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CMS-1500 (08-05)Billing Guidelines

Department of Medical Assistance Services

February 2010www.dmas.virginia.gov

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This presentation is to facilitate training of the This presentation is to facilitate training of the subject matter in Chapter V of the Virginia Medicaid subject matter in Chapter V of the Virginia Medicaid

Physicians Manual.Physicians Manual.

This training contains only highlights of this manual This training contains only highlights of this manual and is not meant to substitute for or take the place of and is not meant to substitute for or take the place of

the the PhysiciansManual. PhysiciansManual.

Providers are responsible for reviewing and adhering Providers are responsible for reviewing and adhering to the to the Physicians ManualPhysicians Manual requirements. requirements.

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Objectives

To familiarize the providers with the billing guidelines of the CMS-1500 claim form.

To give the providers clear instructions on the requirements of DMAS for the completion of the CMS-1500 claim form.

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Participating Providers 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.

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DOB: 05/09/1994 F CARD# 00001

DEPARTMENT OF MEDICAL ASSISTANCE SERVICES

COMMONWEALTH OF VIRGINIA

V I RG I N I A J. R E C I P I E N T

9 9 9 9 9 9 9 9 9 9 9 9

002286

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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

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MediCall

800-884-9730

800-772-9996

804-965-9732

804-965-9733

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Automated Response System (ARS)

Web-based eligibility verification optionFree of Charge.Information received in “real time”.SecureFully HIPAA compliant

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ARS Registration Process

https://uac.fhsc.com/uac/pages/unsecured/common/home.jsf Select the ARS tab on FHSC ARS Home PageChoose “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’

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ARS – Users

ARS User’s Guide

http://www.dmas.virginia.gov/prclaims_billing.htm

Web Support Helpline-

800-241-8726

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Important Contacts

Provider Call Center Provider Enrollment Electronic Claims Coordinator

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Provider Helpline

Claims, covered services, billing inquiries:

800-552-8627

804-786-62738:30am – 4:30pm (Monday-Friday)

11:00am – 4:30pm (Wednesday)

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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

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Electronic Billing

Electronic Claims Coordinator

Mailing Address

First Health Services CorporationVirginia Operations

Electronic Claims Coordinator4300 Cox Road

Glen Allen, VA 23060

E-mail: edivmap@fhsc.com

Phone: (800) 924-6741

Fax: (804) 273-6797

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Claim Attachment FormDMAS-3

The DMAS-3 form is to be used by Electronic Data Interchange (EDI) billers only to submit a non-electronic attachment to an electronic claim. See Chap. V Exhibits pg. 5

Attachment Control Number (ACN) should be indicated on the electronic claim submitted.

The ACN number is the combined information from: Patient Account Number Date of Service Sequence Number

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Claim Attachment FormDMAS 3 – Sample ACN#

Patient Account Number 123456789

Date of Service 09/11/2009

Sequence Number 12345

ACN number listed on form will be- 1234567890911200912345

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Billing on the CMS-1500

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MAIL CMS-1500 FORMS TO:

DEPARTMENT OF MEDICAL ASSISTANCE SERVICES

PRACTITIONERP. O. Box 27444

Richmond, Virginia 23261

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TIMELY FILING

ALL CLAIMS MUST BE SUBMITTED AND PROCESSED WITHIN ONE YEAR FROM THE DATE OF SERVICE

EXCEPTIONSRetroactive/Delayed EligibilityDenied Claims

NO EXCEPTIONSAccident CasesOther Primary Insurance

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TIMELY FILING

Submit claims with documentation attached to the back of the claim form, explaining the reason for delayed submission

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Block 1

The locator will now be used to indicate if the claim is Medicaid, TDO, or ECO.

Enter an ‘X’ in the MEDICAID box for the Medicaid Program

Enter an ‘X’ in the OTHER box for Temporary Detention Order (TDO) or Emergency Custody Order (ECO)

MEDICAID

(Medicaid #)

Block 1

CHAMPUS

(Sponsor's SSN)

1. MEDICARE

(Medicare #)

MEDICAID CLAIM

2. PATIENT'S NAME (Last Name, First Name, Middle Initial)

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TRICARE

GROUP

(SSN or ID)

Block 1

BKL LUNG(SSN)

CHAMPVA

(Member ID#)

TDO or ECO CLAIM14

FECAHEALTH PLAN

OTHER

(ID)

1a. INSURED'S I.D. NUMBER (FOR PROGRAM IN ITEM 1)

Block 1a: Recipient ID Number

(Be sure to include all 12 digits)

123456789014

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Block 2: Patient's Name

2. PATIENT'S NAME (Last name, First Name, Middle Initial)

Smith, Sam5. PATIENT'S ADDRESS (No., Street)

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Is Patient’s Condition Related To? Block-10

If the condition is related to an auto accident, and you have this information, place the postal code (i.e. VA, TN, WV) of the state in which the accident occurred.

Block 10: Accident-Related

10. IS PATIENT'S CONDITION RELATED TO:

a. EMPLOYMENT? (CURRENT OR PREVIOUS)

b. AUTO ACCIDENT?

c. OTHER ACCIDENT?

YES NO

PLACE (State)

YES

YES

NO

NO

You MUST check YES or NO for a, b & c18

WV

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Insurance Plan Name or Program NameBlock-11c

Providers that are billing for non-Medicaid Managed Care Organizations (MCO) co-pays please insert ‘HMO COPAY’

The amount billed to Medicaid in 24F (Charges) must represent only the enrollees co-payment amount for the HMO, and the Explanation of Benefits (EOB) must be attached.

Use the CPT or HCPCS procedure code that was billed as the primary procedure to the HMO.

This does not apply to enrollees in a Medicaid HMO, e.g., Medallion II.

Block 11c - Insurance Plan Name or Program Name

c. INSURANCE PLAN NAME OR PROGRAM NAME

HMO COPAY

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CHANGE – Is There Another Health Benefit Plan?

Block-11d

Providers should always check ‘YES’ if there is verification of Third Party Liability

If there is no other coverage check no or leave blank

Block 11d - Is There Another Health Benefit Plan?

d. IS THERE ANOTHER HEALTH BENEFIT PLAN?

YES NO If yes, return to and complete item 9 a-d.

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DMAS does not require items 9 a-d to be completed.

Blocks 17 and 17b- Conditional

17. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE

17- Name of the Recipient’s PCP17b- PCP’s NPI

17a.

17b. NPI 1234567890

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Block 19- Conditional Use

19. RESERVED FOR LOCAL USE

Clinical Laboratory Improvement Amendment (CLIA) Number of the physician office laboratory (POL)

performing the service.

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21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY

1.

2.

3.

4.

3441

Block 21: Diagnosis Codes

May enter up to 4 codes

Omit decimals

2963

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Prior Authorization NumberBlock-23

If service requires prior authorization, enter the eleven digit PA number assigned by KePRO

Enter the number pre-assigned to the TDO or ECO form that is obtained from the magistrate authorizing the TDO/ECO.

23. PRIOR AUTHORIZATION NUMBER

Block 23: Prior Authorization Number - Conditional

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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

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TPL Information Block 24A-shaded red area

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

24. A.DATE(S) OF SERVICE

From ToMM DD YY MM DD YY

Block 24A: Dates of Service

12 01 09 12 01 09

12 01 09 12 31 09

1

2

TPL27.08amount paid by primary carrier $27.08

68TPL Information

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TPL Billing Scenarios

No other insurance Check ‘NO’ in Locator 11d or leave blank Do not document any information in the

shaded red area of 24A 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

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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

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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

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TPL Billing Scenarios

Primary carrier does not pay Provider not enrolled with carrier Check ‘YES’ in Locator 11d Attach letter documenting the provider is not

enrolled with the primary carrier Do not document any information in the shaded

red area of 24A

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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

Do not document any information in the shaded red area of 24A

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NDC Information Block-24A

Qualifier ‘N4’ is used followed by the National Drug Code (NDC) whenever a HCPCS J-code is submitted in 24D.

No spaces between the qualifier and the NDC number

Must be left justified

24. A.DATE(S) OF SERVICE

From ToMM DD YY MM DD YY

Block 24A: Dates of Service

12 01 09 12 01 09

12 01 09 12 16 09

1

2

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N400026064871

NDC Information

24. A.DATE(S) OF SERVICE

From ToMM DD YY MM DD YY

Block 24A: Dates of Service

12 01 09 12 01 09

12 01 09 12 31 09

1

2

TPL and NDC information31

TPL27.08N400026064871

If both NDC andTPL apply to a

single procedureboth must be placed on the

same line, it doesnot matter which

comes first

24. A.DATE(S) OF SERVICE

From ToMM DD YY MM DD YY

Block 24A: Dates of Service

12 01 09 12 01 09

12 01 09 12 16 09

1

2

Both FROM and TO datesmust be completed

Dates must be within same calendar month36

B.Place

ofService

Block 24B: Place of Service

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11-Office location

21- Inpatient

Medicaid accepts the same 2 digit CMS Place of Service codes as

Medicare.37

Note: Type of Serviceis no longer required

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Emergency IndicatorBlock 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

C.

EMG

Block 24C: EMG

Medicaid will accept a ‘Y’ in this Locator to indicate that the procedure was an

emergency 39

Y

D.

Block 24D: Procedure Codes

PROCEDURES, SERVICES, OR SUPPLIES(Explain Unusual Circumstances)

CPT/HCPCS MODIFIER

2299254

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J Code Mandate: Block 24D When billing a J Code the red shaded area

must have the unit of measurement (UOM) qualifier.

Valid qualifiers:F2: international unitML: milliliterGR: gramUN: unit

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J-Code Mandate: Block 24D

Enter the actual metric decimal quantity (units) administered to the patient

If reporting a fraction of a unit, use the decimal point

The maximum number of bytes allowed for the quantity is 13, including the decimal point.

D.

Block 24D: Procedure Codes

PROCEDURES, SERVICES, OR SUPPLIES(Explain Unusual Circumstances)

CPT/HCPCS MODIFIER

J0881

GR0.0004

J0881 constitutes 1mcg of a drug, the quantity given was 400 mcg which converts to 0.0004 grams

21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY

1.

2.

3.

4.

34431

Block 24E: Diagnosis Code

E.

DIAGNOSISPOINTER

1

2963

1,2

Enter the entry 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.

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F.

$ CHARGES

Block 24 F: Charges

Enter the usualand customary charges

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G.DAYS

ORUNITS

Block 24G: Days or Units

1

Enter the number of times or hours the procedure, service, or item was provided during the service period.

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H.

Block 24H: EPSDT/Family Plan

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1

EPSDTFamilyPlan

1-EPSDT2-Family Planning Service

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CHANGE – ID.QUALBlock-24I

Qualifier ‘1D’ is to be used in the red shaded area for claims being submitted using the Atypical Provider Identifier (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.

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CHANGE – Rendering Provider ID #

Block-24J

The shaded red area will contain the current Atypical Provider Identifier (API) or;

The open area will contain the NPI of the provider rendering the service

Block 24I: ID. Qual.

& 24J: Rendering Provider ID #

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I.ID.

QUAL

J.RENDERING

PROVIDER ID. #

NPI

ID 9876543210

Block 24I: ID. Qual.

& 24J: Rendering Provider ID #

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I.ID.

QUAL

J.RENDERING

PROVIDER ID. #

NPI

ZZ Taxonomy (if needed)

12345647890

26. PATIENT ACCOUNT NUMBER

Block 26: Patient’s Account Number

(Optional)

12345678918765

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Can not exceed 17 alphanumeric digits

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Total ChargeBlock 28

DMAS now requires this locator to be completed

Enter the total charges for the services in 24F lines 1-6.

28. TOTAL CHARGE

Block 28: Total Charges

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$

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Amount Paid(Personal/Waiver Services ONLY)

Block 29 Patient pay amount is taken from

services billed on 24A – line 1 If multiple services are provided on

the same date of service another form must be completed since only one line can be submitted if patient pay is to be considered in the processing of this service

28. AMOUNT PAID

Block 29: Amount Paid

(Personal and Waiver Services ONLY)

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$

Enter the Patient Pay amount as indicated on the DMAS-122

31. SIGNATURE OF PHYSICIAN OR SUPPLIERINCLUDING DEGREES OR CREDENTIALS

(I certify that the statements on the reverseapply to this bill and are made a part thereof.)

SIGNED DATE

Block 31: Signature & Date

If there is a signature waiveron file, you may stamp, print,

or computer-generate the signature.55

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Service Facility LocationInformationBlock-32

Enter information for the location where services were renderedFirst line-NameSecond line-AddressThird line-City, State, 9 digit zip code

Physicians with multiple offices-the zip code must reflect the office location where services were rendered

No punctuation in the address Space between city and state Include hyphen for the 9 digit zip code

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Service Facility Location InformationBlock-32a-b

Enter the 10 digit NPI number of the service provider in 32a OR;

Enter ‘1D’ qualifier with the API in 32b

Block 32: Service Facility Location Information

32. SERVICE FACILITY LOCATION INFORMATION

a. b.NPI

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Billing Provider Info & PH #Block-33

Enter the information to identify the provider that is requesting to be paidFirst line-NameSecond line-AddressThird 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

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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

Block 33: Billing Provider Info & PH #

33. BILLING PROVIDER INFO & PH #

a. b.NPI

( )

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22. MEDICAID RESUBMISSIONCODE ORIGINAL REF. NO.

Block 22: Adjustments and Voids

1032 xxxxxxxxxxxxxxxxAdjustment

or

Resubmission Code

From originalremittanc

eVoid

Chap. V, Medicaid Physician’s Manual has code list.64

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THANK YOUDepartment of Medical

Assistance Services

www.dmas.virginia.gov