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Welcome to the Montana Medicaid Provider Training Spring 2007

Welcome to the Montana Medicaid Provider Training Spring 2007. Today’s Schedule. Introduction New Claim Forms Re-enrollment SURS Pharmacy QMB, SLMB and QI Bloodhound PERM NPI Questions and Answers. Introduction and Housekeeping. Smooth Sailing with New Claim Forms.

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Welcome to the Montana Medicaid Provider Training Spring 2007

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  1. Welcome to the Montana MedicaidProvider TrainingSpring 2007

  2. Today’s Schedule Introduction New Claim Forms Re-enrollment SURS Pharmacy QMB, SLMB and QI Bloodhound PERM NPI Questions and Answers

  3. Introductionand Housekeeping

  4. Smooth Sailing with New Claim Forms

  5. Complete Instructions and Information • Available at: • CMS 1500: www.nucc.org • UB-04: www.nubc.org • Both: www.cms.hhs.gov Includes field definitions and valid data for all fields

  6. Institutional ClaimsUB-04 • Registration Points • Where does the OCR software look to “align” the claim to read the data: 1. Provider Name, address, city 42. Revenue Code 50. Payer Name 74. Principal Procedure

  7. The Paper Claim:UB-04

  8. Zip + 4 (required) form locator 01 Patient Number form locator 3a Type of bill form locator 4 Header Date of Service (Statement Cover Period) form locator 6 PASSPORT #/ Exemption form locator 7 Client Name form locator 8a UB-04 (Top) Key Form Locators

  9. Admit Date form locator 12 Admit Hour form locator 13 Admit Type form locator 14 Admit Source form locator 15 Discharge Status form locator 17 UB-04 (Top)

  10. Condition Codes form locators 18-28 A4 = Family Planning B3 = Pregnancy Value Codes form locators 39-41 1 = Medicare Deductible 2 = Medicare Co-insurance 68 = EPO units UB-04 (Top Half)

  11. Revenue Code form locator 42 National Drug Code form locator 43 UB-04 (Mid-Section)

  12. Data is required for any injectable billing form locator 43 NDC Units qualifier F2 - International Unit GR - Gram ML - Milliliter UN - Unit Units - as defined by qualifier UB-04 (Mid-Section)

  13. CPT/HCPCS code (outpatient) form locator 44 Line level date of service (outpatient) form locator 45 *Line 23 = Bill Date Units form locator 46 Line level charges form locator 47 UB-04 (Mid-Section)

  14. Other payer names form locator 50 TPL/Medicare Payment form locator 54 Billing Provider NPI form locator 56 Atypical provider # from locator 57 UB-04 (Mid Section)

  15. Client ID Number form locator 60 Prior Authorization form locator 63 Diagnosis Codes form locator 66,67; A - Q UB-04 (Bottom Half)

  16. Admit Diagnosis form locator 69 Cost Share Indicator form locator 73 ICD-9 (surgical) procedures & dates (inpatient) form locator 74; a-e UB-04 (Bottom)

  17. Attending Provider form locator 76 UB-04 (Bottom) *NPI required if the following providers: -Inpatient Hospital -Outpatient Hospital -Rural Health Clinic -Indian Health Services -Freestanding Dialysis Clinic -Federally Qualified Health Center

  18. Operating Provider form locator 77 *(NPI required) Other Provider form locator 78-79 *(NPI required) Taxonomy Codes Qualifier = B3 and Taxonomy form locators 81CC a-d *(required) UB-04 (Bottom)

  19. Questions?

  20. Professional ClaimsCMS-1500

  21. CMS-1500 Registration Points Where does the OCR software look to align the claim to read the data? Fields: 2 – Client Name 5 – Address 1st character of: Address, City, Zip 9 – Other insured information

  22. CMS-1500 Registration Points Cont. Fields: 9a – Policy / Group number 9c – Employer’s name 9d – Insurance Plan name 24A – From Date of Service

  23. CMS-1500

  24. Client Name field – 2 Client ID: field – 10d field – 1a field – 9a field – 11a CMS-1500 (Top)

  25. TPL Indicators: field – 11c field – 9d field – 11d = Y CMS-1500 (Mid-section)

  26. For Schools CSCT Team Number field 19 Diagnosis Code field 21 Prior Authorization # field 23 PASSPORT field 17a Referring NPI field 17b CMS-1500 (Mid-section)

  27. Qualifier = N4 NDC Units Qualifier F2 – International Unit GR – Gram ML – Milliliter UN – Unit Units – as defined by qualifier NDC (National Drug Code) Shaded area above each line on which an injectable is billed: CMS-1500 (Mid-section)

  28. CPT/HCPCS/Modifiers field 24D Diagnosis Pointer field 24E Charges field 24F Dates of Service field 24A Place of Service field 24B Emergency Indicator field 24C CMS-1500 (Mid-section)

  29. Days or Units field 24G CMS-1500 (Mid-section) EPSDT/Family Planning field 24H

  30. Rendering field 24J (shaded area) *Taxonomy for ZZ qualifier *Atypical number for 1D qualifier *NPI Rendering NPI Qualifier field 24I *Qualifier ZZ for taxonomy *Qualifier 1D for atypical provider CMS-1500 (Mid-section)

  31. TPL Payment field 29 Signature and Date field 31 Patient Account # field 26 Total Claim Charge field 28 CMS-1500 (Bottom)

  32. Taxonomy Qualifier ZZ and Taxonomy field 33b Atypical Provider Qualifier 1D and provider number field 33b Billing Provider Zip + 4 required field 33 Billing Provider NPI (Healthcare Provider) field 33a CMS-1500 (Bottom)

  33. Questions?

  34. WINASAP Set Up • Latest version 5.11 • Designed for NPI and Taxonomy

  35. WINASAP Reference Fields Taxonomy Code: Reference then Taxonomy Code

  36. WINASAP Reference Fields Reference File: Need to add Taxonomy Code

  37. WINASAP Professional/Institutional Claim Select: Add

  38. WINASAP Professional/Institutional Claim Enter 10 digit Taxonomy Code with Description

  39. WINASAP Provider Reference Provider Data Tab: Provider ID type: National Provider Identifier Provider ID Number: NPI number Provider Taxonomy Code: Enter Taxonomy Code for specific provider being billed.

  40. WINASAP Professional/Institutional Claim Identification Type: Select:Employers Tax ID Number Identification Number:Enter EIN number

  41. WINASAP Professional Claim Select: Billing Provider Select: Rendering Provider if different

  42. WINASAP Professional Claim: NDC Select: National Drug Code

  43. WINASAP Professional Claim: NDC National Drug Code Drug Unit Price Unit of Measurement Quantity Prescription Number

  44. WINASAP Professional Claim: Schools Team Select: Claim Notes

  45. WINASAP Professional Claim: Schools Team Note Reference Code:Select Additional Information Note Text: Input Teams Number

  46. X12 Information • NDC Code • NDC Code: Loop 2410, Segment Lin, Data Element 03 • Prescription Number: Loop 2410, Segment REF, Data Element 02 • Units: Loop 2410, Segment CTP, Data Element 04 • Unit Price: Loop 2410, Segment CTP, Data Element 03

  47. NDC Code Continued • Drug Unit Type: Loop 2410, Segment CTP, Data Element 05-1 • F2= International • GR=Gram • ML=Milliliter • UN=Unit

  48. X12 Information • Taxonomy Code: Professional/Institutional • Qualifier ZZ, Segment PRV, Data Element 02 • Billing/Pay To: Loop 2000A, Segment PRV, Date Element 03 • Rendering Claim: Loop 2310A, Segment PRV, Data Element 03 • Rendering Line: Loop 2420A, Segment PRV, Data Element 03

  49. X12 Information • Schools-Teams: • Qualifier 09 • Loop 2300, Segment CN1, Data Element 01 • Loop 2300, Segment CN1, Data Element 04, • 2 byte number ie: “02”, “17”, etc

  50. X12 Information • NPI Code: Professional • Qualifier XX ,Segment NM108 • Billing NPI: Loop 2010AA, Segment NM109 • Pay to NPI: Loop 2010AB, Segment NM109 • Rendering Claim Level: Loop2310A, Segment NM109 • Referring Claim Level: Loop2300A, Segment Ref02

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