2005 Coordinated Payor Billing Workshops

1. 2005 Coordinated PayorBilling Workshops Unisys June 2005

2. Introduction. • Bureau for Medical Services • Carla Parmelee, MMIS Program & Policy Coordinator • Bonnie Meehan, Disease State Management Coordinator • Unisys • Amanda Hiser, Provider Services Manager • Virginia Leffingwell, Provider Representative • Angie Richards, Provider Representative

3. Contact Information. • Member Services Monday - Friday • 888-483-0797 8:00 am until 5:00 pm • 304-348-3365 • Provider Services Monday - Friday • 888-483-0793 8:00 am until 5:00 pm • 304-348-3360 • Pharmacy Help Desk Monday - Saturday • 888-483-08018:30 am until 9:00 pm Sunday 12:00 pm until 6:00 pm • Access AVRS using same phone numbers • 24 hours a day, 7 days a week • Email Addresses • edihelpdesk@unisys.com • wvmmis@unisys.com

4. Mailing Addresses. Claim Forms Mailing Address Unisys • PO Box 3765 NCPDP UCF Pharmacy • PO Box 3766 UB-92 • PO Box 3767 HCFA-1500 • PO Box 3768 ADA-2002 Dental Charleston, WV 25337 • PO Box 2254 Hysterectomy, Sterilization and Abortion Forms Charleston, WV 25328-2254

5. Mailing Addresses. • Provider Services Mailing Address Unisys • PO Box 2002 Charleston, WV 25327-2002 • PO Box 625 Charleston, WV 25322-0625 • Provider Relations,Member Services • Enrollment & EDI Help Desk

6. Dental Billing Information. • Anterior Teeth • Permanent Teeth • 6-11 • 22-27 • Primary Teeth • C-H • M-R • The following procedure codes may only be billed on anterior teeth • D2330 • D2331 • D2390 • D3346 • D3410 – requires prior authorization

7. Dental Billing Information (cont). • Posterior Teeth • Permanent Teeth: 1-5, 12-16, 17-21, 28-32 • Primary Teeth: A, B, I, J, K, L, S, T • The occlusal and buccal surfaces may only be billed on posterior teeth • The following procedure codes may only be billed on posterior teeth • D2391 • D2392 • D2393 • D2394 • D3421 – requires prior authorization

8. Timely Filing Policy. • To meet timely filing requirements for WV Medicaid, claims must be received within one year from the date of service • The year is counted from the date of receipt to the “from” date on a HCFA or the “admit” date on a UB-92 • Claims that are over one year old must have been billed and received within the one year filing limit. • The original claim must have had the following valid information listed on it: • Correct provider number • Correct member number • Correct date of service • Correct type of bill

9. Timely Filing Policy (cont). • Claims that are over one year old must be submitted to Provider Relations with a copy of the original remittance advice • Services with dates of service over two years old are NOT eligible for reimbursement • This policy is applicable to reversal/replacement claims • If you submit a reversal/replacement claim with a date of service that is over one year old, the replacement claim must be billed on paper with a copy of the original remittance advice • You are NOT allowed to add additional services to the replacement claim • If additional services are billed on the replacement claim that were not billed on the original claim and the dates of service are over one year old, the claim will be denied for timely filing

10. Medicare Primary Claims. • Timely Filing • The normal WV Medicaid timely filing requirement for Medicare primary claims is one year from the EOMB date • These limits have been extended due to the claim processing issues • Timely filing will be overridden if the date on the EOMB is 07/01/2003 or after • Once all of the Medicare primary claims have been processed, we will post a message on the web portal indicating the date the normal timely filing requirements will resume • Claims Processing • The back log of all paper Medicare primary claims has been processed • Beginning 07/08/2005, the web portal is available to direct data enter Medicare and TPL primary claims

11. TPL Primary Claims. • Timely Filing • The normal WV Medicaid timely filing requirement for TPL primary claims is one year from the date of service • These limits have been extended due to the claim processing issues • Timely filing will be overridden if the date of service is 07/01/2003 or after • Once all of the TPL primary claims have been processed, we will post a message on the web portal indicating the date the normal timely filing requirements will resume • Claims Processing • Unisys and BMS is in the process of reviewing the test results for the TPL primary claims • Providers will be notified via the web portal when Unisys is able to process these claims on paper and electronically

12. TPL Primary Claims (cont). • Providers are required to bill insurance as primary before billing Medicaid • The only exceptions to this rule are EPSDT, pediatrics, and maternity care visits • Providers cannot refuse to accept Medicaid due to the patient having a primary payer • New TPL billing procedures • Claims will be calculated the same as the Medicare primary claims are • It is very important for providers to attach the insurance EOBs on all paper claims, including denial reasons • If no EOB is attached with the coinsurance, deductible, and/or denial reasons, the claims will pay $0.00 • Coinsurance and deductible information must also be included on electronic claims • When billing electronic claims, insurance EOBs must be sent to Unisys with the provider number and member number listed on the EOB • Refer to Chapter 600, Section 620 for more details

13. Reversals / Replacement Claims. • Original Claims Processed in ACS System • Reversals • Only paid claims can be reversed • Must be submitted on paper to Unisys • Complete Reversal Form • Checks cannot be submitted when the original claim was processed in ACS system • Replacement Claims • Only paid claims can be replaced • If you are replacing a claim which has been reversed, this claim must be attached and cannot be submitted separately • Timely filing guideline for replacement claims is two years from the date of service • The replacement claim must reflect all lines for which you are requesting reimbursement

14. Reversals / Replacement Claims. • Original Claims Processed in Unisys System • Reversals • Only paid claims can be reversed • Can be submitted on paper or via the web portal • If you are billing these through the web portal, follow the instructions closely that are listed under “FAQ” • Replacement Claims • Only paid claims can be replaced • If the date of service on the replacement claim is less than one year old, it can be submitted on paper or via the web portal • If the date of service on the replacement claim is greater than one year old, it must be submitted on paper with the original RA attached • The replacement claim must reflect all lines for which you are requesting reimbursement • If you are billing these through the web portal, follow the instructions closely that are listed under “FAQ”

15. Remittance Advice Changes. • Below are requested changes to the remittance advices that are under review • Adding the conflicting claims number and original date paid to claims/lines that are denying as duplicates • Display the HIPAA adjustment reasons and remark codes, rather than the internal Unisys edits • Add EOB to indicate when a claim pays $0.00 due to primary payer paying more than Medicaid allows • Print the HMO or PAAS information next to the member’s name when a claim denies for edit 153 or 171(complete 06/17/2004) • Addition of an adjustment reason to reversal/replacement claims • Separate Medicare and TPL primary claims from Medicaid primary claims (complete 05/13/2004)

16. Billing Information. • Electronic claims must be received by 5:00 pm on Wednesdays to be considered for that week’s cycle • You must bill with valid procedure and ICD-9 codes for the billed date(s) of service • Consult the 2005 HCPCS, CPT, and/or ICD-9 code books • Outpatient hospital claims should not have ICD-9 surgical procedure codes listed on the claim • Outpatient hospitals claims must use modifier TC on procedures that are divided into professional and technical components • See RBRVS Manuals/Spreadsheets for these codes • Inpatient hospital claims should not use CPT or HCPCS codes in block 44 on a UB92 • Medicare primary claims processed incorrectly on the 05/27/05 remittance advice. • The paid claims will be reprocessed to recoup any overpayments. • The denied claims will be reprocessed if they were denied inappropriately. • Please note that the Medicare primary claims were not separate from the Medicaid claims on this remittance advice. This is due to the claims processing incorrectly. • All Medicare claims will be separate from the Medicaid claims again beginning with the 06/03/05 remittance advice.

17. Billing Information. • Rolling Month Service Limit Change 05/01/05 • Effective 05/01/05, the rolling month has been corrected to allow services to be billed once each month • Services should still be provided one month apart • For example, if you bill on the 15th of one month, the services should not be provided until the 15th of the next month. • If services are provided on the 15th of a month, this limit will not allow for services to provided again on the 1st of the next month • Services that are provided throughout the month and have a rolling month limit per calendar month should be billed by spanning the month • For example, if the service limit is 200 services per month and the services are being provided throughout the month, they must be billed once a month by spanning the dates, the 1st thru the 31st, the 1st thru the 28th, or the 1st thru the 30th

18. Thank you for your attendance! Unisys June 2005