to Medicare requesting the claim to be forwarded to Medicaid for processing coinsurance and deductible amounts. Excludes professional fees when billing Medicaid as primary.

1a Insured’s I.D. Number Required only if billing Medicaid for coinsurance or deductible.

Enter the Member’s Medicare identification number. 2 Patient’s Name Enter the Member’s last name, first name, and middle initial

exactly as it appears on the Member Identification card. 9a Other Insured’s Policy Group Number Enter the Member’s ten-digit Identification number exactly as it

appears on the current Member Identification card. 10 Patient’s Condition Required if Member’s condition is related to employment, auto

accident, or other accident. Check the appropriate “yes” block if Member’s condition relates to one of the above; otherwise, leave blank.

11 Insured’s Policy Group or FECA Number Required only if Member has insurance other than Medicaid or

Medicare and the other insurance has made a payment on the claim. Enter the policy number of the other insurance. Also, complete Fields 11C and 29.

NOTE: If other insurance denies the submitted claim, leave fields 11, 11c, and 29 blank and attach denial statement from carrier.

11c Insurance Plan Name or Program Name Required only if Member has insurance other than Medicaid or

Medicare and the other insurance has made a payment on the claim. Enter the name of the other insurance company. Also, complete Fields 11 and 29.



FIELD NUMBER FIELD NAME AND DESCRIPTION 19 Reserved For Local Use Required for KenPAC and Lock-In members. Enter the eight

digit KY Medicaid provider ID of the referring KenPAC or Lock-In provider. If you are billing during a period when the member had more than one KenPAC or Lock-In physician, a separate claim must be filed for each situation.

21 Diagnosis or Nature of Illness or Injury Enter the appropriate ICD-9-CM diagnosis code. You may enter

up to four diagnosis codes. 24A Date of Service Enter the date of service in numeric format (MMDDYY). 24B Place of Service Enter the appropriate two -digit place of service code which

identifies the location where services were provided. The correct code for inpatient hospital services is 21 and outpatient hospital services is 22. Professional fees for emergency rooms services is 23.

24D Procedures, Services, or Supplies CPT/HCPCS

Enter the appropriate HIPAA compliant procedure code identifying the service or supply provided to the Member.

24E Diagnosis Code Indicator Enter 1, 2, 3, or 4, referencing the diagnosis as indicated in Field

21. 24F Charges Enter the usual and customary charge for the service provided to

the Member. 26 Patient’s Account No. Enter the patient account number, if desired. EDS will key the

first 20 alpha/numeric characters. This number appears on the Medicaid remittance advice as the invoice number.

28 Total Charge Enter the total of all individual charges entered in column 24F.

Total each claim separately. 29 Amount Paid Enter the amount paid, if any, by private insurance. Do not

enter Medicare paid amount.



30 Balance Due Required only if the private insurance made a payment on the

claim. Subtract the private insurance payment entered in Field 29 from the total charge entered in Field 28, and enter the balance due in Field 30.

31 Signature of Physician or Supplier Including Degrees or Credentials

A hand-written signature of the provider’s authorized representative is required. Stamped signatures are not acceptable.

Date Enter the date in numeric format (MMDDYY). This date must be

on or after the date(s) of service billed on the claim. 33 Physician’s, Supplier’s Billing Name, Address, Zip Code,

and Phone Number Enter the provider’s name, address, zip code and phone number

(including area code). PIN

Enter the physician’s eight digit KY Medicaid provider ID. GROUP

Enter the physician’s group number if applicable.



7.2 Resubmission Of Medicare/Medicaid Part B Claims On claims which have Medicare-allowed procedures as well as non-allowed procedures, Medicaid must be billed on separate claims with copies of Medicare remit attached to each claim.

A health insurance claim form, the CMS 1500 (12/90), should be submitted to KY Medicaid when an original Medicare/Medicaid automatic crossover claim has been denied deductible or coinsurance payment by Medicaid or when the provider has received no response from Medicaid within six weeks of the Medicare adjudication date. In both of these situations, a new CMS 1500 (12/90) claim should be completed and submitted to KY Medicaid according to Medicaid guidelines. The provider must attach the corresponding Explanation of Medicare Benefits (EOMB) to this claim . A copy of the EOMB (including adjudication date and Member identification information) will be accepted only in its entirety.

Out-of-KY providers who provide services for KY Medicaid Members must submit claims on a CMS 1500 (12/90) claim to EDS in KY. A copy of the EOMB from the Medicare carrier in the state where the service is provided should be attached to the claim form before payment for services may be considered.

8 Forms Requirements



Forms required for reimbursement of hospital services include, but may not be limited to, the following:

• Certification for Abortion or Miscarriage (MAP-235); • Certification of Premature Birth (MAP-236); • Hysterectomy Consent Form (MAP-251); • Certification of Conditions Met (MAP-346); • Other Hospitalization Form (MAP-383); and,

• Other Services Statement (MAP-397).

Claims and required forms completed incorrectly and submitted to KY Medicaid will result in denial of payment. All forms should be completed according to Medicaid guidelines as outlined in the following instructions. Situations involving crossover claims from Medicare will require the UB-92 billing form, Medicaid required form, and EOMB for processing.

Effective for date of service July 1, 2003, hospitals will no longer require the Sterilization Consent Form (MAP 250) for claims processing.



Example Of Certification For Induced Abortion or Induced Miscarriage Form (MAP-235)

8 Form Requirerments


Completion Of Induced Abortion or Induced Miscarriage Form (MAP-235)

Field Description Physician’s Name Enter the physician’s name. Patient’s Name Enter the Member’s name. Member Identification # Enter the Member’s 10-digit Member

Identification number. Patient’s Address Enter the Member’s address. (Please indicate date and the procedure that was performed.)

Enter the date the procedure was performed and include any other pertinent information.

Physician Signature The physician’s actual signature is required. Stamped signatures are not acceptable.

License Number Enter the physician’s six-digit Unique Physician Identification Number (UPIN) or other license number.

Date Enter the date the form was signed by the physician.



Example Of Certification For Induced Premature Birth Form (MAP-236)



Completion of Certification for Induced Premature Birth Form (MAP-236)

Field Description Physician’s Name Enter the physician’s name. Date Enter the date the procedure was

performed. Procedure Enter the procedure. Name of Mother Enter the name of the mother. Member Identification # Enter the mother’s Member Identification

number. Address Enter the mother’s address. Physician’s Signature The physician’s actual signature is

required. Stamped signatures are not acceptable.

Name of Physician Enter the name of the performing physician.

License Number Enter the physician’s six-digit Unique Physician Identification Number (UPIN) or other license number.

Date Enter the date the form was signed by the physician.



Example of Hysterectomy Consent Form (MAP-251)



8.1 Completion of Hysterectomy Consent Form, (MAP-251)

8.1.1 Purpose Federal regulations (42 CFR 441.250 - 441.258) require individuals receiving a hysterectomy to read and sign a federally-approved consent form with information regarding the procedure. The MAP-251, Hysterectomy Consent Form, provides that information and must be signed by the Member, or her representative, prior to the procedure unless unusual conditions exist (refer to the Medicaid Hospital Manual for information related to these unusual conditions).

8.1.2 General Instructions The “Hysterectomy Consent Form” (MAP-251) is a five (5) part form that must be completed prior to the surgical procedure. The form shall be completed in its entirety and shall be made accessible to all providers who bill for related services. All blanks must be completed. The individuals completing the form shall be advised to enter information in such a manner that all copies are clearly readable and legible. The Member shall be provided with a copy of the consent form for her personal records. The following health care providers will be provided copies of the completed MAP-251:

• Surgeon;

• Assistant surgeon;

• Anesthesiologist (or anesthetist); and,

• Hospital or health care facility.

A copy of the completed MAP-251 shall be maintained by the provider obtaining consent.

Attach the signed and dated MAP-251 to the claim form and submit for processing. When a hysterectomy is performed on an individual who is already sterile, or who required a hysterectomy because of a life-threatening emergency, attach the physician’s written certification that such conditions exist to the claim form and submit for processing.

Order MAP-251 forms from:

EDS P.O. Box 2100 Frankfort, KY 40602-2100

8.1.3 Detailed Instructions for Completion of the Form • Enter the name of the Member;

• Enter the name of the physician providing information about the hysterectomy (attending physician);

• The Member or her representative must read and sign the form prior to the hysterectomy procedure; and,

• The person obtaining consent must sign and date the form prior to the hysterectomy procedure.

NOTE: Federal regulations require that MAP-251 forms be completed without error or corrections. If an error is made or correction is required during the completion of the form, destroy the form and complete another form correctly according to these instructions.



8.2 Completion of Certification of Conditions Met (MAP-346)

Field Description Facility Name Enter the name of the facility. City Enter the city the facility is located. State Enter the state the facility is located. Facility Enter the name of the facility. Name NOTE: Multiple entries can be reflected under

this heading.

Enter the name of the professional. NOTE: Multiple entries can be reflected under this heading.

Professional’s Medicare Number Enter the professional’s Medicare provider ID.

Professional’s License Number NOTE: Multiple entries can be reflected under this heading.

Enter the professional’s license number NOTE: Multiple entries can be reflected under this heading.

Specialty Enter the name of the professional’s specialty (cardiology, radiology, anesthesiology, pathology, encephalography and emergency room physicians.)

Date Of Facility Employment NOTE: Multiple entries can be reflected under this heading.

Enter the date the facility employed this professional.

NOTE: Multiple entries can be reflected under this heading.

Signature Enter the signature of the facility representative or administrator.

Name Print the name of the person signing this form.

Date Enter the date the form was signed. KY Medicaid Provider ID Enter the eight (8) digit KY Medicaid

Provider ID of the facility.



Example of Other Hospitalization Statement Form (MAP-383)



8.3 Completion of Other Hospitalization Statement (MAP-383)

Field Description Name of Facility Enter the name of the facility where other

hospitalization occurs. Member Name/Member Identification Number

Enter the name and ten-digit Member Identification number of the Member.

Date of Admission Enter the date of the admission. Medical Director The signature of the Medical Director of

the Member’s Hospice agency is required. Hospice Agency Enter the name of the Hospice agency. Date Enter the date this form was signed.



8.4 Completion of Other Services Statement (MAP-397) For those services which are usually covered under the hospice benefit but are being billed separately because they have been determined to be totally unrelated to the terminal illness of the member, an Other Services Statement (MAP-397) must be completed in order to obtain approval from KY Medicaid. Instructions for completion of the form are listed below:

1 The name of the agency providing the service, the name and Member Identification number of the member and the date of service must be entered in the appropriate spaces.

2 The ICD-9-CM code for the diagnosis must be entered.

3 The ICD-9-CM code describing the patient’s terminal illness must be entered.

4 Items of durable medical equipment being billed separately must be specifically identified.

5 A description of hospital outpatient services and the reason for the services must be entered.

6 The form must be signed and dated by the medical director of the hospice agency.

7 Documentation verifying that the services are totally unrelated to the terminal illness of the member must be attached to the form.

8 All copies of the form must be submitted to the Department for Medicaid Services, Division of Facilities and Alternative Services. Two copies of the form will be returned to the provider signed by a KY Medicaid representative indicating whether separate payment for the services has been approved or denied.

9 If approved, one copy of the form must be sent to the provider who will bill for the service. The other copy should be retained by the hospice agency.

An example of MAP-397 is on the following page.



MAP-397 (Rev. 6/91) Other Services Statement

This is to certify that the service(s) checked below provided by

Name of Agency for ________________________________________________________ beginning on

Member Name/MAID Number _____________________________ is/are not related in any way to the terminal illness

Date of this patient. The reason for the service(s) is _________________________/__________________

Diagnosis ICD 9 CM Code The patient’s terminal illness is ________________________/___________________

Diagnosis ICD 9 CM Code Charges for this/these service(s) should not be billed to the hospice agency but should be billed directly to the Kentucky Medicaid Program.

Signed: Medical Director

Hospice Agency

Date

Durable Medical Equipment (List) _____________________________________

Hospital Outpatient Services (Please Describe Service/Reason) _____________

Please attach documentation indicating service(s) is/are not related to terminal illness.

Is this the first time this patient has required services not related to terminal illness?

Yes No

If no, date(s) of previous service __________________________________________. Previous diagnosis not related to terminal illness for which services were required ICD 9 CM Code _____ Approved by the Medicaid Program _____ Denied by the Medicaid Program

Medicaid Signature Date

9 Appendix A


9 Appendix A

9.1 Internal Control Number (ICN) An Internal Control Number (ICN) is assigned by EDS to each claim. During the imaging process a unique control number is assigned to each individual claim for identification, efficient retrieval, and tracking. The ICN consists of 17 digits and contains the following information:

0 - 06005 - 0 - 0 - 600 - 0 - 001 - 00

1 2 3 4 5 6 7 8 1. Claim Input Indicator

0 = Exam-entered 1 = Keyed 2 = Accounts Receivable 3 = Electronic Claims Submission (ECS) 4 = Beginning 12/1/95, any claim that generates a credit and sufficient money isn’t

available to satisfy the amount due, the claim credit ICN will reflect a (4) for financial reporting.

5 = No Pay 6 = Electronic Point of Service (POS) 7 = Capitation 8 = Encounter 9 = Mass Adjustments - Mass Adjusted/Credit Claims

2. Date of Receipt (Calendar Year and Julian Date; 2006, 005 = January 5, 2006)

3. Not used.

4. Not used.

5. Batch Number (Batch Range)

6. Type of Document: 0 = New Day Claim 1 = Credit 2 = Adjustment/Debit 3 = Unit Dose Return 4 = Electronic Denied adjustments Effective 4/15/05 5 = N/A

7. Document Number Within the Batch.

8. Line Number Within the Claim

10 Appendix B


10 Appendix B

10.1 Inpatient Revenue Codes Following is a representative sample list of the revenue codes that are accepted by KY Medicaid when billing for inpatient services on the UB-92 billing form.

INPATIENT REVENUE CODES

DESCRIPTION

001 Total Charges

100 All Inclusive Room And Board Plus Ancillary

101 All Inclusive Room And Board

110 Private Room-Board, General

111 Medical/Surgical/Gyn

112 OB

113 Pediatric

114 Psychiatric

115 Hospice

116 Detoxification

117 Oncology

118 Rehabilitation

120 Semi-Private Room And Board, General


122 OB

123 Pediatric

124 Psychiatric

125 Hospice

126 Detoxification

127 Oncology

128 Rehabilitation

130 Semi-Private (3-4 Bed) Room, General

10 Appendix B



DESCRIPTION


132 OB

133 Pediatric

134 Psychiatric

135 Hospice

136 Detoxification

137 Oncology

138 Rehabilitation

140 Deluxe Private Room, General


142 OB

143 Pediatric

144 Psychiatric

145 Hospice

146 Detoxification

147 Oncology

148 Rehabilitation

150 Room (Ward), General


152 OB

153 Pediatric

154 Psychiatric

155 Hospice

156 Detoxification

157 Oncology

158 Rehabilitation

160 Other Room And Board, General

10 Appendix B



DESCRIPTION

164 Sterile Environment

170 Nursery, General

171 Newborn

172 Premature

173 Room and Board Nursery III

174 Room and Board Nursery IV

175 Neonatal Icu

200 Intensive Care Room, General

201 Surgical

202 Medical

203 Pediatric

204 Psychiatric

206 Post ICU

207 Burn Care

208 Trauma

210 Coronary Care Room, General

211 Myocardial Infarction

212 Pulmonary Care

213 Heart Transplant

214 Post-CCU

230 Incremental Nursing, General

231 Nursery

233 ICU

234 CCU

240 All Inclusive Ancillary, General

250 Hospital, General

251 Generic Drugs

10 Appendix B



DESCRIPTION

252 Non-Generic Drugs

254 Drugs Incident To Other Diagnostic Services

255 Drugs Incident To Radiology

256 Experimental Drugs

257 Non-Prescription

258 IV Solutions

260 IV Therapy, General

261 Infusion Pump

270 Medical/Surgical Supplies, General

271 Non-Sterile Supply

272 Sterile Supply

274 Prosthetic Devices

275 Pace Maker

276 Intraocular Lens

278 Other Implants

280 Oncology, General

290 Minor Home Adapt/Environment Access

300 Laboratory, General

301 Chemistry

302 Immunology

303 Renal Patient (Home)

304 Non-Routine Dialysis

305 Hematology

306 Bacteriology And Microbiology

307 Urology

310 Pathology, General

311 Cytology

10 Appendix B



DESCRIPTION

312 Histology

314 Biopsy

320 Radiology Diagnostic, General

321 Angiocardiography

322 Arthrography

323 Arteriography

324 Chest X-Ray

330 Radiology-Therapeutic, General

331 Chemotherapy - Injected

332 Chemotherapy - Oral

333 Radiation Therapy

334 Chemotherapy Ed Cancer Hemophilia

335 Chemotherapy - IV

340 Nuclear Medicine, General

341 Diagnostic

342 Therapeutic

350 CT Scan, General

351 Head Scan

352 Body Scan

360 Operating Room, General

361 Minor Surgery

362 Organ Transplant - Other Than Kidney

367 Kidney Transplant

370 Anesthesia, General

371 Anesthesia, Incident To Radiology

372 Anesthesia Incident To Other Diagnostic Services

374 Acupuncture

10 Appendix B



DESCRIPTION

380 Blood, General

381 Packed Red Cells

382 Whole Blood

383 Plasma

384 Platelets

385 Leukocytes

386 Other Components

387 Other Derivatives (Cryoprecipitate)

390 Blood Storage And Processing, General

391 Blood Administration

400 Other Imaging Services, General

401 Mammography

402 Ultra Sound

403 Screening Mammography

404 Pet Scan

410 Respiratory Services, General

412 Inhalation Services

413 Hyper baric Oxygen Therapy

420 Physical Therapy, General

421 Visit Charge

422 Hourly Charge

423 Group Rate

424 Evaluation Or Re-Evaluation

440 Speech Therapy, General

441 Visit Charge

442 Hourly Charge

443 Group Rate

10 Appendix B



DESCRIPTION

444 Evaluation Or Re-Evaluation

450 Emergency Room, General (For Services Provided Prior To June 1,1991)

460 Pulmonary Function

470 Audiology, General

471 Diagnostic

472 Treatment

480 Cardiology, General

481 Cardiac Cath Lab

482 Stress Test

483 Echo cardiology

610 MRI, General

611 Brain (Including Brainstem)

612 Spinal Cord (Including Spine)

621 Supplies Incident To Radiology

622 Supplies Incident To Other Diagnostic Services

623 Surgical Dressings

634 Erythropoietin (EPO) Less Than 10,000 Units

635 Erythropoietin (EPO) 10,000 Or More Units

700 Cast Room, General

710 Recovery Room, General

720 Labor/Delivery Room, General

721 Labor

722 Delivery

723 Circumcision

724 Birthing Center (For Services Provided Prior To June 1, 1991)

730 EKG/ECG, General

10 Appendix B



DESCRIPTION

731 Holter Monitor

732 Telemetry (Includes Fetal Monitoring)

740 EEQ, General

750 Gastro-Intestinal Services, General

790 Lithotripsy, General

800 Inpatient Renal Dialysis, General

801 Inpatient Hemodialysis

802 Inpatient Peritoneal (Non-Capd)

803 Inpatient Continuous/Ambulatory Peritoneal Dialysis (Capd)

804 Inpatient Continuous/Cycling Peritoneal Dialysis (Ccpd)

810 Organ Acquisition, General

811 Living Donor

812 Cadaver

813 Unknown Donor

814 Other Kidney Acquisition

815 Cadaver Donor - Heart

816 Other Heart Acquisition

817 Donor - Liver

890 Donor Bank, General

891 Bone

892 Organ (Other Than Kidney)

893 Skin

900 Psychiatric/Psychological Treatments, General

901 Electroshock Treatment

920 Other Diagnostic Services, General

921 Peripheral Vascular Lab

922 Electromyelogram

10 Appendix B



DESCRIPTION

923 Pap Smear

924 Allergy Test

925 Pregnancy Test

940 Other Therapeutic Services, General

942 Other Therapeutic Services

943 Cardiac Rehabilitation

946 Complex Medical Equipment Routine

947 Complex Medicaid Equipment Ancillary

960 Pro Fee General

963 Anesthesiologist (MD)

971 Pathologist (MD)

972 Radiologist - Diagnostic (MD)

973 Radiologist - Therapeutic (MD

974 Radiologist - Nuclear Medicine (MD)

985 Cardiologist - Ekg (MD)

986 Cardiologist - Eeg (MD)

997 Admission Kits

10 Appendix B


10.2 Incremental Nursing Revenue Codes The following ICU/CCU Incremental Nursing Revenue Codes listed in Column A cannot be reimbursed by the Medicaid Program unless they are billed in conjunction with the appropriate accommodation revenue codes in column B.

A B

230, 231 Can Only Be Reimbursed in Conjunction With 170-175

230,233 Can Only Be Reimbursed in Conjunction with 200-208

230,234 Can Only Be Reimbursed in Conjunction With 210-214

10.2.1 All Inclusive Accommodation, Appropriate Type Of Bills Each hospital has a choice in determining the type of billing to utilize when billing for services provided to their Members. The facility shall be consistent in their billing procedures for all payers. Use the following guideline to determine the appropriate procedure:

1. If billing detailed charges, enter accommodation revenue codes 110-219 plus appropriate revenue codes for all covered ancillary and professional services and revenue code 001 for total charges;

2. If billing an all inclusive accommodation (revenue code 100) which includes ancillary services, do not include any other revenue codes except those codes representing professional services and revenue code 001 for total charges;

3. If billing an all inclusive accommodation revenue code 101, the facility is permitted to include regular ancillary charges plus professional services and revenue code 001 for total charges;

4. If billing an all inclusive accommodation revenue code 101 plus all inclusive ancillary revenue code 240 do not include any other charges except those codes representing professional services and revenue code 001 for total charges; and,

5. If billing for regular accommodation revenue codes 110-219 plus all inclusive ancillary revenue code 240, do not include any other codes except for professional services and revenue code 001 for total charges.

11 Appendix C


11 Appendix C

11.1 Outpatient Revenue Codes The following is a list of the revenue codes that are reimbursable by KY Medicaid when billing for outpatient services on the UB-92 billing form.

OUTPATIENT REVENUE CODES

DESCRIPTION

250 Hospital, General

251 Drugs/Generic

252 Drugs/Non-Generic

254 Drugs Incident to Other Diagnostic Services

255 Drugs Incident to Radiology

258 IV Solution

260 IV Therapy, General

261 IV Therapy, Infusion Pump

270 Med/Surg Supplies/Devices

271 Non Sterile Supplies

272 Sterile Supplies

274 Prosthetic

275 Pace Maker

276 Intraocular Lens

278 Other Implants

280 Oncology

290 Minor Home Adapt/Environment Access

300* Lab, General

301 Chemistry

302 Immunology

303 Renal

304 Non-Routine Dialysis

11 Appendix C



DESCRIPTION

305 Hematology

306 Bacteriology/Microbiology

307 Urology

310 Lab, Pathology

311 Cytology

312 Histology

314 Biopsy

320 Radiology, Diagnostic

321 Angiocardiography

322 Arthrography

323 Arteriography

324 Chest X-Ray

330 Radiology, Therapeutic

331 Chemotherapy, Injected

332 Chemotherapy, Oral

333 Radiation Therapy

334 Chemotherapy Ed Cancer Hemophilia

335 Chemotherapy - IV

340 Nuclear Medicine, General

341 Nuclear Medicine, Diagnostic

342 Nuclear Medicine, Therapeutic

350 CT Scan, General

351 CT Scan, Head Scan

352 CT Scan, Body Scan

360 Operating Room, Service General

361 Operating Room, Minor Surgery

370 Anesthesia, General

11 Appendix C



DESCRIPTION

371 Anesthesia Incident to Radiology

372 Anesthesia Incident to Other Diagnostic Services

374 Anesthesia, Acupuncture

380 Blood, General

381 Packed Red Cells

382 Whole Blood

383 Plasma

384 Platelets

385 Leucocytes

386 Blood, other Components

387 Blood, Other Derivatives (Cryoprecipitate)

390 Blood Storage and Processing

391 Blood Administration

400 Other Imaging Service General

401 Mammography

402 Ultra Sound

403 Screening Mammography

410 Respiratory Service General

412 Inhalation Service

413 Hyperbaric Service

420 Physical Therapy, General

421 Physical Therapy, Visit Charge

422 Physical Therapy, Hourly Charge

423 Physical Therapy, Group Rate

424 Physical Therapy, Evaluation or Re-Evaluation

440 Speech-Language Pathology, General

441 Speech-Language Path. - Visit Charge

11 Appendix C



DESCRIPTION

442 Speech-Language Path. - Hourly Charge

443 Speech-Language Path. - Group Rates

444 Speech-Language Path. - Evaluation or Re-Evaluation

450 Emergency Room

460 Pulmonary Function

470 Audiology, General

471 Audiology, Diagnostic

472 Audiology, Treatment

480 Cardiology, General

481 Cardic Cath, Lab

482 Stress Test

510 Clinic, General

512 Dental Clinic

516 Urgent Care Clinic

517 Family Practice Clinic

610 MRI, General (Effective Date 11/25/85)

611 MRI, Brain (Effective Date 11/25/85)

612 MRI, Spine (Effective Date 11/25/85)

621 Supplies Incident to Radiology

622 Supplies, Incident to Other Diagnostic Services

623 Surgical Dressings

634 Erythropoietin (EPO) Less Than 10,000 Units

635 Erythropoietin (EPO) 10,000 or More Units

636 Drug Requiring Detailed Coding

700 Cast Room

710 Recovery Room

720 Labor Room/Delivery, General

11 Appendix C



DESCRIPTION

721 Labor Room

722 Delivery Room

723 Circumcision

724 Birthing Center

730 EKG/ECG (Electrocardiogram), General

731 Holter Monitor

732 Telemetry (Including Fetal Monitoring)

740 EEG (Electrocencephalogram), General

750 Gastro-Intestinal Service, General

760 Observation/Treatment Room

761 Treatment Room

762 Observation Room

790 Lithotripsy, General

817 Liver Acquisition

890 Donor Bank Storage Human Organs

891 Donor Bank, Bone

892 Donor Bank, Organ (Other Than Kidney)

893 Donor Bank, Skin

901 Electroshock Treatment

920 Other Diagnostic Services

921 Peripheral Vascular Lab

922 Electromyelogram

923 Pap Smear

924 Allergy Test

925 Pregnancy Test

940 Other Therapeutic Service

943 Cardiac Rehabilitation

11 Appendix C



DESCRIPTION

963 Anesthesiologist (MD)

971 Pathologist (MD)

972 Radiologist - Diagnostic (MD)

973 Radiologist - Therapeutic (MD)

974 Radiologist - Nuclear Medicine

981 E.R. Professional Fee

985 Cardiologist - EKG (MD)

986 Cardiologist - EEG (MD)

001 Total Charges

* Effective July 1, 1994, Department for Medicaid Services implemented the ClaimCheck® auditing system for out-patient laboratory services. Revenue codes 300-319 are audited through this system.

12 Appendix D


12 Appendix D

12.1 Inpatient and Outpatient Professional Component The following revenue codes (column A) are professional component revenue codes that cannot be reimbursed by the Medicaid Program unless they are billed in conjunction with the revenue codes in column B.

A B

963 Can Only be Reimbursed in Conjunction With 370 or 374

971 Can Only be Reimbursed in Conjunction With 300 through 307 310 through 312 314 or 460

972 Can Only be Reimbursed in Conjunction With 320 through 324 350 through 352 400 through 402 610 through 612 750, 790 and 920 through 925

973 Can Only be Reimbursed in Conjunction With 330,331,332,333, or 335

974 Can Only be Reimbursed in Conjunction With 340 through 342 350 through 352

985 Can Only be Reimbursed in Conjunction With 480 through 482, 730 731 or 943

986 Can Only be Reimbursed in Conjunction With 320, 740

Revenue code 981 is payable only on an outpatient type of bill (131 and 134).

13 Appendix E


13 Appendix E

13.1 Outpatient Drugs The following biological and blood constituents are the only drugs payable on the outpatient basis for services provided prior to July 1, 1990.

Revenue Code Biological and Blood Constituents

258 Base IV Solutions (Without Drug Additives)

270 Cortisone Injections

270 Rabies Drug Treatment

270 Tetanus Toxoid

303 Medications Associated With Renal Dialysis Treatment

331 Chemotherapy for Any Blood or Chemical Dyscrasia (e.g. Cancer, Hemophilia)

387 Anti-hemophilia Factor (AHF)

387 Rho (D) Immune Globulin (Human)

636 Drugs Requiring Detailed Coding

Note: For services provided on or after July 1, 1990, Ky Medicaid reimbursement is available for drugs (Revenue Codes 250-252) administered in the outpatient department. Reimbursement is not available for take home drugs or drugs which have been deemed less than effective by the Food and Drug Administration (FDA).

14 Appendix F


14 Appendix F

14.1 Remittance Advice This packet is intended as a step-by-step guide in reading your EDS Remittance Advice (RA). The sections following are organized to describe all major categories related to processing/adjudicating claims. To enhance this document’s usability, detailed descriptions of the fields on each page are discussed, reading the data from left to right, top to bottom.

14 Appendix F


14.1.1 Examples Of Pages In Remittance Advice There are several types of pages, including separate corresponding pages for Medicare/Medicaid (Crossover Claims) for each type, contained in a Remittance Advice, however if a provider does not have activity during the cycle in that particular category, those pages are not included. Following are examples of pages which may appear in your Remittance Advice:

FIELD DESCRIPTION Returned Claims This section lists all claims that have been returned to the

provider via an RTP letter. The RTP letter explains why the claim is being returned. These claims are returned because they are missing information pertinent to processing.

Paid Claims This section lists all claims paid in the cycle. Denied Claims This section lists all claims that denied in the cycle. Claims In Process This section lists all claims that have been suspended as of

the current cycle. The provider should maintain this page and compare with future Remittance Advices until all the claims listed have appeared on the PAID CLAIMS page or the DENIED CLAIMS page. Until that time, the provider need do nothing with the claims listed in this section.

Adjusted Claims This section lists all claims that have been submitted and processed for adjustment or claim credit transactions.

Mass Adjusted Claims This section lists all claims that have been mass adjusted at the request of the Department for Medicaid Services (DMS).

Accounts Receivable Summary

This section lists financial transactions with activity during the week of the payment cycle.

NOTE: It is imperative the provider maintains any A/R page with an outstanding balance.

Summary of Benefits Page

This section details all categories contained in the Remittance Advice for the current cycle, month to date, and year to date. Explanation of Benefit (EOB) codes listed throughout the Remittance Advice is defined in this section.

NOTE: FOR YOUR OWN RECONCILIATION OF CLAIMS PAYMENTS AND CLAIMS RESUBMISSION OF DENIED CLAIMS, IT IS HIGHLY RECOMMENDED YOU KEEP ALL REMITTANCE ADVICES FOR AT LEAST ONE YEAR.

14 Appendix F


14.2 Title The header information that follows is contained on every page of the Remittance Advice. KENTUCKY DEPARTMENT FOR MEDICAID SERVICES PAGE: 2 AS OF 03/11/2004 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE: 03/13/2004 REMITTANCE ADVICE

FIELD DESCRIPTION PAGE The number of the page within each Remittance

Advice. AS OF The date the payment cycle was adjudicated. RUN DATE The date the Remittance Advice was printed. RA NUMBER A system generated number for the Remittance

Advice. PROVIDER NAME The name of the provider that billed. (The type of

provider is listed directly below the name of provider.) CLAIM TYPE The type of claims listed on the Remittance Advice. PROVIDER ID The eight-digit Medicaid assigned provider ID of the

billing provider.

The category (type of page) begins each section and is centered (for example, *PAID CLAIMS*). All claims contained in each Remittance Advice are listed in numerical order of the prescription number.

14.2.1.1 Banner Page

All Remittance Advices have a “banner page” as the first page. The “banner page” contains provider specific information regarding upcoming meetings and workshops, “top ten” billing errors, policy updates, billing changes etc. It is imperative that you pay close attention to this page.

14 Appendix F


KENTUCKY DEPARTMENT FOR MEDICAID SERVICES PAGE: 1 AS OF 03/18/2004 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE: 03/19/2004 REMITTANCE ADVICE ---- NEWSLETTER UPDATE ---- *********************ATTENTION PROVIDER******************************** THE CENTERS FOR MEDICARE AND MEDICAID SERVICES, CMS,SHARP AND HAWK HAVE DEVELOPED A SERIES OF FREE WORKSHOPS, PRODUCTS AND SERVICES TO PROVIDE PRACTICAL INFORMATION ON HOW HIPAA WILL AFFECT MEDICAL PRACTICES. FOR DATES, TIMES AND LOCATIONS OF A WORKSHOP NEAR YOU, GO TO HTTP://WWW.KYMA.ORG/HIPAA_CMS_FLYER.PDF HAVE HIPAA QUESTIONS? SEND YOUR EMAILS TO [email protected]. INDIVIDUALS CAN SUBSCRIBE TO A LIST OR CHANGE THEIR NAME IF ALREADY SUBSCRIBED BY SENDING AND EMAIL FROM YOUR EXISTING ADDRESS TO [email protected] AND ENTERING THE FOLLOWING IN BODY OF EMAIL(DO NOT ENTER SUBJECT) SUBSCRIBE HAWK YOURFIRSTNAME YOURLASTNAME IF YOU HAVE FURTHER QUESTIONS, GO TO HTTP://WWW.ARCHIMEDES-COMMUNITY.ORG/SIGS/LISTSERVS/LISTSERVS.HTM.

14 Appendix F


KENTUCKY DEPARTMENT FOR MEDICAID SERVICES PAGE: 2 AS OF 03/18/2004 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE: 03/19/2004 REMITTANCE ADVICE RA NUMBER: 009257 PROVIDER NAME: ANYTOWN GENERAL HOSPITAL GENERAL HOSPITAL CLAIM TYPE: INPATIENT SERVICES PROVIDER ID: 01000000 * P A I D C L A I M S * INVOICE MAID CLAIM SERVICE DATES BILLED PROF AMOUNT FROM CLAIM PAID NUMBER NAME NUMBER ICN FROM THRU CHARGES COMP OTHER SRCS AMOUNT EOB 410214 DRIVER N 4039999999 39608801701038500 05/24/1995-05/25/1995 3900.05 0.00 0.00 552.32 00365 01 PS: 21 REV: 0120 QTY: 1 05/24/1995-05/25/1995 250.00 0.00 0.00 02 PS: 21 REV: 0250 QTY: 37 05/24/1995-05/25/1995 116.17 0.00 0.00 03 PS: 21 REV: 0255 QTY: 1 05/24/1995-05/25/1995 207.36 0.00 0.00 04 PS: 21 REV: 0270 QTY: 15 05/24/1995-05/25/1995 109.15 0.00 0.00 05 PS: 21 REV: 0300 QTY: 21 05/24/1995-05/25/1995 735.94 0.00 0.00 06 PS: 21 REV: 0320 QTY: 1 05/24/1995-05/25/1995 58.67 0.00 0.00 07 PS: 21 REV: 0351 QTY: 2 05/24/1995-05/25/1995 1327.95 0.00 0.00 08 PS: 21 REV: 0410 QTY: 54 05/24/1995-05/25/1995 273.68 0.00 0.00 09 PS: 21 REV: 0450 QTY: 1 05/24/1995-05/25/1995 100.83 0.00 0.00 00753 10 PS: 21 REV: 0480 QTY: 1 05/24/1995-05/25/1995 405.76 0.00 0.00 11 PS: 21 REV: 0730 QTY: 4 05/24/1995-05/25/1995 188.54 0.00 0.00 12 PS: 21 REV: 0760 QTY: 1 05/24/1995-05/25/1995 126.00 0.00 0.00 00753 426027 TRAVIS J 3839999999 39608901702035200 03/17/1996-03/20/1996 4080.15 0.00 0.00 1656.96 00365 01 PS: 21 REV: 0120 QTY: 3 03/17/1996-03/20/1996 825.00 0.00 0.00 02 PS: 21 REV: 0250 QTY: 56 03/17/1996-03/20/1996 601.24 0.00 0.00 03 PS: 21 REV: 0270 QTY: 21 03/17/1996-03/20/1996 169.38 0.00 0.00 04 PS: 21 REV: 0300 QTY: 20 03/17/1996-03/20/1996 992.85 0.00 0.00 05 PS: 21 REV: 0310 QTY: 2 03/17/1996-03/20/1996 97.00 0.00 0.00 06 PS: 21 REV: 0320 QTY: 2 03/17/1996-03/20/1996 129.08 0.00 0.00 07 PS: 21 REV: 0360 QTY: 1 03/17/1996-03/20/1996 240.24 0.00 0.00 08 PS: 21 REV: 0370 QTY: 2 03/17/1996-03/20/1996 103.96 0.00 0.00 09 PS: 21 REV: 0410 QTY: 63 03/17/1996-03/20/1996 602.56 0.00 0.00 10 PS: 21 REV: 0710 QTY: 1 03/17/1996-03/20/1996 215.14 0.00 0.00 11 PS: 21 REV: 0730 QTY: 2 03/17/1996-03/20/1996 103.70 0.00 0.00 CLAIMS PAID ON THIS RA: 3 TOTAL BILLED: 11,884.72 TOTAL PAID: 3,313.92

14 Appendix F


14.3 Paid Claims Page

FIELD DESCRIPTION INVOICE NUMBER The 20-digit alpha/numeric Patient Control Number

from Form Locator 3. MEMBER NAME The Member’s last name and first initial. IDENTIFICATION NUMBER The Member’s ten-digit Identification number as it

appears on the Member’s Identification card. ICN The 17-digit unique system generated identification

number assigned to each claim by EDS. CLAIM SERVICE DATES FROM THRU

The date or dates the service was provided in month, day, and year numeric format.

BILLED CHARGES The usual and customary charge for services provided for the Member.

AMT. FROM OTHER SOURCES

Amount paid, if any, by private insurance (excluding Medicaid and Medicare).

CLAIM PMT. AMT. The total dollar amount reimbursed by Medicaid for the claim listed.

EOB Explanation of Benefit. All EOB’s detailed on the Remittance Advice are listed with a description/definition on the SUMMARY OF BENEFITS PAGE of the Remittance Advice.

CLAIMS PAID ON THIS RA: The total number of paid claims on the Remittance Advice.

TOTAL BILLED: The total dollar amount billed by the provider for all claims listed on the PAID CLAIMS page of the Remittance Advice.

TOTAL PAID: The total dollar amount paid by Medicaid for all claims listed on the PAID CLAIMS page of the Remittance Advice.

14 Appendix F


KENTUCKY DEPARTMENT FOR MEDICAID SERVICES PAGE: 6 AS OF 03/18/2004 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE: 03/19/2004 REMITTANCE ADVICE RA NUMBER: 009257 PROVIDER NAME: ANYTOWN GENERAL HOSPITAL GENERAL HOSPITAL CLAIM TYPE: INPATIENT SERVICES PROVIDER ID: 01000000 * D E N I E D C L A I M S * INVOICE MAID CLAIM SERVICE DATES BILLED PROF AMOUNT FROM CLAIM PAID NUMBER NAME NUMBER ICN FROM THRU CHARGES COMP OTHER SRCS AMOUNT EOB 425962 FRANKLIN J 4019999999 39608901702034900 03/16/1996-03/18/1996 3564.01 0.00 0.00 0.00 00282 01 PS: 21 REV: 0120 QTY: 2 03/16/1996-03/18/1996 550.00 0.00 0.00 02 PS: 21 REV: 0250 QTY: 47 03/16/1996-03/18/1996 374.35 0.00 0.00 03 PS: 21 REV: 0270 QTY: 10 03/16/1996-03/18/1996 87.89 0.00 0.00 04 PS: 21 REV: 0300 QTY: 11 03/16/1996-03/18/1996 571.31 0.00 0.00 05 PS: 21 REV: 0352 QTY: 2 03/16/1996-03/18/1996 1564.65 0.00 0.00 06 PS: 21 REV: 0410 QTY: 58 03/16/1996-03/18/1996 312.11 0.00 0.00 07 PS: 21 REV: 0730 QTY: 2 03/16/1996-03/18/1996 103.70 0.00 0.00 REMARK CODES: 00 00282 426071 SMITH J 3449999999 39608901702035100 03/18/1996-03/20/1996 1984.94 0.00 0.00 0.00 00294 01 PS: 21 REV: 0120 QTY: 2 03/18/1996-03/20/1996 550.00 0.00 0.00 02 PS: 21 REV: 0250 QTY: 9 03/18/1996-03/20/1996 150.18 0.00 0.00 03 PS: 21 REV: 0255 QTY: 2 03/18/1996-03/20/1996 228.10 0.00 0.00 04 PS: 21 REV: 0270 QTY: 12 03/18/1996-03/20/1996 133.81 0.00 0.00 05 PS: 21 REV: 0300 QTY: 7 03/18/1996-03/20/1996 440.10 0.00 0.00 06 PS: 21 REV: 0320 QTY: 1 03/18/1996-03/20/1996 166.75 0.00 0.00 07 PS: 21 REV: 0730 QTY: 2 03/18/1996-03/20/1996 103.70 0.00 0.00 08 PS: 21 REV: 0921 QTY: 1 03/18/1996-03/20/1996 212.30 0.00 0.00 REMARK CODES: 00 00290 CLAIMS DENIED ON THIS RA: 2 TOTAL BILLED: 5,548.95 TOTAL PAID: 0.00

14 Appendix F


14.4 Denied Claims Page



appears on the Member’s Identification card. ICN The 17-digit unique system generated identification








CLAIMS DENIED ON THIS RA The total number of denied claims on the Remittance Advice.

TOTAL BILLED The total dollar amount billed by the Home Health Services for all claims listed on the DENIED CLAIMS page of the Remittance Advice.

TOTAL PAID The total dollar amount paid by Medicaid for all claims listed on the DENIED CLAIMS page of the Remittance Advice.

14 Appendix F


KENTUCKY DEPARTMENT FOR MEDICAID SERVICES PAGE: 10 AS OF 03/18/2004 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE: 03/19/2004 REMITTANCE ADVICE RA NUMBER: 009257 PROVIDER NAME: ANYTOWN GENERAL HOSPITAL GENERAL HOSPITAL CLAIM TYPE: INPATIENT SERVICES PROVIDER ID: 01000000 * C L A I M S I N P R O C E S S * INVOICE MEMBER IDENTIFICATION CLAIM SERVICE DATES BILLED PROF AMOUNT FROM CLAIM PAID NUMBER NAME NUMBER ICN FROM THRU CHARGE COMP OTHER SRCS AMOUNT EOB 000000070017140 AKRIDGE E 4069999999 19600401864006100 07/29/1994-07/31/1994 1858.50 0.00 0.00 0.00 00110 000000070017140 AKRIDGE E 4069999999 19600401866006800 08/01/1994-08/12/1994 140197.2 0.00 0.00 0.00 00110 000000070015565 KENNERLY B 4129999999 19601701861003500 07/01/1994-07/07/1994 7085.00 0.00 0.00 0.00 00110 CLAIMS SUSPENDED ON THIS RA: 3 TOTAL BILLED: 149,141.48 TOTAL PAID: 0.00

14 Appendix F


14.5 Claims In Process Page



appears on the Member’s Identification card. ICN The 17-digit unique system-generated identification








CLAIMS SUSPENDED ON THIS RA

The total number of suspended claims on the Remittance Advice.

TOTAL BILLED The total dollar amount billed by the Home Health Services for all claims listed on the CLAIMS IN PROCESS page of the Remittance Advice.

TOTAL PAID The total dollar amount paid by Medicaid for all claims listed on the CLAIMS IN PROCESS page of the Remittance Advice.

14 Appendix F


KENTUCKY DEPARTMENT FOR MEDICAID SERVICES PAGE: 14 AS OF 03/18/2004 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE: 03/19/2004 REMITTANCE ADVICE RA NUMBER: 009257 PROVIDER NAME: ANYTOWN GENERAL HOSPITAL GENERAL HOSPITAL CLAIM TYPE: OUTPATIENT CROSSOVERS PROVIDER ID: 01000000 * C L A I M S R E T U R N E D * ICN REASON CODE 19612900500002200 07 19612900500002200 07 CLAIMS RETURNED ON THIS RA: 2

14 Appendix F


14.6 Returned Claim

FIELD DESCRIPTION ICN The 17-digit unique system generated identification

number assigned to each claim by EDS. REASON CODE A code denoting the reason for returning the claim. CLAIMS RETURNED ON THIS RA

The total number of returned claims on the Remittance Advice.

NOTE: CLAIMS APPEARING ON THE “RETURNED CLAIM” PAGE ARE FORTHCOMING IN THE MAIL. THE ACTUAL CLAIM IS RETURNED WITH A “RETURN TO PROVIDER” SHEET ATTACHED INDICATING THE REASON FOR THE CLAIM BEING RETURNED.

14 Appendix F


KENTUCKY DEPARTMENT FOR MEDICAID SERVICES PAGE: 15 AS OF 03/18/2004 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE: 03/19/2004 REMITTANCE ADVICE RA NUMBER: 009257 PROVIDER NAME: ANYTOWN GENERAL HOSPITAL CLAIM TYPE: OUTPATIENT SERVICES PROVIDER ID: 01000000 * A D J U S T E D C L A I M S * AMT. FROM INVOICE MAID CLAIM SERVICE DATES BILLED OTHER CLAIM PMT NUMBER NAME NUMBER ICN FROM THRU CHARGES SOURCES AMOUNT EOB 1 *** ADJUSTMENT TO CLAIM 19529601073082000 ORIGINALLY PAID ON 06/21/1996 FOR MEMBER MUNCIE COLLEE MAID # 4029999999 PROVIDED 07/09/1995 BILLED AMOUNT: 66.00 PAID AMOUNT: 21.93 ADJ RSN CODE: 60 *** NEW CLAIM 09533200770202300 MUN024 MUNCIE C 4029999999 09533201770202300 07/09/1995-07/09/1995 66.00 0.00 43.86 00311 01 PS: 22 PROC: 72220 MOD: QTY: 2 07/09/1995-07/09/1995 66.00 0.00 43.86 00311 THE NET EFFECT OF THIS ADJUSTMENT IS 21.93 THE TOTAL NET EFFECT ON THIS RA IS 21.93 CLAIMS ADJUST/CREDIT ON THIS RA: 2 TOTAL BILLED: 0.00 TOTAL PAID: 21.93

Providers have an option of requesting an adjustment, as indicated above; or requesting a cash refund (form and instructions for completion can be found in the Billing Instructions).

If a cash refund is submitted, an adjustment CANNOT be filed. If an adjustment is submitted, a cash refund CANNOT be filed.

14 Appendix F


14.7 Adjusted Claims Page The information on this page reads left to right and does not follow the general headings until *** NEW CLAIM information begins.

FIELD DESCRIPTION INVOICE NUMBER The 20-digit alpha/numeric Patient Control Number from

Form Locator 3. MEMBER NAME The Member’s last name and first initial. IDENTIFICATION NUMBER The Member’s ten-digit Identification number as it appears

on the Member’s Identification card. ICN The 17-digit unique system generated identification




AMOUNT FROM OTHER SOURCES


CLAIM PMT AMOUNT The total dollar amount reimbursed by Medicaid for the claim listed.


1 *** ADJUSTMENT TO CLAIM This begins the information for the original claim data to be adjusted/credited. The number to the left of the asterisks indicates the item number of the adjustment transaction being detailed. In this example it is “1”, indicating the first adjustment/credit transaction listed. The ICN of the original claim being adjusted/credited follows.

ORIGINALLY PAID ON The date the original claim being adjusted/credited was paid by Medicaid.

FOR MEMBER The Member’s last and first name. MEMBER NUMBER The identification number for the Member. PROVIDED The date the service was provided in month, day, and year

numeric format. BILLED AMOUNT The amount that was billed on the original claim being

adjusted/credited. PAID AMOUNT The original amount paid by Medicaid. ADJ RSN CODE Denotes the reason for the adjustment/credit. All reason

codes detailed on the Remittance Advice are listed with a description/definition on the SUMMARY OF BENEFITS PAGE of the Remittance Advice. See Appendix D for a list of values.

14 Appendix F


FIELD DESCRIPTION *** NEW CLAIM This begins the new information of the adjusted claim and

is followed by a 17-digit ICN assigned to the adjustment/credit that is listed. The new ICN notifies the provider if the transaction is a credit or an adjustment. The sixth digit from the right indicates a claim credit if it is a “1” and an adjustment if it is a “2”.

At this point, the information follows the general headings of the Remittance Advice indicating the adjusted transaction results.

INVOICE NUMBER The office account number the provider has assigned to this Member, if applicable.

MEMBER NAME The Member’s last name and first initial. IDENTIFICATION NUMBER The Member’s ten-digit Identification number as it appears

on the Member Identification card. ICN The 17-digit unique system generated identification




AMOUNT FROM OTHER SOURCES


CLAIM PMT AMOUNT The total dollar amount reimbursed by MEDICAID for the claim listed.


THE NET EFFECT OF THIS ADJUSTMENT IS

This is the sum of the specific transaction detailed for this adjustment and its effect on the total transaction.

THE TOTAL NET EFFECT OF THIS RA IS

This is the sum of all transactions detailed for adjustments/ credits on the Remittance Advice and the total effect on the transactions.

CLAIMS ADJUST/CREDIT ON THIS RA

The number of transactions (adjustments and/or claim credits) on the Remittance Advice.

TOTAL BILLED The total dollar amount billed on the ADJUSTED CLAIMS page of the Remittance Advice.

TOTAL PAID The total dollar amount paid on the ADJUSTED CLAIMS page of the Remittance Advice.

14 Appendix F


KENTUCKY DEPARTMENT FOR MEDICAID SERVICES PAGE: 16 AS OF 03/18/2004 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE: 03/19/2004 REMITTANCE ADVICE RA NUMBER: 009257 PROVIDER NAME: ANYTOWN GENERAL HOSPITAL CLAIM TYPE: FINANCIALS PROVIDER ID: 01000000 * A C C O U N T R E C E I V A B L E S U M M A R Y * LOC RSN SETUP AGE COST SETT AMT A/R AMOUNT UNPAID ST PP PAYOUT INT INT BALANCE CD CD DATE (DAYS) FYE REQUESTED INC/DEC RECD/RECP BALANCE CD IND AMOUNT CALC RECD A/R ICN: 29604101010100006 A/R XREF ICN: 29604101710100006 ADJ REASON - RECOUPMENT - OTHER U 55 02101996 0037 00000000 29530.45 0.00 20239.45 9291.00 A R 0.00 0.00 0.00 9291.00 RECOUPMENT/PAYMENT SCHEDULE DUE DATE AMOUNT DUE DUE DATE AMOUNT DUE DUE DATE AMOUNT DUE DUE DATE AMOUNT DUE 02221996 29530.45 55 03181996 7099.27 ADJ REASON: RECOUPMENT - OTHER A/R ICN: 29607101617000100 A/R XREF ICN: ADJ REASON - PAYOUT - OTHER U 36 03111996 0007 00000000 0.00 0.00 0.00 0.00 P 219.51 0.00 0.00 0.00 RECOUPMENT/PAYMENT SCHEDULE DUE DATE AMOUNT DUE DUE DATE AMOUNT DUE DUE DATE AMOUNT DUE DUE DATE AMOUNT DUE NOTE: YOUR REFUND MUST BE RECEIVED BY EDS PRIOR TO THE SCHEDULED DUE DATE. IF YOUR REFUND IS NOT RECEIVED IN SUFFICIENT TIME, THE AMOUNT DUE WILL BE RECOUPED ON YOUR NEXT AVAILABLE REMITTANCE ADVICE. FOR FURTHER EXPLANATION ON A SPECIFIC ACCOUNT RECEIVABLE ITEM, PLEASE CONTACT THE PROVIDER RELATIONS UNIT AT 800-807-1232. WHEN MAKING AN INQUIRY, PLEASE HAVE AVAILABLE THE A/R ICN AND YOUR PROVIDER ID. THIS WILL ASSIST THE PROVIDER RELATIONS SPECIALIST IN EXPEDITING YOUR REQUEST.

14 Appendix F


14.8 Accounts Receivable Summary Page FIELD DESCRIPTION

LOC CD A two-character code indicating the Department for Medicaid Services branch/division or other agency that originated the Accounts Receivable. See Appendix C for a list of values.

RSN CD A two-byte alpha/numeric code specifying the reason an accounts receivable was processed against a provider’s account. See Appendix D for a list of values.

SETUP DATE The date entered on the accounts receivable transaction in MM/DD/CCYY format. This date identifies the beginning of the accounts receivable event.

AGE (DAYS) The system generated number of days the accounts receivable transaction has been in “active” or “hold” status from setup date to current date.

COST SETT FYE The eight-digit date entered on the accounts receivable transaction in MMDDYYYY format. This date is defined by the provider as the administrative business year end.

AMT REQUESTED The original accounts receivable transaction amount when the adjustment reason indicates monies are owed from the provider.

A/R INC/DEC This amount is the net amount of adjustments to increase or decrease the original amount requested.

AMOUNT RECD/RECP This amount is the total of the provider checks and recoupment amounts posted to this accounts receivable transaction.

UNPAID BALANCE The system generated balance remaining on the accounts receivable transaction does not include interest balances.

ST CD A one-character code indicating the status of the accounts receivable transaction. See Appendix E for a list of valid values.

PP IND A one-digit code indicating a recoupment payment plan schedule. Valid values are: X DMS has approved the provider to be on a payment plan. (12 payments or less) M DMS has approved the provider to be on a payment plan. (More than 12 payments) R The provider is not on a payment plan.

PAYOUT AMOUNT This is the amount paid to the provider when the adjustment reason indicates money is owed to the provider.

INT CALC This is the amount of interest calculated for an approved payment plan.

INT RECD This is the total amount posted to the interest calculated. BALANCE The system generates the net balance of this accounts

receivable transaction which includes the original amount plus interest calculated minus adjustments, payments and recoupment.

The following information appears before the values of the above listed column information.

14 Appendix F


FIELD DESCRIPTION A/R ICN This is the 17-digit Internal Control Number used to identify and

relate records for one accounts receivable transaction. This number must be referenced when inquiring on any accounts receivable.

A/R X/REF ICN This is the 17-digit Internal Control Number used to identify and relate one accounts receivable transaction to another accounts receivable transaction.

ADJ REASON The definition of the two digit reason code. DUE DATE The date that monies are due to EDS to satisfy the accounts

receivable (60 days from setup date). If a payment plan has been established, several due dates are shown.

AMOUNT DUE The amount due for each due date listed. If a payment plan has not been setup, the entire amount appears in the first AMOUNT DUE column.

ANY RECOUPMENT ACTIVITY OR PAYMENTS RECEIVED FROM THE PROVIDER list below the “RECOUPMENT PAYMENT SCHEDULE.” All initial accounts receivable allow 60 days from the “setup date” to make payment on the accounts receivable. After 60 days, if the accounts receivable has not been satisfied nor a payment plan initiated, monies are recouped from the provider on each Remittance Advice until satisfied.

This is your only notification of an accounts receivable setup. Please keep all Accounts Receivable Summary pages until all monies have been satisfied.

14 Appendix F


KENTUCKY DEPARTMENT FOR MEDICAID SERVICES PAGE: 17 AS OF 03/18/2004 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE: 03/19/2004 REMITTANCE ADVICE RA NUMBER: 009257 PROVIDER NAME: ANYTOWN GENERAL HOSPITAL GENERAL HOSPITAL PROVIDER ID: 01000000 * S U M M A R Y O F B E N E F I T S P A G E * CLAIMS REMITTANCE SUMMARY CHECK NUMBER 6584966 NUMBER BILLED NET PAY PROCESSED AMOUNT AMOUNT PAID CLAIMS 45 13572.26 7797.05 PAID ADJ. CLAIMS 0 0.00 0.00 PAID MASS ADJ. CLAIMS 0 0.00 0.00 DENIED CLAIMS 40 75172.22 CLAIMS IN PROCESS 105 124528.81 RETURNED CLAIMS 0 BEGINNING CLAIM CREDIT BALANCE 0.00 ENDING CLAIM CREDIT BALANCE 0.00 A/R TRANSACTIONS DEBIT 0.00 A/R TRANSACTIONS CREDIT 0.00 TOTAL PROVIDER CREDIT BALANCE 1507.12 SUBTOTAL CHECK AMOUNT 7797.05 BEGINNING POS/ELIG CREDIT BALANCE 0.00 MINUS POINT OF SALE FEES 0.00 MINUS ELIGIBILITY TRANSACTIONS 0.00 ENDING POS/ELIG CREDIT BALANCE 0.00 NET CHECK AMOUNT 7797.05 MONTH-TO-DATE PAID CLAIMS 354 180771.40 97532.29 MONTH-TO-DATE PAID ADJ/FINANCIAL 0 0.00 0.00 MONTH-TO-DATE DENIED CLAIMS 165 146828.10 YEAR-TO-DATE PAID CLAIMS 1311 654871.12 375294.86 YEAR-TO-DATE PAID ADJ/FINANCIAL 0 0.00 0.00 YEAR-TO-DATE DENIED CLAIMS 684 525090.82 NET 1099 AMOUNT 339553.79

14 Appendix F


KENTUCKY DEPARTMENT FOR MEDICAID SERVICES PAGE: 18 AS OF 03/18/2004 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE: 03/19/2004 REMITTANCE ADVICE RA NUMBER: 009257 PROVIDER NAME: ANYTOWN GENERAL HOSPITAL GENERAL HOSPITAL PROVIDER ID: 01000000 EOB THE FOLLOWING IS A DESCRIPTION OF THE EXPLANATION OF BENEFIT (EOB) CODES THAT APPEAR ABOVE: COUNT 00061 PAID IN FULL BY MEDICAID. 14 00102 CLAIM DETAIL DENIED. LATE BILLING DATE OF SERVICE PAST ONE 2 YEAR FILING LIMIT. VERIFIES THAT EACH DETAIL OF A CLAIM IS RECEIVED WITHIN 1 YEAR FROM THE DATE OF WHICH THE SERVICE WAS RENDERED. 00110 CLAIM SUSPENDED FOR REVIEW. 68 00250 THIS MEMBER IS NOT ON OUR ELIGIBILITY FILE. PLEASE 1 VERIFY MAID NUMBER.

14 Appendix F


KENTUCKY DEPARTMENT FOR MEDICAID SERVICES PAGE: 19 AS OF 03/18/2004 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE: 03/19/2004 REMITTANCE ADVICE RA NUMBER: 009257 PROVIDER NAME: ANYTOWN GENERAL HOSPITAL GENERAL HOSPITAL PROVIDER ID: 01000000 REMARK THE FOLLOWING IS A DESCRIPTION OF THE REMARK CODES THAT APPEAR ABOVE: COUNT 00102 DETAIL LINE LATE BILLING (MORE THAN 1 YEAR FROM TDOS). 2 00250 MEMBER NOT ON ELIGIBILITY FILE. 1 00259 MEMBER NOT ELIGIBLE ON HEADER OR DETAIL DOS -

14 Appendix F


KENTUCKY DEPARTMENT FOR MEDICAID SERVICES PAGE: 13 AS OF 03/18/2004 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE: 03/19/2004 REMITTANCE ADVICE RA NUMBER: 009257 PROVIDER NAME: ANYTOWN GENERAL HOSPITAL GENERAL HOSPITAL PROVIDER ID: 01000000 RSN THE FOLLOWING IS A DESCRIPTION OF THE ADJUSTMENT REASONS THAT APPEAR ABOVE: COUNT: 60 PROVIDER INITIATED ADJUSTMENT 1 * END OF RA *

14 Appendix F


KENTUCKY DEPARTMENT FOR MEDICAID SERVICES PAGE: 20 AS OF 03/18/2004 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE: 03/19/2004 REMITTANCE ADVICE RA NUMBER: 009257 PROVIDER NAME: ANYTOWN GENERAL HOSPITAL GENERAL HOSPITAL PROVIDER ID: 01000000 RTP CODE RETURN CODE DESCRIPTION COUNT 05 CLAIM FORM/EOMB NOT LEGIBLE 2 07 MEMBER ID NUMBER MISSING 1 * END OF RA *

14 Appendix F


14.9 Summary Of Benefits Page FIELD DESCRIPTION CLAIMS REMITTANCE SUMMARY

Column heading identifying the types of data summarized.

CHECK NUMBER The number of the check associated with the Remittance Advice.

NUMBER PROCESSED The number of claims processed under each individual heading (listed on the left of page), where applicable.

BILLED AMOUNT The total billed dollar amount for services billed by the provider on the Remittance Advice.

NET PAY AMOUNT The total dollar amount reimbursed by the Department for Medicaid Services (DMS) under each individual heading (listed on the left of page), where applicable.

PAID CLAIMS The number of paid claims processed, amount billed, and amount paid by Medicaid. These figures correspond with the summary line of the last page of PAID CLAIMS section.

PAID ADJ CLAIMS The number of adjusted/credited claims processed, adjusted/credited amount billed, and adjusted/credited amount paid or recouped by Medicaid. If money is recouped, the dollar amount is followed by a negative (-) sign. These figures correspond with the summary of the last page of the ADJUSTED CLAIMS section.

PAID MASS ADJ CLAIMS The number of mass adjusted/credited claims, mass adjusted/credited amount billed, and mass adjusted/credited amount paid or recouped by Medicaid. These figures correspond with the summary line of the last page of the MASS ADJUSTED CLAIMS section. Mass Adjustments are initiated by Medicaid and EDS for issues that affect a large number of claims or providers. These adjustments have their own section “MASS ADJUSTED CLAIMS” page, but are formatted the same as the ADJUSTED CLAIMS page.

DENIED CLAIMS These figures correspond with the summary line of the last page of the DENIED CLAIMS section.

CLAIMS IN PROCESS The number of claims processed that suspended along with the amount billed of the suspended claims. These figures correspond with the summary line of the last page of the CLAIMS IN PROCESS section.

BEGINNING CLAIM CREDIT BALANCE

The amount of money the provider owes Medicaid as a result of a claim adjustment, claim credit, or mass adjustment that could not be satisfied from the previous Remittance Advice.

14 Appendix F


FIELD DESCRIPTION ENDING CLAIM CREDIT BALANCE

The balance of money owed to Medicaid after monies received during the current Remittance Advice have been applied.

A/R TRANSACTION DEBIT The total dollar amount paid out to a provider once a request has been received from Medicaid.

A/R TRANSACTION CREDIT The total dollar amount recouped to satisfy outstanding claim credit balances or accounts receivable.

TOTAL PROVIDER CREDIT BALANCE

The total dollar amount the provider owes Medicaid as a result of a claim adjustments, claim credits, mass adjustments, and/or an accounts receivable balance unsatisfied pertaining to the current Remittance Advice.

SUBTOTAL CHECK AMOUNT The total of the provider warrant check after the above figures have been calculated.

BEGINNING POS/ELIG CREDIT BALANCE

Not Applicable.

NET CHECK AMOUNT The total of the provider check after the POS fees and eligibility transactions have been subtracted from the SUBTOTAL CHECK AMOUNT.

MONTH-TO-DATE PAID CLAIMS

A month to date number and total billed and reimbursed of paid claims.

MONTH-TO-DATE PAID ADJ/FINANCIAL

A month to date number and total billed and reimbursed of adjusted claims and financial transactions.

MONTH-TO-DATE DENIED CLAIMS

A month to date number and total billed of denied claims.

YEAR-TO-DATE PAID CLAIMS A year to date number and total billed and reimbursed of paid claims.

YEAR-TO-DATE ADJ/FINANCIAL

A year to date number and total billed and reimbursed of adjusted claims and financial transactions.

YEAR-TO-DATE DENIED CLAIMS

A year to date number and total billed of denied claims.

NET 1099 AMOUNT The total year to date taxable income received from Medicaid.

14 Appendix F


EXPLANATION OF BENEFITS

FIELD DESCRIPTION EOB A five-digit number denoting the EXPLANATION OF

BENEFITS detailed on the Remittance Advice. EOB CODE DESCRIPTION Description of the EOB Code. All EOB Codes

detailed on the Remittance Advice are listed with a description/ definition.

COUNT Total number of times an EOB Code is detailed on the Remittance Advice.

EXPLANATION OF REMARKS

REMARK A five-digit number denoting the remark identified on the Remittance Advice.

REMARK CODE DESCRIPTION Description of the Remark Code. All remark codes detailed on the Remittance Advice are listed with a description/definition.

COUNT Total number of times a Remark Code is detailed on the Remittance Advice.

EXPLANATION OF ADJUSTMENT CODES

ADJUSTMENT CODE A two-digit number denoting the reason for returning the claim.

ADJUSTMENT CODE DESCRIPTION

Description of the adjustment Code. All adjustment codes detailed on the Remittance Advice are listed with a description/definition.

COUNT Total number of times an adjustment Code is detailed on the Remittance Advice.

EXPLANATION OF RTP CODES

RTP CODE A two-digit number denoting the reason for returning the claim.

RETURN CODE DESCRIPTION Description of the RTP Code. All RTP codes detailed on the Remittance Advice are listed with a description/ definition.

COUNT Total number of times an RTP Code is detailed on the Remittance Advice.

15 Appendix G


15 Appendix G

15.1 Remittance Advice Location Codes (LOC CD) The following is a two-character code indicating the Department for Medicaid Services branch/division or other agency that originated the Accounts Receivable:

A Long Term Care B Hospital/Clinical C SURS D Patient Access Branch E Orthodontic F Office of Inspector General G Attorney General H KENPAC I Individual and Group Services J Fraud K Facility Services L Pharmacy M HMS N DMS Commissioner O Other P Program Integrity S Sapient U EDS AA Facilities Service Branch AB Community-Based Service AC Mental Health/Mental Retardation AD Hospital & Outpatient Facilities Services AE Physicians Branch AF Specialty Services Branch AG Utilization Review Branch AH Recovery Operations AI KENPAC AJ Pharmacy AK KCHIP AL Children’s Program Branch AM Healthwatch AN PRO

16 Appendix H


16 Appendix H

16.1 Remittance Advice Reason Code (ADJ RSN CD or RSN CD) The following is a two-byte alpha/numeric code specifying the reason an accounts receivable was processed against a provider’s account:

01 Prov Refund – Health Insur Paid 02 Prov Refund – Member/Rel Paid 03 Prov Refund – Casualty Insu Paid 04 Prov Refund – Paid Wrong Vender 05 Prov Refund – Apply to Acct Recv 06 Prov Refund – Processing Error 07 Prov Refund-Billing Error 08 Prov Refund – Fraud 09 Prov Refund – Abuse 10 Prov Refund – Duplicate Payment 11 Prov Refund – Cost Settlement 12 Prov Refund – Other/Unknown 13 Acct Receivable – Fraud 14 Acct Receivable – Abuse 15 Acct Receivable – TPL 16 Acct Recv – Cost Settlement 17 Acct Receivable – EDS Request 18 Recoupment – Warrant Refund 19 Act Receivable-SURS Other 20 Acct Receivable – Dup Payt 21 Recoupment – Fraud 22 Civil Money Penalty 23 Recoupment – Health Insur TPL 24 Recoupment – Casualty Insur TPL 25 Recoupment – Member Paid TPL 26 Recoupment – Processing Error 27 Recoupment – Billing Error 28 Recoupment – Cost Settlement 29 Recoupment – Duplicate Payment 30 Recoupment – Paid Wrong Vendor 31 Recoupment – SURS 32 Payout – Advance to be Recouped 33 Payout – Error on Refund 34 Payout – RTP 35 Payout – Cost Settlement 36 Payout – Other 37 Payout – Medicare Paid TPL 38 Recoupment – Medicare Paid TPL 39 Recoupment – DEDCO 40 Provider Refund – Other TLP Rsn 41 Acct Recv – Patient Assessment 42 Acct Recv – Orthodontic Fee 43 Acct Receivable – KENPAC 44 Acct Recv – Other DMS Branch 45 Acct Receivable – Other

46 Acct Receivable – CDR-HOSP-Audit 47 Act Rec – Demand Paymt Updt 1099 48 Act Rec – Demand Paymt No 1099 49 PCG 50 Recoupment – Cold Check 51 Recoupment – Program Integrity Post Payment Review Contractor A 52 Recoupment – Program Integrity Post Payment Review Contractor B 53 Claim Credit Balance 54 Recoupment – Other St Branch 55 Recoupment – Other 56 Recoupment – TPL Contractor 57 Acct Recv – Advance Payment 58 Recoupment – Advance Payment 59 Non Claim Related Overage 60 Provider Initiated Adjustment 61 Provider Initiated CLM Credit 62 CLM CR-Paid Medicaid VS Xover 63 CLM CR-Paid Xover VS Medicaid 64 CLM CR-Paid Inpatient VS Outp 65 CLM CR-Paid Outpatient VS Inp 66 CLS Credit-Prov Number Changed 67 TPL CLM Not Found on History 68 FIN CLM Not Found on History 69 Payout-Withhold Release 71 Withhold-Encounter Data Unacceptable 72 Overage .99 or Less 73 No Medicaid/Partnership Enrollment 74 Withhold-Provider Data Unacceptable 75 Withhold-PCP Data Unacceptable 76 Withhold-Other 77 A/R Member IPV 78 CAP Adjustment-Other 79 Member Not Eligible for DOS 80 Adhoc Adjustment Request 81 Adj Due to System Corrections 82 Converted Adjustment 83 Mass Adj Warr Refund 84 DMS Mass Adj Request 85 Mass Adj SURS Request 86 Third Party Paid – TPL 87 Claim Adjustment – TPL 88 Beginning Dummy Recoupment Bal 89 Ending Dummy Recoupment Bal

16 Appendix H


90 Retro Rate Mass Adj 91 Beginning Credit Balance 92 Ending Credit Balance 93 Beginning Dummy Credit Balance 94 Ending Dummy Credit Balance 95 Beginning Recoupment Balance 96 Ending Recoupment Balance 97 Begin Dummy Rec Bal 98 End Dummy Recoup Balance 99 Drug Unit Dose Adjustment AA PCG 2 Part A Recoveries BB PCG 2 Part B Recoveries CB PCG 2 AR CDR Hosp

DG DRG Retro Review DR Deceased Member Recoupment IP Impact Plus IR Interest Payment CC Converted Claim Credit Balance MS Prog Intre Post Pay Rev Cont C OR On Demand Recoupment Refund RP Recoupment Payout RR Recoupment Refund SS State Share Only UA EDS Medicare Part A Recoup XO Reg. Psych. Crossover Refund

17 Appendix I


17 Appendix I

17.1 Remittance Advice Status Code (ST CD) The following is a one-character code indicating the status of the accounts receivable transaction:

A Active B Hold Recoup - Payment Plan Under Consideration C Hold Recoup - Other D Other-Inactive-FFP-Not Reclaimed E Other – Inactive - FFP F Paid in Full H Payout on Hold I Involves Interest – Cannot Be Recouped J Hold Recoup Refund K Inactive-Charge off – FFP Not Reclaimed P Payout – Complete Q Payout – Set Up In Error S Active - Prov End Dated T Active Provider A/R Transfer U EDS On Hold W Hold Recoup - Further Review X Hold Recoup - Bankruptcy Y Hold Recoup - Appeal Z Hold Recoup - Resolution Hearing

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Provider Billing Instructions - KYMMISuatweb.kymmis.com/kymmis/pdf/billingInstr/01Hospital... · 2006-09-22 · Provider Billing Instructions For Hospital Services Provider Type –