Medicaid Biller Training
description
Transcript of Medicaid Biller Training
Medicaid Biller Training
For Out-of-state Providers
Resources New ProvidersNew Providers
Refer to Michigan Medicaid website, Refer to Michigan Medicaid website, Provider EnrollmentProvider Enrollment MI Eligibility Verification System MI Eligibility Verification System 1-888-696-3510
Prior Authorization – Prior Authorization – (All(All Non Emergency Services require PA) Non Emergency Services require PA) MA eligibility 517-335-5198 CSHCS eligibility 517-335-9440CSHCS eligibility 517-335-9440
Michigan Uniform Billing ManualMichigan Uniform Billing Manual Phone: 517-703-8622 | Fax: 517-327-4564Phone: 517-703-8622 | Fax: 517-327-4564 www.michigansubc.orgwww.michigansubc.org
Health Claim Form Association 1500Health Claim Form Association 1500 Refer to Michigan Medicaid website, Medicaid Provider Manual, Refer to Michigan Medicaid website, Medicaid Provider Manual, BILLING
& REIMBURSEMENT FOR PROFESSIONALS, section 3. section 3.Website – www.michigan.gov/mdch >> PROVIDERS >> Website – www.michigan.gov/mdch >> PROVIDERS >> INFORMATION FOR MEDICAID PROVIDERS INFORMATION FOR MEDICAID PROVIDERS
Medicaid Provider Medicaid Provider Explanation codesExplanation codes, Reason & Remark codes, Reason & Remark codes Provider Specific Information (Provider Specific Information (Fee-Screens)Fee-Screens)
Provider SupportProvider SupportPhone: 800-292-2550 Phone: 800-292-2550 Email: [email protected] Email: [email protected]
PROVIDERSPROVIDERS
Information for Information for Medicaid ProvidersMedicaid Providers
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Provider Enrollment When to contact Provider Enrollment:• New Providers
• Refer to Michigan Medicaid website, Provider Enrollment for the enrollment form
• When any information associated with your Trading Partners Agreement changes
• Tax ID/Affiliation• Addresses• License (renewed, restored, additional)• Specialties• Billing Agents• NPI
PROVIDER ENROLLMENT UNIT
MEDICAID PAYMENTS DIVISION [email protected]
MEDICAL SERVICES ADMINISTRATION
MICHIGAN DEPARTMENT OF COMMUNITY HEALTH
PO BOX 30238 Phone: 517-335-5492
LANSING, MI 48909 Fax: 517-241-8233
National Provider Identifier (NPI)
Providers may now apply for their NPI through CMSMust have NPI by May 23, 2007MI Medicaid does not currently require NPI but greatly encourages applying nowMore NPI Information: https://nppes.cms.hhs.gov 1-800-465-3203 (NPI Toll-Free) [email protected]
MMISMMISComing SoonComing Soon
Online Provider EnrollmentOnline Provider Enrollment Online EligibilityOnline Eligibility Online Claims SubmissionOnline Claims Submission Online Claim StatusOnline Claim Status And More, All Direct from And More, All Direct from MDCHMDCH
Eligibility Verification
Automated Voice Response System (AVRS) – Free (1-888-696-3510) Need Provider Type/ID and beneficiary information
WebDenis - Free (www.bcbsm.com/providers)
Medifax - for a fee (www.medifax.com)
Healthcare Data Exchange (HDX) - for a fee (www.hdx.com )
Eligibility Verification Scope/CoverageLevel of Care (LOC)
Third Party Liability (TPL)
Scp/Cvrg – 2-digit alpha/numeric code indicating which Medical Assistance Program the beneficiary is enrolled (i.e. Medicaid, CSHCS, ABW, MOMS, etc.)LOC – A modifier to the patients Scope/Coverage indicating other circumstances (i.e. nursing facility or hospice patient, enrolled in HMO, beneficiary is incarcerated, etc.)TPL – Any other payers preceding Medicaid; Medicaid is always the payer of last resort.
Eligibility Verification
Common Level of Care Code Blank (No LOC code) - fee-for-service (FFS). 02 - nursing facility services 11 - Adult Benefit Waiver (CHP) 07 - Medicaid Health Plan (MHP) 10 – Patient Pay amount 16 - hospice
Common Scope Code 1 - Medicaid 2 - Medicaid 3 - Adult Benefit
Waiver 4 - Refugees
and Repatriates
Scope/Coverage 0 (zero) - No Medicaid
eligibility/coverage (Deductible / Spend-down)
E - Emergency or urgent Medicaid coverage only
F - Full Medicaid coverage G - Adult Benefit Waiver
Eligibility PoliciesBeneficiary Eligibility Chapter, Medicaid Provider Manual
(Eligibility Code Descriptions)
Adult Benefits Waiver Chapter, Medicaid Provider Manual (Coverages and Limitations)
Children’s Special Health Care Services Program Chapter, Medicaid Provider Manual
Medicaid Health Plans, Medicaid Provider Manual (HMO responsibilities)
MI CHILD – www.michigan.gov/mdch >> Health Care Coverage >> Children and Teens (NOT MEDICAID)
Third Party Liability (TPL) at MDCH
Medicare “Buy-In” Unit at MDCH
Third Party Liability (TPL)
To remove or update other insurance To remove or update other insurance information from Third Party Liability information from Third Party Liability (TPL) file:(TPL) file:
Phone 800-292-2550 (option 4)Phone 800-292-2550 (option 4) Fax 517-346-9817Fax 517-346-9817 Email Email [email protected]
Medicare “Buy-In” Unit (MDCH)
The Medicare Buy-In Unit is responsible for: Processing Medicare premium payments for
eligible Medicaid beneficiaries. Other Insurance Coding for Medicare on the
Medicaid system. Alien information for Medicaid beneficiaries that
are age 65 or over, must have the date of entry forwarded to the Buy-In Unit if the beneficiary has not been in the US for over 5 consecutive years.
The Medicare Buy-In unit will not be able to address questions from the beneficiaries.
Lewis Cass Building Phone: 517-335-5488
320 South Walnut Fax: 517-335-0478Lansing, MI 48913 Email [email protected]
Medicaid Billing Limitations
12 month limitation from Date of Service (DOS)
–Inpatient admission- 12 month from discharge date
Continuous Activity Within 120 days from last rejectionDocumentation is needed for:
–Claim replacements when Previously billed with incorrect:
Provider ID NumberBeneficiary ID Number
PAPER No confirmation
until CRN appears on RA
30-60 days to appear on Medicaid RA
Must attach EOB No paper clips,
white out or dot matrix printers
ELECTRONIC 997
Acknowledgement receipt from Medicaid
7-14 days to appear on Medicaid RA
No EOB needed A list of approved
billing agents is posted at Electronic Billing website
Claim Submission
Electronic BillingShopping for an Electronic Billing Agent
Billing Agent Authorization Form
835/277U Request Form
Billing Agent’s responsibilities
Billing And Reimbursement Chapters, Medicaid Provider Manual
Medicaid accepts electronic Primary, Secondary and Tertiary claims EOB’s are not needed when submitting
secondary/tertiary claims electronically CAS Codes are required
Complete Loop 2400 and 2430 for claim Procedure Code and Modifier (Professional)
Professional claims only need to be sent on paper when attachments (besides EOB’s) are needed
Electronic Claims
Medicaid is accepting crossover claims from WPS and AdminaStar
Bulletin All Provider 04-05, issued June 1, 2004 Bulletin MSA 05-02, issued January 1, 2005
Provider ID must be included in Loop 2010AA Example = REF*1D*108888888~
Medicaid will soon allow the Provider ID in Loop 2310B, Rendering Billing Provider IDFAQ’s posted at Provider Updates webpage
Crossover Claims(Special Services)
Crossover Claims(Special Services)
Troubleshooting Crossover Medicare EOB says that the “Claim was forwarded to
MDCH for Reimbursement” but claim never appears on Medicaid Remittance Advice: This means that your Medicaid Provider Type and ID were
not in the proper provider identifying field within your electronic claim
See your vendor for correction Rebill to Medicaid any crossover claims that do not appear
within 30 days of Medicare EOB
Groups of providers who submit batches of claims under one Medicare group ID but more than one Medicaid Provider ID should not attempt to crossover until further notice
The 835 is the only electronic format available Paper is still available
835 reports all paid and rejected claims 277U will report pended claims
MDCH edits no longer exist Nationally recognized Reason/Remark codes
Posted electronically and on paper RA Crosswalk available at website
www.michigan.gov/mdch >> Providers >> Information for Medicaid Providers >> Electronic Billing
835 – Electronic Remittance Advice
Remittance Advice
MSA Remittance Advice
Payment Information by beneficiaryIssued by MDCHDate, Provider Type/ID, & Amounts match Warrant Date, Provider Type/ID, & AmountsOne RA issued to each Provider ID
State of Michigan Remittance Advice
Attached to the “Check”Check and RA (AKA “Warrant”)Payment information by Provider Type/ID and Tax IDIssued by Department of Treasury“39S 391”= MDCH/MedicaidOne RA issued to each Tax ID
Checks and Remittance Advice (EOB) mailed separately
ReplacementReplacementExamples of when a claim may need to be replaced:
To return an overpayment (report "returning money" in Remarks section);
To correct information submitted on the original claim (other than to correct the Provider ID number and/or the beneficiary ID number). Refer to the Void/Cancel subsection below;
To report payment from another source after MDCH paid the claim (report "returning money" in Remarks section); and/or
To correct information that the scanner may have misread (state reason in Remarks section).
ReplacementReplacement
To replace a previously paid claim, UB-92-
indicate 7 (xx7) as the third digit in the Type of Bill Form locator frequency.
enter the 10-digit Claim Reference Number (CRN) of the last approved claim being replaced
the reason for the replacement in Remarks. The Provider ID number and beneficiary ID number on the replacement claim must be the same as on the original claim.
Refer to Michigan Medicaid manual, BILLING & REIMBURSEMENT FOR INSTITUTIONAL, section 3.1
ReplacementReplacementTo replace a previously paid claim,
HCFA 1500- Report code 7 in the left side of Item 22 Report the ten-digit Claim Reference Number (CRN)
of the previously paid claim in the right side of Item 22
State reason in the Remarks sectionNOTE: If the resubmission code of 7 is missing the
claim cannot be processed as a replacement claim.If all service lines of a claim were rejected, the services must be resubmitted as a new claim, not a replacement claim.
Refer to Michigan Medicaid manual, BILLING & REIMBURSEMENT FOR PROFESSIONALS, section 4.1
Void/Cancel Void/Cancel If a claim was paid under the wrong provider or beneficiary ID Number,providers must void/cancel the claim. UB-92
indicate an 8 in the Type of Bill (xx8) as the third digit frequency.
enter the 10-digit CRN of the last approved claim or adjustment being cancelled and
enter in Remarks Section the reason for the void/cancel.
A new claim may be submitted immediately using the correct provider or beneficiary ID number.
A void/cancel claim must be completed exactly as the original claim.Refer to Michigan Medicaid manual, BILLING & REIMBURSEMENT FOR INSTITUTIONAL, section 3.2
Void/Cancel Void/Cancel If a claim was paid under the wrong provider or beneficiary ID Number,providers must void/cancel the claim. HCFA 1500
Report code 8 in the left side of Item 22 Report the ten-digit Claim Reference Number
(CRN) of the previously paid claim in the right side of Item 22
complete one service line and enter zero dollars
(000) in all money fields. State reason in the Remarks sectionRefer to Michigan Medicaid manual, BILLING &
REIMBURSEMENT FOR PROFESSIONALS, section 4.2
Prior Authorization Prior Authorization
All out of state services that have been prior authorized must
indicate in Remarks (F.L. 19) “OUT OF STATE”
prior authorization number in prior authorization field
AppealsAppeals
1. Claim is submitted to MDCH (PO Box (PO Box 30043)30043)
2. Claim is denied3. If necessary, correct claim information
indicated as insufficient/incorrect on RA and resubmit
4. If corrected claim is rejected contact Provider Support Hotline for counsel (1-800-292-2550)
AppealsAppeals
5. Hotline advice is followed, but claim is still processed improperly
6. Send paper claim with letter explaining situation/history and request for action to Special Payments’ Research and Analysis (PO Box 30731)
7. Research and Analysis either denies request or processes but system still rejects
AppealsAppeals
8. If all requirements have been satisfied and all instruction followed but claim continues to reject, MDCH Administrative Tribunal should be contacted
MDCH Administrative Tribunal & Appeals DivisionMDCH Administrative Tribunal & Appeals Division
PO Box 30763PO Box 30763
Lansing, MI 48909Lansing, MI 48909
Phone: 517-334-9500Phone: 517-334-9500