Medicaid Eligibility Verification Options & CMS-1500 (08-05) Billing Guidelines

1. Medicaid Eligibility Verification Options & CMS-1500 (08-05) Billing Guidelines October – December 2008 www.dmas.virginia.gov Department of Medical Assistance Services

2. ************ This presentation is to facilitate training of the subject matter in Chapter V of the Virginia Medicaid Psychiatric Services Manual. This training contains only highlights of this manual and is not meant to substitute for or take the place of the Psychiatric Services Manual.

3. Objectives Upon completion of this training you should be able to : • Correctly utilize Medicaid options to verify eligibility • Understand timely filing guidelines • Properly submit Medicaid claims, adjustments and voids

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. COMMONWEALTH OF VIRGINIA DEPARTMENT OF MEDICAL ASSISTANCE SERVICES 002286 999999999999 VIRGINIA J. RECIPIENT DOB: 05/09/1964F CARD# 00001

6. Important Contacts • MediCall • ARS- Web-Based Medicaid Eligibility • Provider Call Center • Provider Enrollment

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

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

10. UAC Registration Process Go to https://virginia.fhsc.com • Select the ARS tab on FHSC ARS Home Page • Choose “User Administration” • 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’

11. ARS –Users • Web Support Helpline- • ARS Manual (User Guide) 800-241-8726 http://virginia.fhsc.com

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. Provider Enrollment New provider numbers or change of address: First Health – PEU P. O. Box 26803 Richmond, VA 23261 888-829-5373 804-270-5105 804-270-7027 - Fax

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. Billing on the CMS-1500

16. MAIL CMS-1500 FORMS TO: DEPARTMENT OF MEDICAL ASSISTANCE SERVICES PRACTITIONER P. O. Box 27444 Richmond, Virginia 23261

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

18. TIMELY FILING • Submit claims with documentation attached (to the back of claim) explaining the reason for delayed submission

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. CMS-1500CLAIM FORM: Use ONLY the ORIGINAL RED & WHITE CMS-1500 (08-05) Invoice Photocopies are not Acceptable Computer generated claims must match NUCC uniform standards

21. Block 1 TRICARE MEDICAID 1.MEDICARE CHAMPUS (Medicare#) (Medicaid#) (Sponsor'sSSN) 21

22. Block 1a: Recipient ID Number 1a.INSURED'SI.D.NUMBER(FORPROGRAMINITEM1) 123456789014 (Be sure to include all 12 digits) 22

23. Block 2: Patient's Name 2.PATIENT'SNAME(Lastname,FirstName,MiddleInitial) Smith, Sam 23

24. Block 10: Accident-Related 10.ISPATIENT'SCONDITIONRELATEDTO: a.EMPLOYMENT?(CURRENTORPREVIOUS) YES NO PLACE(State) b.AUTOACCIDENT? YES NO c.OTHERACCIDENT? NO YES You MUST check YES or NO for a, b & c 24

25. Block 11d - Is There Another Health Benefit Plan? d. IS THERE ANOTHER HEALTH BENEFIT PLAN? DMAS does not require providers to complete Blocks 9 a-d If yes, return to and complete item 9 a-d. NO YES Providers must indicate YES for all patients who have any other insurance coverage. Regardless of whether payment is received from the primary carrier for service provided. 25

26. Block 21: Diagnosis Codes 21.DIAGNOSISORNATUREOFILLNESSORINJURY 3441 1. 3. 2963 2. 4. May enter up to 4 codes Omit decimals 26

27. Block 23: Prior Authorization Number - Conditional 23.PRIORAUTHORIZATIONNUMBER 27

28. Blocks 24A thru 24J • These blocks have been divided into open areas and a shaded red line area • The shaded area is ONLY for supplemental information • Instructions will be given on when the use of the shaded area is required for claims processing

29. TPL Information Block 24A • Qualifier ‘TPL’ will be used followed by dollars/cents amount whenever an actual payment is made by a third party carrier • No spaces between the qualifier and dollars and no $ symbol used • Decimal between dollars and cents is required to read paid amount correctly • Must be left justified

30. TPL Information Block 24A • DMAS will set COB code based on the information given in locator 11d: • No, or nothing indicated-no other carrier on file for the recipient, Medicaid will pay primary • No, or nothing indicated and system has other insurance coverage on file - claim will deny bill other insurance • No, or nothing indicated and ‘TPL’ qualifier with payment listed in 24a red shaded area – Medicaid will coordinate benefits with other carrier

31. TPL Information Block 24A • DMAS will set COB code based on the information given in locator 11d: • Yes, and ‘TPL’ qualifier with payment in 24a red shaded area primary carrier billed and paid, Medicaid will coordinate benefits with the primary carrier • Yes, but nothing in 24a red shaded area and other carrier billed and made no payment. Providers must attach current documentation of non-payment from the other carrier. Copy of explanation of benefits denial or information documented on agency/group letterhead is acceptable documentation.

32. Block 24A: Dates of Service 24.A. DATE(S)OFSERVICE From To MMDDYY MMDDYY TPL27.08 08 08 09 01 09 01 1 09 01 08 09 16 08 2 BothFROMand TOdates must be completed Dates must be within same calendar month

33. Block 24B: Place of Service Note: Type of Service is no longer required B. Place of Service 11-Office location 21 – Inpatient 11 Medicaid accepts the same 2 digit CMS Place of Service codes as Medicare. 33

34. Emergency Indicator-24C • This locator will be used to indicate whether the procedure was an emergency • DMAS will only accept a ‘Y’ for yes in this locator • If there was no emergency leave blank

35. Block 24C: EMG C. EMG 35

36. Block 24D: Procedure Codes D. PROCEDURES,SERVICES,ORSUPPLIES (ExplainUnusualCircumstances) CPT/HCPCS MODIFIER T1016 90806 36

37. Block 24E: Diagnosis Code 21.DIAGNOSISORNATUREOFILLNESSORINJURY 34431 1. 3. 2963 2. 4. E. DIAGNOSIS POINTER 1 Enter the identifier of the ICD-9-CM diagnosis code listed in Locator 21. To identify more than one diagnosis code, separate the indicators with a comma. 1,2 37

38. Block 24 F: Charges F. $CHARGES Enter the usual and customary charges 38

39. Block 24G: Days or Units G. DAYS OR Enter the number of times or hours the procedure, service, or item was provided during the service period. UNITS 1 31 39

40. Block 24H: EPSDT/Family Plan H. EPSDT Family Plan 1 1-EPSDT 40

41. ID.QUAL Block-24I • Qualifier ‘1D’ is to be used in the red shaded area for claims being submitted using the Atypical Provider Identifier (API). • DMAS requires Treatment Foster Care agencies to bill with an API. • Qualifier ‘ZZ’ is to be used to indicate the taxonomy code-only when the NPI is used and only if necessary to adjudicate the claim.

42. Rendering Provider ID # Block-24J • The shaded red area will contain the API OR • The open area will contain the NPI of the provider rendering the service.

43. Block 24I: ID. Qualifier & 24J: Rendering Provider ID # J. RENDERING PROVIDER ID. # I. ID. QUAL 1D 0012345671 NPI Atypical Provider Identifier 43

44. Block 24I: ID. Qualifier & 24J: Rendering Provider ID # I. ID. QUAL J. RENDERING PROVIDER ID. # ZZ Taxonomy (if needed) 1234567890 NPI National Provider Identifier 44

45. Block 26: Patient’s Account Number 26.PATIENTACCOUNTNUMBER 12345678918765 Can not exceed 14 alphanumeric digits 45

46. Block 28: Total Charges 28.TOTALCHARGE $ 46

47. Block 31: Signature & Date 31.SIGNATUREOFPHYSICIANORSUPPLIER INCLUDINGDEGREESORCREDENTIALS (Icertifythatthestatementsonthereverse applytothisbillandaremadeapartthereof.) SIGNED DATE If there is a signature waiver on file, you may stamp, print, or computer-generate the signature. 47

48. Block 32Service Facility Location Information • Enter information for the location where services were rendered • First line-Name • Second line-Address • Third line-City, State, 9 digit zip code • No punctuation in the address • Space between city and state • Include hyphen for the 9 digit zip code

49. Block 32Block 32, cont’d.Service Facility Location Information • Providers with multiple offices/locations - the zip code must reflect the office/ location where services were rendered • Enter the 10 digit NPI number of the service location in 32a. OR • Enter ‘1D’ qualifier with the API in 32b

50. Block 32: Service Facility Location Information 32. SERVICE FACILITY LOCATION INFORMATION a. NPI b. 50