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2. This presentation is to facilitate training of the subject matter in Chapter V of the Virginia Medicaid Mental Retardation Community Services Manual.This training contains only highlights of this manual and is not meant to substitute for or take the place of the Mental Retardation Community S
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1. 1 Department of Medical Assistance Services Eligibility Verification Options and
CMS-1500 Billing Guidelines
For
Intellectual Disabilities (Mental Retardation) Waiver
2. 2
3. 3 Agenda
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 Important Contacts
MediCall
ARS- Web-Based Medicaid Eligibility
Provider Call Center
Provider Enrollment
Electronic Claims Coordinator
6. 6 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.
7. 7 MediCall/Automated Response System (ARS) Available 24 hours a day, 7 days a week
Medicaid Eligibility Verification
Claims Status
Patient Pay Information
Prior Authorization Information
Primary Payer Information
Medallion Participation
Managed Care Organization Assignment
8. 8 MediCall
800-884-9730
800-772-9996
804-965-9732
804-965-9733
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 ARS Registration Process https://uac.fhsc.com/uac/pages/unsecured/common/home.jsf
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’
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 ARS User’s Guide
http://www.dmas.virginia.gov/prclaims_billing.htm
Web Support Helpline-
800-241-8726
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 Patient Pay Information Effective March 1, 2009, 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 redetermination of eligibility
Change in the enrollee’s situation is reported
13. 13 Patient Pay Information It is anticipated that patient pay information for all long term care enrollees will be in the MMIS by December 2009.
MMIS 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.
15. 15 Provider Helpline Claims, covered services, billing inquiries:
800-552-8627
804-786-6273
8:30am – 4:30pm (Monday-Friday)
11:00am – 4:30pm (Wednesday)
16. 16 Duplicate Remittance Advice Effective July 1, 2009, DMAS will process and send requests for duplicate provider remittance advices via secure email.
A processing fee will be applied to all paper requests for duplicate remittance advices, effective July 1, 2009.
The requests should be directed to the Provider Helpline.
17. 17 Provider Enrollment New provider enrollment, Electronic Fund Transfer (EFT) or change of address:
First Health – PEU
P. O. Box 26803
Richmond, VA 23261
888-829-5373
804-270-5105
804-270-7027 - Fax
18. 18 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
19. 19 Excluded Individuals/Entities The U.S. Department of Health and Human Services Office of Inspector General (HHS-OIG) has the authority to exclude individuals and entities from participation in Medicare, Medicaid and all Federal healthcare programs
HHS-OIG excluded individuals or entities are prohibited from being reimbursed by DMAS for any items or services that they have furnished, ordered or prescribed
20. 20
This ban includes payment for administrative and management services not directly related to patient care
Providers are required to identify excluded individuals and entities
This ensures that DMAS is not paying any excluded individuals or entities for services rendered
Excluded Individuals/Entities
21. 21 No payment can be made for any items or services ordered or prescribed by an excluded physician when the furnishing party either knew or should have known of the exclusion
Medicaid providers may be subject overpayment liability and civil monetary penalties when they do not abide by this Federal Regulation
Excluded Individuals/Entities
22. 22 How to Ensure Program Integrity Screen all employees and contractors to determine whether they have been excluded
Search HS-OIG List of Excluded Individuals/Entities (LEIE) website monthly
Immediately report to DMAS any exclusion information discovered
There are steps that can be taken to ensure compliance with these Federal regulations and Virginia Medicaid policy
First, screen all new and existing employees and contractors to ascertain whether they have been excluded
Next-Once this information has been determined it is advised that you search this database monthly to validate continued eligibility.
And lastly If any exclusion information is discovered this should immediately be reported to DMAS.There are steps that can be taken to ensure compliance with these Federal regulations and Virginia Medicaid policy
First, screen all new and existing employees and contractors to ascertain whether they have been excluded
Next-Once this information has been determined it is advised that you search this database monthly to validate continued eligibility.
And lastly If any exclusion information is discovered this should immediately be reported to DMAS.
23. 23 Reporting Discoveries are to be sent in writing to the address below and should include the:
individual or business name
provider identification number
State action, if any, has been taken
DMAS
Attn: Program Integrity/Exclusions
600 E. Broad St. Ste 1300
Richmond, VA 23219 The information pertaining to these discoveries should be sent in writing and should include the indiv. or bus. Name, and the provider’s identification number (if applicable) also with what action , if any has been taken to date. The information should be sent to the address provided. The information pertaining to these discoveries should be sent in writing and should include the indiv. or bus. Name, and the provider’s identification number (if applicable) also with what action , if any has been taken to date. The information should be sent to the address provided.
24. 24 Accessing the LEIE HHS-OIG maintains the LEIE
Provides information about parties excluded from participation in Medicare, Medicaid and all other Federal healthcare programs
The online database is located at
http://www.oig.hhs.gov/fraud/exclusions.asp The Dept of Health and Human Services’ Office of the Inspector General maintais the LEIE which is the database which provides the information on excluded parties. We have provided the link directly into this site. The Dept of Health and Human Services’ Office of the Inspector General maintais the LEIE which is the database which provides the information on excluded parties. We have provided the link directly into this site.
25. 25 Billing on the CMS-1500
26. 26 MAIL CMS-1500 FORMS TO: DEPARTMENT OF MEDICAL ASSISTANCE
SERVICES
PRACTITIONER
P. O. Box 27444
Richmond, Virginia 23261
27. 27 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
28. 28 TIMELY FILING Submit claims with documentation attached (to the back of claim) explaining the reason for delayed submission
29. 29
34. d. IS THERE ANOTHER HEALTH BENEFIT PLAN?
36. 36 ICD-9 Diagnosis Codes All claims submitted to DMAS will require a current ICD-9 diagnosis code for payment processing.
Some 3-digit diagnosis codes are valid
317 (mild mental retardation) is a valid 3-digit DX code
319 (mental retardation) is a valid 3-digit DX code
37. 37 ICD-9 Diagnosis Codes If the current year ICD-9 book indicates the diagnosis code requires 4-5 digits, the code listed on the claim submission must include 4-5 digits
318 (other specified mental retardation) requires an additional 4th digit to be a valid diagnosis code: 3180, 3181 or 3182
Claims submitted without a valid diagnosis code will be denied
39. 39 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
40. 40 Block 24A – Shaded Red Area:TPL Information Billing Scenarios No other insurance
Check ‘NO’ in Locator 11d or leave blank
Primary Carrier pays covered service
Provider receives Explanation of Benefits (EOB)
Check ‘YES’ in Locator 11d
Document primary payment information in the shaded red area of 24A on claim form
DMAS does not require an attached copy of the EOB when provider receives payment from primary carrier
42. 42 TPL Billing Scenarios Primary carrier does not pay
Payment applied to deductible/claim denied
Provider receives EOB
Check ‘YES’ in Locator 11d
Attach copy of EOB showing non-payment to the back of the DMAS claim form
Do not document any information in the shaded red area of 24A
43. 43 TPL Billing Scenarios Primary carrier does not pay
Service not covered
Check ‘YES’ in Locator 11d
Attach EOB documenting that services are not covered or, attach letter verifying the service is not covered
Do not document any information in the shaded red area of 24A
44. 44 TPL Billing Scenarios Primary carrier does not pay
Carrier will not enroll provider
Check ‘YES’ in Locator 11d
Attach letter documenting the primary carrier will not enroll the provider
Do not document any information in the shaded red area of 24A
45. 45 TPL Billing Scenarios Primary carrier does not pay
Policy is no longer active/coverage terminated
Check ‘YES’ in Locator 11d
Attach EOB verifying that the policy is not active or, attach letter verifying the policy is not active
Advise patient/guardian to contact Local DSS with policy termination documentation/information
47. 47 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
53. 53 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).
OR-
Qualifier ‘ZZ’ is to be used to indicate the taxonomy code - only when the National Provider Identifier is used and only if necessary to adjudicate the claim.
54. 54 DMAS Service Types May Require A Taxonomy Code on Claims
55. 55 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
60. 60 Block 29: Amount Paid Patient pay amount is taken from services billed in Block 24A – line 1
If multiple services are provided on the same date of service, another form must be completed. Only one line per claim form can be submitted if patient pay is to be considered in the processing of this service.
63. 63 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
64. 64 Block 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
66. 66 Block 33 Billing Provider Info & PH #- Enter the information to identify the provider that is requesting to be paid
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
Phone number is to be entered in the area to the right of the field title, no hyphen or space used
67. 67 Billing Provider Info & PH #-Block-33a-b Enter the 10 digit NPI number of the service location in 33a.
OR
Enter ‘1D’ qualifier with the API in 33b
70. THANK YOU Department of Medical Assistance Services
www.dmas.virginia.gov