Virginia Medicaid Eligibility Verification Options CMS-1450 Billing Guidelines

1. Virginia Medicaid Eligibility Verification Options&CMS-1450 Billing Guidelines Nursing Facility Providers October – November 2008 www.dmas.virginia.gov

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

3. 3 Objectives Upon completion of this presentation participants will understand: How to utilize Medicaid Eligibility Verification Options Timely filing guidelines How to properly submit Medicaid claims, adjustments and voids

4. 4 As a Participating Provider You Must- Determine the patient’s 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.

5. 5 The most visible change will be the implementation of the new plastic Medicaid card. Here is an example of the format. The most visible change will be the implementation of the new plastic Medicaid card. Here is an example of the format.

6. 6 Medicaid Verification Options MediCall ARS- Web-Based Medicaid Eligibility

7. 7 MediCall 800-884-9730 800-772-9996 804-965-9732 804-965-9733

8. 8 MediCall Available 24 hours a day, 7 days a week Medicaid Eligibility Verification Claims Status Prior Authorization Information Primary Payer Information Medallion Participation Managed Care Organization Assignment

9. 9 Automated Response System ARS Web-based eligibility verification option Free of Charge. Information received in “real time”. Secure Fully HIPAA compliant

10. 10 UAC Registration Process https://uac.fhsc.com/uac/pages/unsecured/common/home.jsf Follow the on-screen instructions for help with registration, this is a 3-step process to request, register and activate a new account Answer the initial ‘Who are you?’ question by selecting ‘I do not have a User ID and need to be a Delegated Administrator’ Beginning on February 19, 2007, you may register for access to the new UAC by navigating to virginia.fhsc.com and selecting the ARS tab and then selecting the “User Administration” option. The registrant will be guided through a 3-step process to request, register, and activate a new account. The process can be started by answering the initial ‘Who are you?’ question by selecting ‘I do not have a User ID and need to be a Delegated Administrator’. The registration process is designed to include the provider in the decision-making process. Beginning on February 19, 2007, you may register for access to the new UAC by navigating to virginia.fhsc.com and selecting the ARS tab and then selecting the “User Administration” option. The registrant will be guided through a 3-step process to request, register, and activate a new account. The process can be started by answering the initial ‘Who are you?’ question by selecting ‘I do not have a User ID and need to be a Delegated Administrator’. The registration process is designed to include the provider in the decision-making process.

11. 11 ARS –Users Web Support Helpline 800-241-8726 Assistance during the registration process General information You are required to enroll and begin using the new Web Site by May 23, 2007. You are required to enroll and begin using the new Web Site by May 23, 2007.

12. 12 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)

13. 13 Provider Enrollment New provider enrollment, change of address, or Electronic Fund Transfer (EFT) sign-up or changes: First Health – PEU P. O. Box 26803 Richmond, VA 23261 888-829-5373 804-270-5105 804-270-7027 - Fax

14. 14 Electronic Billing Electronic Claims Coordinator Mailing Address First Health Services CorporationVirginia OperationsElectronic Claims Coordinator4300 Cox RoadGlen Allen, VA 23060 E-mail: edivmap@fhsc.com Phone: (800) 924-6741 Fax: (804) 273-6797

15. 15 Billing on the CMS-1450

16. 16 MAIL CMS-1450 FORMS TO: Virginia Medical Assistance Program P. O. Box 27443 Richmond, Virginia 23261

17. 17 TIMELY FILING ALL CLAIMS MUST BE SUBMITTED AND PROCESSED WITHIN ONE YEAR FROM THE DATE OF SERVICE EXCEPTIONS Retroactive Eligibility Delayed Eligibility Denied Claims NO EXCEPTIONS Other Primary Insurance Accidents

18. 18 TIMELY FILING Submit claims with documentation attached to the back of the form, explaining the reason for delayed submission You should have the word “Attachment” in the Remarks field, Locator 80

19. 19 Printing Must be RED OCR dropout ink or the exact match Computer generated form must match/line up with National Uniform Claim Committee standard Print 100% of actual size, set page scaling to “none” Set page scaling to ‘none’ Margins must be exact DMAS will not reprocess claims denied for scanning issues as a result of failure to follow the above instructions

20. 20

21. 21 Locator 1: Provider’s Name, Address and Phone Number Enter the provider’s name, complete mailing address and telephone number of the provider that is submitting the bill and which payment is to be sent. NOTE: DMAS will need to have the 9 digit zip code on line four, left justified for adjudicating the claim.

23. 23 Locators 3a and 3b 3a Patient Control Number - Enter the patient’s unique financial account number which does not exceed 20 alphanumeric characters. 3b Medical/Health Record - Enter the number assigned to the patient’s medical/health record by the provider. This number cannot exceed 24 alphanumeric characters.

24. Locators 3a- Patient Control Number & 3b- Medical/Health Record Number

25. 25 Locator 4 :Type of Bill Enter the code as appropriate. The Type of Bill field has been increased from three digits to four digits by adding a leading zero. Claims submitted without the required four digit bill type will be denied.

26. 26 Locator 4: Type of Bill 0211 Original Inpatient Nursing Home Invoice 0212 Interim Inpatient Nursing Home Invoice 0213 Continuing Inpatient Nursing Home Invoice 0214 Last Inpatient Nursing Home Invoice 0217 Adjustment Inpatient Nursing Home Invoice 0218 Void Inpatient Nursing Home Invoice

27. 27 Locator 4: Type of Bill 0621 Original Intermediate Care Inpatient Invoice 0622 Interim Intermediate Care Inpatient Invoice 0623 Continuing Intermediate Care Inpatient Invoice 0624 Last Inpatient Intermediate Care Invoice 0627 Adjustment Intermediate Care Invoice 0628 Void Intermediate Care Invoice

28. 28 Bill Type Notes Bill type 0211 or 621- This bill type should be used whenever the admission and the discharge date are within the same month. Bill type 0212 or 622 – This bill type should be used when the admission date equals the (from date) of service and the resident is still a resident as of the thru date of service.

29. Bill Type Notes Bill type 0213 or 623 – This bill type should be used whenever the admission occurred in prior months (or billing cycle) and the discharge has not occurred. This bill type has no limit on the number of occurrences. Bill type 0214 or 624 – This bill type should be used when the resident has been discharged from the facility. The discharge date is the date of the thru date of service. Should a resident be discharged and re-admitted within the same month the re-admission would then start with the bill types of 0211 or 0212, or 0611 or 0621. Whenever interim bill types are utilized the admission date remains the same.

31. Locator 6: Statement Covers Period

32. Locator 8: Patient Name/Identifier

33. Locator 10: Patient Birthdate

34. Locator 11: Sex

35. Locator 12: Admission/Start of Care The start date for this episode of care. For inpatient services this is the date of admission. For all other services, the date the episode of care began: Nursing Facility - Admission or re-admission date

36. Locator 12: Admission/Start of Care

37. Locator 13: Admission Hour

38. Locator 14: Priority Type of Visit Appropriate PRIORITY TYPE codes accepted by DMAS are:

39. Locator 14: Priority (Type) of Visit

40. Locator 15: Source of Referral for Admission or Visit Appropriate codes accepted by DMAS are:

41. Locator 15: Source of Referral for Admission or Visit  (Examples for Nursing Facility)

42. Locator 15: Source of Referral for Admission Visit

43. Locator 17:Patient Discharge Status Appropriate codes accepted by DMAS in claims processing:

44. Locator 17:Patient Discharge Status Appropriate codes accepted by DMAS in claims processing:

45. Locator 17: Patient Discharge Status Appropriate codes accepted by DMAS in claims processing:

46. Locator 17: Patient Discharge Status

47. Locators 18-28: Condition Codes These codes are used by DMAS in the adjudication of claims:

48. Locators 18-28: Condition Codes (Required if Applicable)

49. Locator 30:Crossover Part A Indicator (Required if Applicable)

50. Locators 31-34:Occurrence Code and Dates (Required if Applicable)

51. Locators 35-36:Occurrence Code and Span Dates (Required if Applicable)

52. Note: DMAS will be capturing the number of covered or non-covered day (s) or units for outpatient services with these required value codes: 80 Enter the number of covered days for inpatient nursing facility or the number of days for re-occurring outpatient claims. 81 Enter the number of non-covered days for nursing facility

53. Locators 39-41: Value Codes and Amount Enter the appropriate code (s) to relate amounts or values to identify data elements necessary to process this claim. One of the following codes must be used to indicate coordination of third party insurance carrier benefits: 82 No Other Coverage 83 Billed and Paid (enter amount paid by primary carrier) 85 Billed Not Covered/No Payment

54. Locators 39-41: Value Codes and Amount For Medicare Crossover Claims, the following codes must be used with one of the third party insurance carrier codes: A1 Deductible from Part A A2 Coinsurance from Part A Other codes may be used if applicable.

55. Locators 39-41: Value Codes and Amount

56. 56 Locator 42: Revenue Code Enter the appropriate revenue code (s) for the service provided. Note: Multiple services for the same item, providers should aggregate the service under the assigned revenue code and then total the number of units that represent those services DMAS has a limit of five pages for one claim The Total Charge revenue code (0001) should be the last line of the last page of the claim

57. Locator 42: Revenue Code

58. Locator 43: Revenue Description

59. Locator 44: HCPCS/Rates/HIPPS Rates Codes

60. Locator 45: Service Date (Required if Applicable)

61. Locator 46: Service Units

62. Locator 47: Total Charges Whenever revenue code 0658 is billed the total charges must reflect the number of covered days times the nursing facility rate.Whenever revenue code 0658 is billed the total charges must reflect the number of covered days times the nursing facility rate.

63. Locator 48: Non-Covered Charges (Required if Applicable)

64. 64 Locator 50: Payer Name A-C Enter the payer from which the provider may expect some payment for the bill. When Medicaid is the only payer, enter “Medicaid” on line A. If Medicaid is the secondary or tertiary payer, enter on lines B or C.

65. Locator 50: Payer Name A-C

66. Locator 54:Prior Payments (Required if Applicable)

67. 67 Locator 56: National Provider Identification (NPI) Providers must share their NPI with the DMAS Provider Enrollment Unit (PEU). Once your NPI is on file with the PEU, providers must list their NPI in this field.

68. Locator 56: NPI

69. Locator 58: Insured’s Name

70. Locator 59: Patient’s Relationship to Insured Note: appropriate codes accepted by DMAS are:

71. Locator 59: Patient’s Relationship to Insured

72. Locator 60: Insured’s Unique Identification

73. 73 Locator 64:Document Control Number (DCN) This locator is to be used to list the original Internal Control Number (ICN) for APPROVED claims that are being submitted to adjust or void the original claim.

74. Locator 64:Document Control Number (Required if Applicable)

75. Locator 66: Diagnosis and Procedure Code Qualifier (ICD Version Indicator)

76. Locator 67: Principal Diagnosis Code

77. Locator 69: Admitting Diagnosis

78. Locator 74: Principal Procedure Code and Date (Required if Applicable)

79. Change - Locator 74a-e: Other Procedure Codes and Date (Required if Applicable)

80. Locator 76: Attending Provider

81. Locator 80: Remarks Field

82. Locator 81: Code-Code Field DMAS previously assigned different provider numbers for each type of service performed. Medicaid payment was then issued based on the type of service billed. DMAS will be using this field to capture a taxonomy code for claims that are submitted for one NPI with multiple business types

83. 83 Locator 81: Code-Code Field The taxonomy code will be required for providers who do not have a separate NPI for each different service billed to VA Medicaid. Code B3 is to be entered in the first small space and the provider taxonomy code is to be entered in the second large space. The third space should be blank.

84. Locator 81: Code-Code Field

85. DMAS Service Types That MAY Require A Taxonomy Code on Claims

86. 86 REMITTANCE VOUCHERSections of the Voucher APPROVED for payment. PENDING for review of claims. DENIED no payment allowed. DEBIT (+) Adjusted claims creating a positive balance. CREDIT (-) Adjusted/Voided claims creating a negative balance.

87. 87 REMITTANCE VOUCHERSections of the Voucher FINANCIAL TRANSACTION EOB DESCRIPTION ADJUSTMENT DESCRIPTION/REMARKS- STATUS DESCRIPTION REMITTANCE SUMMARY- PROGRAM TOTALS

88. THANK YOU www.dmas.virginia.gov