Intellectual Disability Community Waiver

1. Department of Medical Assistance Services Intellectual Disability Community Waiver Eligibility Verification and Direct Data Entry Billing Requirements February 2013 www.dmas.virginia.gov 1

2. This presentation is to facilitate training of the subject matter in the Virginia Medicaid manuals.This training contains only highlights of the manual and is not meant to substitute for or take the place of the manual.Providers are responsible for reviewing and adhering to all Medicaid manual requirements.

3. Department of Medical Assistance Services Agenda • DMAS Web Portal • Eligibility Verification Options • Patient Pay Information • Important Contacts • Direct Data Entry Billing Guidelines • Timely Filing www.dmas.virginia.gov 3

4. Department of Medical Assistance Services DMAS Web Portal • https://www.virginiamedicaid.dmas.virginia.gov/wps/portal • Current, most up-to-date information on Virginia Medicaid programs: • Provider Memos Available for Review • Access to Medicaid Manuals • Provider Forms • Provider Profile Maintenance • Automated Response System • Direct Data Entry (DDE) www.dmas.virginia.gov 4

5. Department of Medical Assistance Services DMAS Web Portal • https://www.virginiamedicaid.dmas.virginia.gov/wps/portal • Current, most up-to-date information on Virginia Medicaid programs: • Provider Memos Available for Review • Access to Medicaid Manuals • Provider Forms • Provider Profile Maintenance • Automated Response System • Direct Data Entry (DDE) www.dmas.virginia.gov 5

6. Department of Medical Assistance Services As a participating Provider You Must • Determine the patients identity. • Verify the patient’s age. • Verify the patient’s eligibility • Accept, as payment in full the amount paid by Virginia Medicaid. • Bill any and all other third party carriers. www.dmas.virginia.gov 6

7. COMMONWEALTH OF VIRGINIA DEPARTMENT OF MEDICAL ASSISTANCE SERVICES 002286 999999999999 V I RG I N I A J. R E C I P I E N T DOB: 05/09/1994F CARD# 00001

8. Department of Medical Assistance Services Medicaid Eligibility Verification Options MediCall/ Automated Response System (ARS) www.dmas.virginia.gov 8

9. Department of Medical Assistance Services MediCall/Automated Response System (ARS) • Available 24 hours a day, 7 days a week • Medicaid Eligibility Verification • Claim Status • Patient Pay Information • Prior Authorization Information • Primary Payer Information • Managed Care Organization Assignments www.dmas.virginia.gov 9

10. Department of Medical Assistance Services MediCall 800 - 884 - 9730 800 - 772 - 9996 800 - 965 - 9732 800 - 965 - 9733 www.dmas.virginia.gov 10

11. Department of Medical Assistance Services Automated Response System (ARS) • Web based eligibility verification option • Free of Charge • Information received in “real time” • Secure • Fully HIPPA compliant www.dmas.virginia.gov 11

12. Department of Medical Assistance Services ARS Registration Process • First Time Users • Go to https://www.virginiamedicaid.dmas.virginia.gov/wps/portal/Webregistration • Establish an user ID and password • By registering you are acknowledging yourself as a staff member with administrative rights for the organization www.dmas.virginia.gov 12

13. Department of Medical Assistance Services ARS Web Support Call Center • Questions regarding new user registration, temporary password or password resets, call: 1-866-352-0496 Available 8 am – 5 pm Monday – Friday (No Holidays) www.dmas.virginia.gov 13

14. Department of Medical Assistance Services Patient Pay Information • The local department of social services (LDSS) will enter data regarding the individual’s patient pay obligation into the Medicaid Management Information System (MMIS) at the time action is taken on a case: • Result of application for long term care services • Time of the annual re-determination of eligibility • Change in the enrollee’s situation is reported • Medicaid patient pay information is available via MediCall and ARS. • Providers responsible for collecting the patient pay amount should review the information prior to billing each month. www.dmas.virginia.gov 14

15. ARS Patient Pay Information Patient Pay Information Begin-End (Date Time Period) Patient Pay Status V 06/01/2012- 06/30/2012 658.00 06/01/2012 - 06/30/2012 488.00 A 15

16. Department of Medical Assistance Services Provider Call Center Claims, covered services, billing inquiries: 800-552-8627 804-786-6273 8:30am – 4:30pm (Monday-Friday) 11:00am – 4:30pm (Wednesday) www.dmas.virginia.gov 16

17. Department of Medical Assistance Services Provider Enrollment New provider enrollment, Electronic Fund Transfer (EFT) or change of address: Xerox– PEU P. O. Box 26803 Richmond, VA 23261 888-829-5373 804-270-5105 804-270-7027 - Fax www.dmas.virginia.gov 17

18. Department of Medical Assistance Services Direct Data Entry www.dmas.virginia.gov 18

19. Accessing DDE Department of Medical Assistance Services • Once registered for the Web Portal, the Primary Account Holder (PAH) and Organization Administrator (OrgAdmin) will automatically have access to DDE • Other users identified as Authorized Staff, will need to be assigned a new role called Authorized Staff-Claims to have access to DDE www.dmas.virginia.gov 19

20. Direct Data Entry (DDE) of Claims Department of Medical Assistance Services • DDE allows the submission of professional claims by entering the information at the required locators as detailed in the billing instructions within the User Guide • http://www.virginiamedicaid.dmas.virginia.gov • Under Provider Resources tab select Claims Direct Data Entry (DDE) • Provides access to DDE User Guide, Tutorial and FAQs www.dmas.virginia.gov 20

21. Department of Medical Assistance Services Direct Data Entry (DDE) of Claims • Through the DDE process providers will have the ability to • create a new initial claim • create templates • request an adjustment or void www.dmas.virginia.gov 21

22. Department of Medical Assistance Services Accessing the Claims DDE • Upon successful login, you will be directed to the secure • Provider Welcome Page • Navigational tabs will direct you to Claims DDE • and Automated Response System functions • https://www.virginiamedicaid.dmas.virginia.gov www.dmas.virginia.gov 22

23. Department of Medical Assistance Services Claims Menu-Access www.dmas.virginia.gov 23

24. Department of Medical Assistance Services Claims Main Page • DDE functions can be accessed here www.dmas.virginia.gov 24

25. Department of Medical Assistance Services Create New Professional Claim www.dmas.virginia.gov 25

26. Void/Replacement Claim

27. Is this a void/replacement (adjustment) of a paid claim: • System defaults to ‘No’ and requires no Claim Resubmission Information fields related to a prior claim • If ‘Yes’ is selected, the system requires Claim Resubmission Information fields be entered as well as the original paid claim except areas changing for adjustment. • Claim Resubmission Information section has the following required fields: • Resubmission Type Code (required) Select the 4 digit code identifying the reason for adjusting or voiding an individual claim

28. Department of Medical Assistance Services Resubmission Type Options- Adjustments • 1028- Correcting procedure/service code • 1029- Correcting diagnosis code • 1030- Correcting charges • 1031- Correcting units/ visits/studies/procedures • 1032-IC reconsideration of documented allowance • 1033- Correcting admitting/referring/ prescribing Provider Identification Number www.dmas.virginia.gov 1023- Primary carrier has made additional payment 1024- Primary carrier denied payment 1025- Accommodation charge correction 1026- Patient payment amount changed 1027- Correcting service periods 28

29. Department of Medical Assistance Services Resubmission Type Options – Voids • 1047- Duplicate payment was made • 1048- Primary carrier has paid full charge • 1051- Enrollee not my patient • 1052-Miscellaneous • 1060- Other insurance available www.dmas.virginia.gov 1042- Original claim has multiple incorrect items 1044- Wrong provider identification number 1045- Wrong enrollee eligibility number 1046- Primary carrier paid DMAS max allowance 29

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

31. Patient and Insured Information

32. Patient's Last Name (REQUIRED) – Enter the Last Name of the member receiving the service. • First Name (REQUIRED) – Enter the First Name of the member receiving the service. • MI (optional) – Enter the member's middle initial. • Insured's I.D. Number (REQUIRED) – Enter the 12 digit Virginia Medicaid Identification number for the member receiving the service.

33. Is Patient's Condition Related To: (REQUIRED) • Related Cause 1– Select whether or not the member’s condition is the result of an employment accident. • Drop down options: • Not Related To Employment • Related To Employment • Related Cause 2– Select whether or not the member’s condition is related to an auto accident. • Dropdown options: • Not Related To An Auto Accident • Related To An Auto Accident • If ‘Related to an Auto Accident’, the system requires you to enter the state where the auto accident occurred. • Related Cause 3– Select whether or not the member’s condition is related to an accident other than auto or employment. • Drop down options: • No Accident • Accident

34. Is there another Health Benefit Plan? (REQUIRED) – This field always defaults to ‘No’ but if other third party coverage exists, select ‘Yes’ and enter Other Coverage Information. • If ‘Yes’ is entered and other insurance pays this must be listed as Supplemental Data • If ‘Yes’ is entered and other insurance does not pay standard TPL guidelines must be followed • Attachments must be indicated in Service Location section

35. Physician or Supplier Information CLIA # This is not required

36. Date of Current (optional/situational) – Select the reason from drop down options and enter the date in the format MM/DD/YYYY • Illness(First Symptom)-Waiver services providers will enter the date care began from the DMAS-93 (PA Letter) • Diagnosis or Nature of illness or Injury (REQUIRED) – Enter the appropriate diagnosis code, which describes the nature of the illness or injury for which the service was rendered. You have to enter at least one diagnosis code out of four. • Service Authorization # (optional/situational) - Enter the Service Authorization Number for approved services that require a service authorization.

37. Click on ‘Add Service Line Item’ Button to add additional Line items Service Line Item After entering information You must Save, Reset, or Cancel Note: Taxonomy Code is entered here if applicable

38. Service Date Begin (REQUIRED) – Enter the date on which the service was first rendered. Format is MM/DD/YYYY • Service Date End (REQUIRED) – Enter the date on which the service was last rendered. Format is MM/DD/YYYY. • Place of Service (REQUIRED) – Select the two digit code which best describes where the services were rendered. • 12 – Home • Procedure Code (REQUIRED) – Enter the code that describes the procedure rendered or the service provided. • Modifiers (optional/situational) – Enter the appropriate modifiers if applicable.

39. Diagnosis Pointers (REQUIRED) – Select the diagnosis pointer related to the date of service and the procedure performed for the primary diagnosis. The system requires you to enter at least one diagnosis pointer value out of four. • Drop down options: • 1 • 2 • 3 • 4

40. Saved Service Line Items Click on Service Line Item to view After entering information You must Save, Delete, or Cancel

41. Save/Reset/Cancel • After entering information in identified sections, you will have the following options: • Save- saves the data as part of your DDE claim • Reset- clears the data entered allowing you to start again • Cancel- will exit or close the current data field • Data will be required to be saved to be included as part of the DDE claim submission

42. After saving the data, each line item will be displayed • Additional information can be entered by selecting the ‘Add’ link • To correct or delete a saved line item, you must first select the line to be amended by clicking on it

43. After selecting the saved line item, you will have the following options: • Correcting the information and save by clicking the Save link • Remove the entry from the claim by clicking on the Delete link • Keep the original data as listed by clicking on the Cancel link

44. Service Location and Attachments

45. Patient Pay Amount • The Amount Paid field is for Personal Care and Waiver services only • Enter the patient pay amount that is due from the patient. • NOTE: The patient pay amount is taken from services billed. • Providers rendering more than one service will need to send another DDE submission for charges not subject to the Patient Pay.

46. If the claim has any attachments, you must select ‘Yes’ and enter the following information: • Patient Account Number (required) – Enter up to 20 alphanumeric characters • Date of Service (required) – Enter from date of service the attachment applies to in the MM/DD/YYYY format • Sequence Number (required) – Enter the provider generated sequence number – maximum of 5 digits

47. A ‘Claim Submitted’ confirmation page will be generated by the system • Print the Claim Submitted page • Staple documents to a copy of the confirmation page and mail to DMAS • Attachment “documentation” must be received by Xerox (DMAS Fiscal Agent) within 21 days of the DDE submission or claim will deny • NOTE: Confirmation page must be the first page of the mailed submitted documents

48. Mailing Address – Claims Submission page and required documents should be mailed within 21 days to: Department of Medical Assistance Services P. O. Box 27444 Richmond, VA 23261-7444

49. Service Facility Location Information

50. Billing Provider Information • This section details information about the provider requesting payment for services rendered. • Billing Provider Information section has both required and optional/situational fields