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UB-04 Workshop

UB-04 Workshop. Presented by Mina Reynaga & Kristen Brice Provider Field Representatives. Contact Xerox. Call 505-246-0710 or 800-299-7304 - to directly reach all provider help desks including Provider Relations, Provider Enrollment, the HIPAA/EMC help desk and TPL.

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UB-04 Workshop

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  1. UB-04 Workshop Presented by Mina Reynaga & Kristen Brice Provider Field Representatives

  2. Contact Xerox Call 505-246-0710 or 800-299-7304 - to directly reach all provider help desks including Provider Relations, Provider Enrollment, the HIPAA/EMC help desk and TPL. • For all contact, Claims, and Correspondence Addresses information go to the following link on the New Mexico Medicaid Web Portal: • https://nmmedicaid.acs-inc.com/nm/general/loadstatic.do?page=ContactUs.html • Email: NMPRSupport@Xerox.com

  3. Important State Websites STATE WEBSITE: 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/2012.html

  4. Xerox Field Representative Provider Field Representative: • Mina Reynaga (505) 246-9988 Ext. 8131233 • Kristen BriceExt. 8131216 • E-mail: Erminia.reynaga@Xerox.com • E-mail: Kristen.brice@Xerox.com • Cc: NMPRSUPPORT@Xerox.com

  5. Important Update • Oct. 1, 2014 will be the compliance date for use of new codes that classify diseases and health problems. These code sets, known as the International Classification of Diseases, 10th Edition diagnosis and procedure codes, or ICD-10, will include codes for new procedures and diagnoses that improve the quality of information available for quality improvement and payment purposes.

  6. Purpose of the Workshop • Provide complete explanation of how to fill out the UB-04 paper claim form for: • Claim Form Instructions • Primary Medicaid • Medicaid secondary to a Third Party Liability (TPL) • HMO copayments • Medicare replacement plans • Additional information • Medicare Crossovers • Inpatient claims for Medicare Part B-only clients. • Medicaid Tertiary

  7. Claim Form Instructions

  8. Where to get a copy of claim form instructions Click on Provider Information

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

  10. Medicaid Primary Claim Forms

  11. Medicaid Primary Outpatient Example Provider Name Street City, State Zip 131 01/14/2008 01/14/2008 Patient Name F 01 01/01/1931 70553 MRI 0610 2386 00 1 A4647 Drugs/Detail Code 0636 1 253 00

  12. Medicaid Primary Outpatient Example 1 1 2639 00 0001 082807 1234567890 MEDICAID Billing NPI 123456789 CONNIE CLIENT 431 9 332S00000X B3 Taxonomy Qualifier

  13. New Hospital Outpatient Payment Method for New Mexico Medicaid • All General Acute Hospitals and Rehabilitation Hospitals must include a procedure code on every line item to receive payment. • It is recommended that you bill all outpatient services for the same date of service on the same claim form all inclusive.

  14. New Hospital Outpatient Payment Method for New Mexico Medicaid • The following resources are available on the HSD/MAD website located at: • http://www.hsd.state.nm.us/mad/PFeeSchedules.html • Hospital Outpatient Payment Method FAQ • Hospital Outpatient Payment Method Revenue Codes • Hospital Outpatient Payment Method Procedure Codes • Notice of Hospital Outpatient Prospective payment System Rates • Explanation of Simulation Spreadsheet for Outpatient services

  15. 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 • (2) 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).

  16. 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

  17. Medicaid Primary Federal Qualified Health Center (FQHC) Example Provider Name Street City, State Zip 791 01/14/2008 01/14/2008 Patient Name 01/01/1931 F 0529 CLINIC VISIT 155 00 1

  18. Medicaid Primary FQHC Example 0001 1 1 155 00 082807 1234567890 MEDICAID Billing NPI 123456789 CONNIE CLIENT 250.00 437.0 401.9 9 B3 332S00000X Qualifier Taxonomy

  19. Medicaid Primary Inpatient Example Provider Name Street City, State Zip Required if pay to is different than physical address. 111 06/05/07 05/30/07 Patient Name 01 05/30/07 F 01/01/1931 Covered days are entered in FL 39 and FL 40 80 5.00 0120 716.00 Room and Board/Semi 5 3580 00 0202 2311.00 ICU/Medical 2 4622 00 0202 2427.00 ICU/Medical 6 14562 00 0250 173 Pharmacy 6074 00 0251 67 Drugs/Generic 710 00 0270 8 Med-Sur Supplies 1089 00 0300 Laboratory or Lab 135 6509 00

  20. Medicaid Primary Inpatient Example 1 1 37146 00 0001 082807 1234567890 MEDICAID Billing NPI 123456789 CONNIE CLIENT Attending physician is only required on inpatient hospital services 431 9 1234567890 ALAN ATTENDING 332S00000X B3 Taxonomy Qualifier

  21. Medicaid Primary Long Term Care W/Covered and Non-Covered Days Example Provider Name Street City, State Zip 653 04/30/07 04/01/07 30 01/01/1931 F 01/01/07 80=covered days 81= non-covered days Covered and Non Covered Days are entered in FL 39 and FL 40 80 27.00 81 3.00 0190 Room and Board 27 8,100 00

  22. Medicaid Primary Long Term Care W/Covered and Non-Covered Days Example 1 0001 1 8,100 00 082807 1234567890 MEDICAID Billing NPI 123456789 CONNIE CLIENT 332S00000X B3 Taxonomy Qualifier

  23. Timely Filing

  24. What is a Transaction Control Number (TCN)? The twelfth digit in an adjustment/ void TCN will either be: 1= Debit 2= Credit 30832300085000001 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 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 ACS: this claim - the 323rd day of 2008, or November 18, 2008

  25. Timely Filing Denials • Re-filing Claims and Submitting Adjustments • UB Form: Put the TCN in Form Locator 64 “Transaction Control Number” (TCN) matching the appropriate payer line, using a paper form.

  26. Timely Filing Denials Re-filing Claims and Submitting Adjustments UB-04 form: Put the TCN in block 64 on the paper form. 1 1 1234567890 8,100 00 0001 082807 123456789 MEDICAID CONNIE CLIENT 332S00000X B3

  27. Medicaid Third Party Liability (TPL) Claim Forms

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

  29. TPL Tips • When filling out a Medicaid claim where TPL is primary payer, be sure to fill in all required primary and secondary payer information. • Always enter the amount the insurance has paid in Box 54 on the UB-04. • If Medicaid requires a PA for the service, then a PA issued by Medicaid Utilization Review is always required when TPL is involved, no matter if TPL paid or denied the service. • Attach the TPL EOB showing the payment/denial with the claim. • Always include the explanation page of the EOB along with the page of the EOB that shows payment/denial.

  30. MedicaidTPLClaimExample 0001 1 1 082807 37146 00 1234567890 UNITEDHEALTHCARE COMMUNITY PLAN TPL Payment 7750 00 29396 00 MEDICAID CONNIE CLIENT 123456789 ABC, INC. 010203 CONNIE CLIENT 123456789 431 9 1234567890 ALAN ATTENDING B3 332S00000X Qualifier Taxonomy

  31. Medicaid HMO/PPO Copayment Claim Forms

  32. HMO Co-Pay Tips • Write “HMO Co-pay Due” on the claim. Attach the EOB. • In the “amount paid” (field Box 54), enter the difference between the billed amount and the co-payment. • Enter the co-payment amount in the “est. amount due” field (BOX 55).

  33. HMO Co-pay Claim Example “HMO COPAY ONLY” Provider Name Street City, State Zip Required if pay to is different than physical address. 111 06/05/07 05/30/07 Patient Name 01 05/30/07 F 01/01/1931 Covered days are entered in FL 39 80 5.00 0120 716.00 Room and Board/Semi 5 3580 00 0202 2311.00 ICU/Medical 2 4622 00 0202 2427.00 ICU/Medical 6 14562 00 0250 173 Pharmacy 6074 00 0251 67 Drugs/Generic 710 00 0270 8 Med-Sur Supplies 1089 00 0300 Laboratory or Lab 135 6509 00

  34. HMO Co-pay Claim Example Cop-pay/ Co-insurance/ Deductible 0001 1 1 37146 00 082807 1234567890 UNITEDHEALTHCARE COMMUNITY PLAN 37046 00 100 00 MEDICAID TPL Payment 010203 CONNIE CLIENT 123456789 ABC, INC. CONNIE CLIENT 123456789 431 9 1234567890 ALAN ATTENDING B3 332S00000X QUALIFIER TAXONOMY

  35. Medicare Replacement Plan Claim Forms

  36. Medicare Replacement Plan (MRP) Claim Tips • Write “Medicare Replacement Plan Only” on the claim. Attach the EOB. • In the “amount paid” field (BOX 54), enter the difference between the billed amount and the co-payment. • Enter the co-payment amount in the “est. amount due” field (Box 55).

  37. MRP Claim Example “Medicare Replacement Plan Only” Provider Name Street City, State Zip Required if pay to is different than physical address. 111 06/05/07 05/30/07 Patient Name 01 05/30/07 F 01/01/1931 80 5.00 0120 716.00 Room and Board/Semi 5 3580 00 0202 2311.00 ICU/Medical 2 4622 00 0202 2427.00 ICU/Medical 6 14562 00 0250 173 Pharmacy 6074 00 0251 67 Drugs/Generic 710 00 0270 8 Med-Sur Supplies 1089 00 0300 Laboratory or Lab 135 6509 00

  38. MRP Claim Example Copay Due Total billed amount 0001 1 1 1500 00 082807 1250 00 HUMANA 1234567890 250 00 MEDICAID CONNIE CLIENT 123456789 ABC, INC. 010203 CONNIE CLIENT 123456789 Billed – Copay = Paid amount value 431 9 1234567890 ALAN ATTENDING B3 332S00000X

  39. Medicare Primary Claim Forms(Crossovers)

  40. Medicare Primary Claims • When billing for clients covered by Medicare for which Medicare has paid something on the claim and the claim DID NOT automatically crossover from Medicare to Xerox, submit those claims via paper to Xerox with the Medicare Explanation of Benefits (EOMB) attached.

  41. Medicare Primary Claims • When primary Medicare claims are submitted on paper: • Fill out claim form exactly as the claim was submitted to Medicare (except for FQHCs.) • Claim must match Medicare EOMB. • Attach Medicare EOMB. • Medicaid does not consider Medicare to be TPL. If any of the TPL information is filled in for a Medicare claim, the claim will deny as “TPL indicated on claim” so be certain that you do not fill in any of the TPL information blocks.

  42. Medicare Primary Example 1 1 37146 00 0001 08282007 1234567890 MEDICARE MEDICAID 123456789A CONNIE CLIENT 123456789 CONNIE CLIENT 431 9 1234567890 ALAN ATTENDING B3 332S00000X TAXONOMY QUALIFIER

  43. Inpatient claims for Medicare Part B-only clients

  44. Inpatient Claims for Medicare Part B-only clients • Certain Medicaid/Medicare clients only have Medicare Part B coverage. • Medicare may cross over the Part B claim with type of bill 121. This claim does not have an accommodation revenue code on it. • The claim will deny and the provider will need to resubmit on paper and include the following four things on the claim:

  45. Inpatient claims for Medicare Part B-only clients • Use type of bill “121”. • Write “Medicare Part B only” on the claim form. • Indicate Medicare paid amount in previous payment box (form locator 54). • Attach a copy of the EOMB indicate Medicare paid amount in previous payment box (form locator 54).

  46. Inpatient claims for Medicare Part B-only clients “MEDICAID PART B ONLY” Provider Name Street City, State Zip Required if pay to is different than physical address. 121 05/30/2007 06/05/2007 Patient Name 01/01/1931 F 01 05/30/2007 80 5.00 716.00 Room and Board/Semi 0120 5 3580 00 2311.00 ICU/Medical 0202 2 4622 00 2427.00 ICU/Medical 0202 6 14562 00 173 Pharmacy 0250 6074 00 67 Drugs/Generic 0251 710 00 8 Med-Sur Supplies 0270 1089 00 Laboratory or Lab 0300 135 6509 00

  47. Inpatient claims for Medicare Part B-only clients 1 1 37146 00 0001 08282012 1234567890 TPL Payment amount MEDICARE 7922 00 29224 00 MEDICAID 123456789 CONNIE CLIENT 123456789 CONNIE CLIENT Attending physician is only required on inpatient services 431 9 1234567890 ALAN ATTENDING B3 332S00000X TAXONOMY QUALIFIER

  48. Medicaid Tertiary Claim Forms

  49. Medicaid Tertiary Claims • Submit a Medicaid tertiary claim as follows: • Medicare primary • TPL secondary • Medicaid tertiary • Fill out the information as you would for a Medicaid Secondary to a TPL claim and add a payer line for the Medicare information. • Attach TPL EOB. • Attach Medicare EOMB.

  50. Medicaid Tertiary Claim Example 1 1 37146 00 0001 08282007 1234567890 MEDICARE UNITEDHEALTHCARE COMMUNITY PLAN 36200 00 946 00 MEDICAID 123456789 CONNIE CLIENT 123456789 ABC, INC. CONNIE CLIENT 010203 123456789 CONNIE CLIENT 431 9 1234567890 ALAN ATTENDING B3 332S00000X TAXONOMY QUALIFIER

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