Medicaid Eligibility Verification Options &

CMS-1500 (08-05) Billing Guidelines

October – December 2008

www.dmas.virginia.gov

Department of Medical Assistance Services

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This presentation is to facilitate training of the subject matter This presentation is to facilitate training of the subject matter in Chapter V of the Virginia Medicaid in Chapter V of the Virginia Medicaid Psychiatric Services Manual..

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

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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

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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.

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DOB: 05/09/1964 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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Important Contacts

MediCall ARS- Web-Based Medicaid Eligibility Provider Call Center Provider Enrollment

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MediCall

800-884-9730

800-772-9996

804-965-9732

804-965-9733

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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

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Automated Response System ARS Web-based eligibility verification option

Free of Charge. Information received in “real time”. Secure Fully HIPAA compliant

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UAC Registration ProcessGo 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’

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ARS –Users

Web Support Helpline- ARS Manual (User Guide)

800-241-8726

http://virginia.fhsc.com

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Provider Call Center

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 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

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Electronic BillingElectronic 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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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

EXCEPTIONS Retroactive/Delayed Eligibility Denied Claims

NO EXCEPTIONS Other Primary Insurance

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TIMELY FILING

Submit claims with documentation attached (to the back of claim) explaining the reason for delayed submission

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

CMS-1500 CLAIM FORM:

Use ONLY the ORIGINAL

RED & WHITEWHITECMS-1500 (08-05) Invoice

Photocopies are not Acceptable

Computer generated claims must match NUCC uniform standards

MEDICAID

(Medicaid #)

Block 1

CHAMPUS

(Sponsor's SSN)

1. MEDICARE

(Medicare #)

TRICARE

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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, Sam

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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 & c

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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

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

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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.

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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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

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

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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

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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.

24. A.DATE(S) OF SERVICE

From ToMM DD YY MM DD YY

Block 24A: Dates of Service

09 01 08 09 01 08

09 01 08 09 16 08

1

2 Both FROM and TO dates

must be completedDates must be within same calendar month

TPL27.08

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.

Note: Type of Serviceis no longer required

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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

C.

EMG

Block 24C: EMG

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D.

Block 24D: Procedure Codes

PROCEDURES, SERVICES, OR SUPPLIES(Explain Unusual Circumstances)

CPT/HCPCS MODIFIER

T101690806

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21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY

1.

2.

3.

4.

34431

Block 24E: Diagnosis Code

E.

DIAGNOSISPOINTER

1

2963

1,2Enter 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. 37

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

1

EPSDTFamilyPlan

1-EPSDT

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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.

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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.

Block 24I: ID. Qualifier

& 24J: Rendering Provider ID #I.

ID.QUAL

J.RENDERING

PROVIDER ID. #

NPI

1D

Atypical Provider Identifier43

0012345671

Block 24I: ID. Qualifier

& 24J: Rendering Provider ID #I.

ID.QUAL

J.RENDERING

PROVIDER ID. #

NPI 1234567890

ZZ Taxonomy (if needed)

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National Provider Identifier

26. PATIENT ACCOUNT NUMBER

Block 26: Patient’s Account Number

12345678918765

Can not exceed 14 alphanumeric digits

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28. TOTAL CHARGE

Block 28: Total Charges

$

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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.47

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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

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Block 32

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

Block 32: Service Facility Location Information

32. SERVICE FACILITY LOCATION INFORMATION

a. b.NPI

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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

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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, Psychiatric Services Manual

has resubmission code list. 54

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. 55

REMITTANCE VOUCHERSections of the Voucher

FINANCIAL TRANSACTION

EOB DESCRIPTION

ADJUSTMENT DESCRIPTION/REMARKS- STATUS DESCRIPTION

REMITTANCE SUMMARY- PROGRAM TOTALS

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THANK YOUDepartment of Medical Assistance

Services

www.dmas.virginia.gov