Online Claim Entry CMS-1500

1. Online Claim Entry CMS-1500 Presented by: Xerox State Healthcare, LLC Provider Relations

2. Resources • When online use: Ask Service Representative • HIPAA.Desk.NM@xerox.com • NMPRSupport@xerox.com • Call Center 505-246-0710 or 800-299-7304 • New Mexico Web Portal • Provider Information section • Links and FAQ section • Provider Login section

3. Online Claim Entry CMS-1500 • Provide information on submitting online CMS-1500 claims: • Claim Form Instructions • Timely Filing • NCCI – National Corrective Coding Initiative • Add/Manage Templates • Medicaid Primary Claims • Medicaid (TPL) Third Party Liability Claims • PPO/HMO Claims • Medicare Replacement Plan Claims • Medicare Primary Claims

4. Important State Websites • STATE WEBSITES: • PROGRAM POLICY MANUAL • http://www.hsd.state.nm.us/mad/policymanual.html • BILLING INSTRUCTIONS • http://www.hsd.state.nm.us/mad/billinginstructions.html • REGISTERS AND SUPPLEMENTS: • http://www.hsd.state.nm.us/mad/registers/2013.html

5. Important Update • On October 1, 2014, the ICD-9 code sets used to report medical diagnoses and inpatient procedures will be replaced by ICD-10 code sets. • The transition to ICD-10 is required for everyone covered by the Health Insurance Portability Accountability Act (HIPAA). Please note, the change to ICD-10 does not affect CPT coding for outpatient procedures and physician services.

6. Claim Form Instructions

7. Where to get a copy of claim form instructions Click Forms , Publications, and Instructions under Provider Information

8. Where to get a copy of claim form instructions Scroll down Open file

9. Timely Filing

10. What is a Transaction Control Number (TCN)? The twelfth digit in an adjustment/ void TCN will either be: 1= Debit 2= Credit 91308700085000001 The first digit indicates what the claim “media” is: 2 = electronic crossover 3 = other electronic claim 4 = system generated claim or adjustment 8 = paper claim 9 = Web portal claim entry Batch number The last two digits of the year the claim was received The claim number within the batch. The numeric day of the year. This is the Julian Date - this represents the date the claim was received by Xerox: this claim was received the 87th day of 2013, or March 28, 2013

11. Timely Filing Denials • Re-filing Claims and Submitting Adjustments • Indicate the TCN in the “Timely Filing Justification – Prior TCN Number” field.

12. NCCI National Corrective Coding Initiative

13. NCCI (National Corrective Coding Initiative) • Is a CMS program that consists of coding policies and edits.  Medicaid NCCI Edits consist of two types:  • NCCI procedure-to-procedure edits that define pairs of Healthcare Common Procedure Coding System (HCPCS)/Current Procedural Terminology (CPT) codes that should not be reported together for a variety of reasons; and • Medically Unlikely Edits (MUE), units-of-service edits, that define for each HCPCS/CPT code the number of units of service beyond which the reported number of units of service is unlikely to be correct (e.g., claims for excision of more than one gallbladder or more than one pancreas).

14. NCCI (National Corrective Coding Initiative) • RA EOB Codes: • 6501 or 6502 - Per the National Correct Coding Initiative, payment is denied because the service is not payable with another service on the same date of service. • 6503 through 6505 - Per the National Correct Coding Initiative, payment is denied because provider billed units of service exceeding limit. • Please visit the link below for any additional information: • http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Data-and-Systems/National-Correct-Coding-Initiative.html

15. Add/Manage Templates

16. CMS-1500 - Add Claim Template Please note template are limited to 25 per user. HINT: think about use procedure code, or dates (billing range dates) The best time to directly enter your claim is Sunday through Friday between the hours of 6 a.m. - 6 p.m. (MST). Claims entered by Friday 6 pm could be adjudicated and reflect as early as Monday on your Remittance Advice.

17. CMS-1500 - Add Claim Template Fill out any information you would like included in your template

18. CMS-1500 - Add Claim Template Fill out any information you would like included in your template

19. CMS-1500 Manage Templates

20. Medicaid Primary Claim Forms

21. Online Claims Entry

22. Online Claims Entry Primary Claim (Cont.) Click on the RED text for the CMS-1500 Claim form instructions

23. Additional Recipient Information Option Sections can be expanded by selecting all sections with Red Text Select “Additional Recipient information” if Patient Condition information is needed to process claim.

24. Other Insurance Information Identify if another heath benefits plan paid or denied

25. Claims Information Sections can be expanded by selecting all sections with Red Text

26. Claims Information – Relevant Dates Expanded ‘Relevant Dates” Section

27. Claims Information – Attachments

28. Claims Information – Attachment Upload Review the Uploading Attachments Restrictions. You can attach files up to 10 MB Do not upload ZIP Files, Excel Spreadsheets or Password Protected Files.

29. Line Item Information Click to add Line Items

30. Adding Additional Line Item Information The fields with Red Asterisks (*) are REQIRED

31. Medicaid Primary Claim Forms Identify if there is another health benefit plan service that either paid or denied

32. Claims Summary Indicate the Total Charge Xx

33. Medicaid Third Party Liability (TPL) Claim Forms

34. Third Party Liability (TPL) Tips • TPL is commercial insurance • TPL must be billed primary to Medicaid • Medicaid does not consider Medicare TPL

35. Medicaid Third Party Liability (TPL) Claim Forms When filling out a Medicaid claim where TPL is primary payer, be sure to fill in all required primary and secondary payer information.

36. Attach a copy of the EOB along with the explanation of denials page Claims Information – Attachments

37. TPL Summary TPL PAYMENT Co-pay/Co-insurance/ Deductible X

38. Medicaid PPO/HMO Co-payment Claim Forms

39. PPO/HMO Co-Pay Tips • In the “Prior Payment Amount” field, enter the difference between the billed amount and the co-payment. • Enter the co-payment amount in the “Amount Due” field.

40. PPO/HMO Co-Pay

41. Attach a copy of the EOB along with the explanation of denials page Claims Information – Attachments

42. PPO/HMO Co-Pay Difference between total charge and the co-payment amount Co-payment amount X

43. Medicare Replacement Plan Claim Forms

44. Medicare Replacement Plan Indicate “Medicare Advantage” on Medicare Replacement Plan submissions

45. Medicare Replacement Plan - Attachments Attach a copy of the EOB along with the explanation of denials page

46. Medicare Replacement Plan Total Charge Difference between total charge and the co-payment amount Co-Payment Amount X

47. Medicare Primary Claim Forms

48. Medicare Primary Claims Indicate “Medicare” on Medicare Crossover submissions

49. Attach a copy of the EOB along with the explanation of denials page Medicare Primary– Attachments

50. Medicare Primary Claims Only Indicate Total charge on Medicare Crossovers Leave the Prior Payment Amount and Amount Due Blank X