Department of Medical Assistance Services

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Department of Medical Assistance Services
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• INTENSIVE REHABILITATION SERVICES
• July-August 2004

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TRAINING OBJECTIVES

• Learn the qualifications of the rehab therapists
• Learn and apply the intensive rehab program
  criteria
• Gain knowledge of all medical record
  documentation requirements
• To understand the purpose of utilization review
  and the appeals process
• Proper utilization of Medicaid eligibility
  options and billing guidelines

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TRAINING OVERVIEW

• Rehabilitation Criteria
• Rehabilitation Services
• Documentation Requirements
• Interdisciplinary Team Requirements
• Utilization Review
• Appeals Process

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COMMONLY USED ACRONYMS

• IR - Intensive Rehab
• DMAS - Department of Medical Assistance Services
• CMS Centers for Medicare and Medicaid Services
• PA - Preauthorization
• POC - Plan of Care
• DME - Durable Medical Equipment

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DMAS WEB SITE

• www.dmas.virginia.gov
• The home page includes
• Recipient information
• Provider information-including all Medicaid
  manuals
• Administration and Business information
• DMAS e-mail notification for subscription

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DMAS WEB SITE (cont.)

• Learning Network-allows access to training
  presentations
• Provider Search-to locate provider in a
  particular location
• Search Forms-allows provider to print DMAS
  required forms

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GENERAL INFORMATION

• Provider Memo dated 3-22-2004 provides
  information regarding
• Plastic ID Cards
• MediCall-24 hour access
• Internet-Automated Response System (ARS)
• Additional helpful provider information

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FREEDOM OF CHOICE

• Virginia Medicaid recipients have the right to
  choose a participating rehabilitation provider

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MEDALLION

• If the recipient is enrolled in MEDALLION, the
  ordering physician must be the MEDALLION care
  physician (PCP), or there must be a referral for
  the service from the MEDALLION PCP.

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MEDALLION (contd)

• The PCP referral may be obtained in writing or
  orally and must be documented in the recipients
  medical record.
• NOTE For more information, refer to Supplement
  A of the Virginia Medicaid Rehabilitation Manual

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COVERED SERVICES

• Medically necessary rehab services are a covered
  service for Medicaid recipients.
• Medical necessity is
• services ordered by a physician
• treatment plan of care
• accepted medical standards of practice
• (not experimental or investigational)
• safe and cost-effective level of care

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PROVIDERS OF SERVICE

• Intensive rehab services may be provided by
• A freestanding rehab hospital, or
• A Comprehensive Outpatient Rehab Facility (CORF),
  or
• An acute care hospital that has a Medicare-exempt
  physical rehab unit

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PREAUTHORIZATION

• All requests for preauthorization must be
  received by WVMI within 72 hours (calendar days)
  of the IR/CORF admission.
• WVMI [phone] or [phone]
• Requests received after 72 hours will be denied
  up to the day of the request.
• Requests may be telephonic or on paper (DMAS-351
  and DMAS-361 forms)

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INTENSIVE REHAB ADMISSION CRITERIA (INCLUDING
CORF)

• A recipient is deemed appropriate for IR/CORF if
  both of the following criteria are met
• Interdisciplinary coordinated team approach
• Services cannot be carried out in a less
  intensive setting

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INTENSIVE REHAB ADMISSION CRITERIA (INCLUDING
CORF) Continued

• In addition, recipients must also meet all of
  the following criteria
• The recipient requires rehab nursing for
  patient/family education, and
• The recipient requires at least two of four
  therapies (PT/OT/SLP/Cognitive)

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INTENSIVE REHAB ADMISSION CRITERIA (INCLUDING
CORF) Continued

• Criteria continued
• Recipient is able to actively participate in
  therapy on a daily basis, and
• The medical condition is stable and compatible
  with an active rehab program, and
• Meets Interqual criteria for preauthorization
  purposes

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INTERQUAL CRITERIA-2004

• Frequent Issues
• Specific Diagnoses - Deconditioning cannot be
  used as a primary diagnosis
• At least 2 disciplines 3h/d 5d/wk
• Discharge planning - when all appropriate rehab
  goals are met, patients must be promptly
  discharged

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INAPPROPRIATE ADMISSIONS

• Admissions for evaluation and/or training solely
  for vocational or educational purposes or
  developmental or behavioral assessments are not
  covered IR/CORF services
• Admissions for evaluation for the same condition
  as a previous rehab admit is a non-covered
  IR/CORF service

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SPECIAL IR ADMISSIONS

• DMAS may negotiate individual contracts with
  in-state or out-of-state IR facilities for
  recipients with special rehab needs.
• For example
• Ventilator-dependent recipients
• Out-of-state placements (when the service is
  not available within Va.)

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SPECIAL IR ADMISSIONS(Continued)

• Preauthorization through DMAS is required prior
  to admission for ventilator-dependent or
  out-of-state placements.
• Contact the DMAS Facility and Home Based
  Services Unit in Richmond, Va.
• Phone [phone]

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THERAPY GUIDELINES FORMEDICAID REIMBURSEMENT

• IMPROVEMENT OF FUNCTION
• Therapy will result in significant and practical
  improvement in the recipients level of
  functioning within a reasonable period of time.

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THERAPY GUIDELINES FORMEDICAID REIMBURSEMENT

• MAINTENANCE THERAPY
• Therapy will NOT result in significant practical
  improvement or the skills of a licensed therapist
  are not required to carry out the treatment to
  maintain or monitor patient function.
• Medicaid reimbursement will NOT be made for
  maintenance therapy.

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CONDITIONS OF DISCHARGE

• Discharge from IR/CORF must be considered when
  one of the following conditions exists
• No further potential for improvement is
  demonstrated
• The skills of a qualified therapist are no longer
  required
• The recipient has reached his/her maximum level
  of progress

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CONDITIONS OF DISCHARGE (contd)

• Limited motivation on the part of the recipient
  or caregiver
• Recipient has an unstable medical condition that
  limits participation
• Progress toward goals cannot be achieved within a
  reasonable period of time
• Interqual discharge criteria no longer met

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THERAPEUTIC FURLOUGH DAYS

• DMAS will not reimburse for intensive
  rehabilitation services for days when a recipient
  is on an overnight therapeutic furlough.
• Such days must not be billed on the UB-92
  invoice.

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IR TRANSFERS - READMITS

• When a recipient requires transfer to acute care
  for
• than 24 hrs d/c recipient from IR
• Note For re-admissions than 24 hrs., each
  team member must re-evaluate the recipients
  functional status (Rehab Manual, Ch. IV, page 5)

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PROSTHETIC - ORTHOTIC SERVICES

• Coverage is available for prosthetic and
  orthotic services when recommended as part of an
  approved IR/CORF program when the following
  criteria are met
• Physician ordered
• Physician-approved treatment or discharge plan

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DURABLE MEDICAL EQUIPMENT AND SUPPLIES

• DME required for home use or to facilitate the
  recipients discharge home may be covered under
  the DME and Supplies program.
• Note refer to the DMAS agency web site for the
  DME Manual requirements.
• www.dmas.virginia.gov
• Provider Manual section

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DOCUMENTATION REQUIREMENTS

• Physician
• Rehab Nursing
• PT
• OT
• SLP
• Cog. Rehab

• Psychology
• Social Work
• Therapeutic Rec.
• Interdisciplinary Team

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DOCUMENTATION REQUIREMENTS

• PHYSICIAN
• History and Physical Examination
• Admission Orders - Plan of Care (medications,
  rehab therapies, treatments, diet, and other
  required services such as psychology, social
  work, therapeutic rec., etc.)
• NOTE 60 day renewal orders - plan of care must
  include all of the same components as the
  admission orders

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DOCUMENTATION REQUIREMENTS

• PHYSICIAN (continued)
• Admission certification on DMAS-127 form
• 60-Day Recertification on DMAS-128 form
• Physician 60-Day Plan of Care Review on the
  DMAS-126 form
• Identification of a discharge plan and discharge
  disposition

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DOCUMENTATION REQUIREMENTS

• PHYSICIAN (continued)
• Progress notes to be written at least every 30
  days
• Progress notes include changes in the recipients
  condition, and
• Recipient response to treatment

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DOCUMENTATION REQUIREMENTS

• PHYSICIAN (continued)
• Discharge summary to be completed within 30 days
  of the recipients discharge from IR/CORF stay
• Discharge order upon discharge from IR/CORF stay
• Any therapies discontinued prior to discharge
  require a physician order

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DOCUMENTATION REQUIREMENTS

• PHYSICIAN (continued)
• All physician documentation must be signed and
  dated by the physician
• Physician signature may include written
  signatures, written initials, computer entry, or
  rubber stamp initialed by physician

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DOCUMENTATION REQUIREMENTS

• NURSING
• Rehab nursing involves patient and family
  education and training. Education and training
  includes skilled nursing care and therapeutic
  rehab activities the patient has learned in the
  rehab sessions that will be carried over onto the
  nursing care unit.

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DOCUMENTATION REQUIREMENTS

• NURSING (Continued)
• Admission evaluation - documentation of the
  patients deficits and need for rehabilitative
  nursing services
• NOTE A registered nurse (RN) or a licensed
  practical nurse (LPN) under the supervision of a
  registered nurse must complete, sign, and fully
  date the evaluation

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DOCUMENTATION REQUIREMENTS

• NURSING (Continued)
• Plan of Care (POC) - documentation of
  individualized, measurable goals with time frames
  for achievement and nursing interventions used to
  achieve patient goals
• NOTE A registered nurse (RN) or a licensed
  practical nurse (LPN) under the supervision of a
  registered nurse must complete, sign, and fully
  date the POC

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DOCUMENTATION REQUIREMENTS

• NURSING (Continued)
• Biweekly Review of the POC - documentation that
  demonstrates review of the recipients response
  to the nursing plan of care/treatment plan
• Note a registered nurse (RN) must review the
  patients response to the POC at least every two
  weeks

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DOCUMENTATION REQUIREMENTS

• NURSING (Continued)
• Weekly progress notes - documentation of nursing
  care provided, patient and/or family education,
  changes in patients condition, patients
  response to nursing interventions, and any
  modifications to the patients goals.
• NOTE A registered nurse (RN) or a licensed
  practical nurse (LPN) under the supervision of a
  registered nurse must complete, sign, and fully
  date all progress notes

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DOCUMENTATION REQUIREMENTS

• REHABILITATIVE THERAPIES
• All rehabilitative therapy services must be
  ordered by a physician.
• The following slides will review documentation
  for the following therapies
• PT, OT, SLP, Cognitive, and Therapeutic
  Recreation

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DOCUMENTATION REQUIREMENTS

• REHABILITATIVE THERAPIES
• Admission Evaluation
• Must be completed by a registered or licensed
  therapist and must include
• Diagnoses of the recipient
• History of any previous treatment
• Prior/current functional status
• Medical findings
• Clinical signs/symptoms
• Therapists recommendations

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DOCUMENTATION REQUIREMENTS

• REHABILITATIVE THERAPIES
• Plan of Care
• Is developed by a qualified therapist and must
  include
• Recipient measurable goals
• Time frames for goal achievement
• Interventions, modalities, treatments
• Frequency and duration of therapies

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DOCUMENTATION REQUIREMENTS

• REHABILITATIVE THERAPIES
• Progress Notes
• Must be written at least every 2 weeks and
  include
• Frequency and duration of the therapies
• Recipient response to treatment
• Review of the plan of care

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DOCUMENTATION REQUIREMENTS

• Progress Notes-continued
• (PT/OT/SLP)
• Supervisory 30 day on-site review and
  documentation is required by a licensed therapist
  when the therapy is provided by an LPTA, COTA,
  SLP (without license), or speech-language
  assistants

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DOCUMENTATION REQUIREMENTS

• Psychology and Social Work Services
• Both services must be ordered by the physician
  prior to implementation
• The following slides will review documentation
  for these two services

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DOCUMENTATION REQUIREMENTS

• Psychology Services
• Admission Evaluation
• Must be written by a licensed psychologist, LPC,
  or LCSW and must include
• History
• Diagnoses
• Identified needs/problems

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DOCUMENTATION REQUIREMENTS

• Psychology Services
• Plan of Care
• Is developed by a qualified therapist and must
  include
• Recipient measurable goals
• Time frames for goal achievement
• Interventions
• Frequency and duration of services

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DOCUMENTATION REQUIREMENTS

• Psychology Services
• Progress Notes
• Must be written at least every 2 weeks and
  include
• Frequency and duration of the services
• Recipient response to interventions
• Review of the plan of care

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DOCUMENTATION REQUIREMENTS

• Social Work Services
• Admission Evaluation
• Must be written by a social worker and must
  include
• Patient social history
• Diagnoses
• Identified needs and problems

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DOCUMENTATION REQUIREMENTS

• Social Work Services
• Plan of Care
• Is developed by a social worker and must include
• Recipient measurable goals
• Time frames for goal achievement
• Interventions
• Frequency and duration of services

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DOCUMENTATION REQUIREMENTS

• Social Work Services
• Progress Notes
• Must be written at least every 2 weeks and
  include
• Frequency and duration of the services
• Recipient response to interventions
• Review of the plan of care

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DOCUMENTATION REQUIREMENTS

• Discharge Summary
• Each discipline must complete a discharge
  summary within 30 days after a recipients
  discharge. The summary must document the
  recipients progress (functional outcome),
  identify goals that were met/not met, and state
  the recommendations for follow-up care.

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DOCUMENTATION REQUIREMENTS

• Discharge Planning
• Is an integral part of the recipients plan of
  care developed by the team disciplines.
• The discharge plan must be addressed during the
  admission evaluation and must be reviewed/revised
  relative to the recipients/familys response to
  rehab.

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INTERDISCIPLINARY TEAM

• The interdisciplinary (ID) team provides a
  comprehensive approach to the intensive
  rehabilitation program
• The ID team must prepare written documentation of
  the ID plan of care within 7 days of admission

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INTERDISCIPLINARY TEAMContinued

• Documentation must include, but is not limited
  to
• Needs of the recipient
• Measurable, recipient oriented goals
• Approaches used to meet the goals
• The discipline(s) responsible for the goals
• Time frames for goal achievement

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INTERDISCIPLINARY TEAMContinued

• The ID team must identify a discharge plan which
  must include, but not limited to
• Anticipated improvements in functional goals
• Time frames for goal achievement
• Recipients discharge destination
• Modifications needed at the recipients home for
  d/c and an alternate d/c plan(s)

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INTERDISCIPLINARY TEAMContinued

• ID team must be held at least every 2 weeks to
  review the plan of care
• Documentation must include
• Progress made toward established
  interdisciplinary goals
• Revisions/changes to goals
• Discharge plan

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INTERDISCIPLINARY TEAMContinued

• Documentation must demonstrate a coordinated team
  approach
• Each discipline must be present at the team
  conference held at least every two weeks
• A review by the team disciplines of each others
  progress notes does not constitute a team
  conference

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DMAS UTILIZATION REVIEW
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PROVIDER UTILIZATION REVIEW (UR)

• Utilization review (UR) ensures high quality care
  as well as the appropriate provision of services.
• IR/CORF providers must comply with all
  documentation requirements in order to receive
  Medicaid reimbursement for the services provided.

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PROVIDER UR PLAN

• DMAS requires 100 UR of all Medicaid recipients
  in an IR/CORF setting.
• The annual facility UR Plan must identify
• Committee organization and meetings
• Admission ongoing review process
• Medical care evaluation (MCE) studies

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DMAS UTILIZATION REVIEW

• The purpose of UR is to ensure
• Services are medically necessary
• Rehab criteria is met
• High quality care is provided
• Services provided as ordered

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DMAS UTILIZATION REVIEW(contd)

• DMAS is responsible for validation of
• Appropriateness of care provided
• Adequacy of services
• Necessity of continued participation
• Feasibility of recipients needs being met in
  alternate settings
• Verification of documentation requirements

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DENIAL OF REIMBURSEMENT

• Payment to the rehab provider may be retracted
  when the provider has failed to comply with
  established Federal (42 CFR) and State (VAC)
  regulations or Medicaid policy requirements as
  outlined in the Virginia Medicaid Rehabilitation
  Manual.

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MEDICAL RECORDS

• Medical records must be retained for not less
  than 5 years after the recipients discharge date
  from IR.
• The records must contain complete documentation,
  be readily accessible, legible, and organized to
  facilitate prompt retrieval.

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APPEAL PROCESS

• RECIPIENT
• PROVIDER

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APPEAL PROCESS

• Recipient Appeals
• If the denied rehab service has not been provided
  to the recipient, the denial may be appealed only
  by the recipient or his/her legally appointed
  representative
• Recipient appeals must be submitted within 30
  days to DMAS Division of Appeals

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APPEAL PROCESS

• Provider Appeals
• The rehab provider has the right to request
  reconsideration of DMAS utilization review
  retractions. The request for reconsideration and
  all supporting documentation, must be submitted
  to DMAS within 30 days of the denial
  notification.

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APPEAL PROCESS

• Provider Appeals (contd)
• First Level Appeal - to the DMAS Supervisor of
  the Facility and Home Based Services Unit
• Second Level Appeal - to the DMAS Division of
  Appeals (IFFC Hearing)
• Third Level Appeal - to the DMAS Division of
  Appeals (Formal Hearing)

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Department of Medical Assistance Services

• Intensive Rehabilitative Services
• Eligibility Verification and Billing
• July-August 2004
• www.dmas.virginia.gov

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As a Participating ProviderYou must -

• Accept as payment in full, the amount paid by
  Medicaid
• Bill any and all other third-party carriers
• Determine the patient's identity
• Verify the patient's age
• Verify the patient's eligibility
• Maintain records for minimum 5 years

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COMMONWEALTH OF VIRGINIA
DEPARTMENT OF MEDICAL ASSISTANCE SERVICES
002286
9 9 9 9 9 9 9 9 9 9 9 9
V I RG I N I A J. R E C I P I E N T
DOB 05/09/1964 F
CARD 00001
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Eligibility Medicaid or Medallion II HMO
You will be able to identify clients enrolled in
a Medallion II HMO by using our MediCall
verification line or their HMO Member ID
Card. Those enrolled in a Medallion II HMO will
also carry a card bearing the name of one of
following plans Carenet, Sentara Family Care,
Healthkeepers Plus, Unicare or Virginia Premier
Health Plan.
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Important Contacts

• MediCall
• Automated Response System
• Provider Call Center
• Customer Service
• Provider Enrollment
• Commonwealth Mailing

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MediCall

• 800-884-9730
• 800-772-9996
• 804-965-9732
• 804-965-9733

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Automated Response SystemARS

• Web-based eligibility verification option
• Free of Charge
• Information received in real time
• Secure
• Fully HIPAA compliant

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Provider Sign-up for FreeWeb-based Eligibility
Option

• First Health Services Corporation
• virginia.fhsc.com

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ARS User Guide Available

• Located on the DMAS web-site under the Whats
  New section
• General information on ARS eligibility
  verification
• Instructions on the using the system
• FAQ(frequently asked questions) section

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ARS- Information Available

• Medicaid client eligibility
• Service limit information
• Claim status
• Prior authorization
• Provider check log

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PROVIDER CALL CENTER

• Claims, covered services, billing inquiries
• DEPARTMENT OF MEDICAL ASSISTANCE SERVICES
• 600 East Broad Street, Suite 1300
• Richmond, Virginia
• 800-552-8627
• 804-786-6273

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Billing Inquiries
Customer Service Department of Medical
Assistance Services 600 East Broad Street, Suite
1300 Richmond, VA 23219
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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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Requests for DMAS Forms and Manuals

• DMAS Order DeskCOMMONWEALTH MARTIN1700
  Venable StreetRichmond, Virginia 23222

Phone [phone] Emaildmas_at_cms-mpc.com
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Billing on the CMS-1450
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MAIL CMS-1450 FORMS

• Department of Medical Assistance Services
• Hospital
• P. O. Box 27443
• Richmond, VA 23261-7443

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TIMELY FILING

• ALL CLAIMS MUST BE SUBMITTED AND PROCESSED
  WITHIN ONE YEAR FROM THE DATE OF SERVICE
• EXCEPTIONS 1. Retroactive
  Eligibility/Delayed Enrollment 2. Previously
  rejected or denied claims
• Submit claims with documentation attached
  explaining the reason for delayed submission.

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CMS-1450 FORMUse ONLY the originalRED and
WHITE InvoicePhotocopies are not acceptable!
88
89
Locator 1 Provider Name and Address
Provider NameStreet Address or Post Office
BoxCity, State, Zip CodePhone Number
89
90
Locator 3 Patient Control
Number
Enter the patient account number. These account
numbers can be all numeric digits or a
combination of alpha and numeric, but cannot
exceed 17 alphanumeric characters.
90
91
Locator 4 Type of Bill
OriginalBill

91
92
Locator 4Enter the code as appropriate

• 111 Original Inpatient Hospital Invoice
• 117 Adjustment Inpatient Hospital Invoice
• 118 Void Inpatient Hospital Invoice
• 131 Original Outpatient Invoice
• 136 Adjustment Outpatient Invoice
• 138 Void Outpatient Invoice
• 741 Original Outpatient Rehab Agency Invoice
• 746 Adjustment Outpatient Rehab Agency
• 746 Void Outpatient Rehab Agency Invoice

92
93
Locator 6 Statement Covers Period
6 STATEMENT COVERS PERIOD
THROUGH
FROM

93
94
Locator 6

• Enter the beginning and ending dates reflected
  by this invoice (include both covered and
  non-covered days). Use both from and to for a
  single day.
• If the total days of service exceed 31 days use
  additional billing invoices.
• Claims submitted which exceed the 31-day
  limitation will be denied, Limit of 31 Days Per
  Billing Invoice Exceeded.

94
95
Locator 6

• The billing period may overlap calendar months
  as long as the 31-day billing limitation is not
  exceeded and does not cross over the providers
  fiscal year for cost settlement. Do not include
  furlough days.

95
96
Locator 7 Covered Days
Enter the total number of Medicaid covered days
as applicable. This should be the total number
of covered accommodation days/units reported in
Locator 46.
96
97
Locator 12 Patient Name
Enter the patient's name - last, first, middle
initial.
97
98
Locator 13 Patient Address
13 PATIENT ADDRESS

Enter the patients address.
98
99
Locator 14 Patient Birthdate
03181995
Enter the month, date, and full year(MMDDYYYY)
99
100
Locator 15 Sex
15 SEX
Enter the sex of the patient as recorded on the
date of admission, outpatient service, or start
of care.
100
101
Locators 17 and 20Admission Information
ADMISSION
17 DATE
18 HR
19 TYPE
20 SRC
101
102
Locator 17 Admission Date
ADMISSION
DATE
Enter the date of admission for inpatient. Enter
the date of service for outpatient.
NOSPACES
NOSLASHES
102
103
Locator 18 Admission Hour
ADMISSION
Enter the hour during which the patient
was admitted for inpatient or outpatient
care. (Not required for outpatient rehab
agencies).
103
104
Locator 19 Admission Type
For inpatient services only, enter the
appropriate code indicating the priority of
admission. (Not required for outpatient rehab
agencies)
104
105
Locator 20 Admission Source
ER 7
Enter the appropriate code for the source of
admission. (Not required for outpatient rehab
agencies)
105
106
Locator 21 Discharge Hour
Enter the hour that the patient was discharged
from inpatient care.
106
107
Locator 22 Patient Status
Enter the status code as of the through date in
Statement Covers Period (Locator 6).
107
108
Locator 23 Medical Record Number (Optional)
23 MEDICAL RECORD NO.
23 MEDICAL RECORD NO.
23 MEDICAL RECORD NO.
Enter the number assigned to the patients
medical/health record by the provider for history
audits. NOTE This number should not be
substituted for the Patient Control Number
(Locator 3 which is assigned by the provider to
facilitate retrieval of the individual financial
record.
108
109
Locators 32-35Occurrence Span Codes and Dates
OCCURRENCE SPAN
32
THROUGH
FROM
CODE
Enter the code(s) in numerical sequence (starting
with 01) and the associated date to define a
significant event relating to this bill that may
affect payer processing.
109
110
Locator 37 Internal Control Number (ICN)
REQUIRED IF APPLICABLE
37
Primary payer
A
Secondary payer
B
Tertiary payer
C
Enter the nine or sixteen digit claim reference
number of the paid claim to be adjusted or
voided. A brief explanation of the adjustment or
void reason is required in Locator 84 (Remarks).
110
111
Locator 39 - 41 Value Codes and Amounts
82
83
85
Enter the appropriate code(s) to relate amounts
or values to identified data elements necessary
to process this claim.
111
112
Locator 39-41

• 82 No Other Coverage- If the enrollee has no
  insurance coverage other than Medicaid.
• 83 Billed and Paid- If the provider has received
  payment from the primary carrier(s), code 83 must
  be entered, and the amount covered by the primary
  carrier entered under the amount section of the
  locator.

112
113
Locator 39-41

• 85 Billed and Not Paid- primary insurance
  carrier has excluded this service, or the
  benefits may be exhausted. Code 85 must be
  entered. Using Code 85 will require an attachment
  containing the name of the insurance, the date
  of denial, and the reason for denial or
  non-coverage.

113
114
Locator 42 Revenue Code
Enter the appropriate revenue code(s) for the
service provided. (Revenue codes allowed by DMAS
for Intensive Rehabilitation services are listed
in Chapter V of the Rehabilitation Manual.)
114
115
Locator 43 Revenue Description
Enter the National Uniform Billing Committee
(NUBC) description and abbreviation.
115
116
Locator 44 HCPCS/Rates
Inpatient Enter the accommodation rate.
Outpatient Enter the applicable Revenue Code.
116
117
Locator 46 Units of Service
Enter the total number of covered accommodation
days or ancillary units of service where
appropriate.
117
118
Locator 47 Total Charges (by Revenue Code)
Enter the total charge(s) pertaining to the
related revenue code for the current billing
period. Total charges must include only covered
charges.
118
119
Locator 47 Total Charges (by Revenue Code)
Note Use revenue code 0001 for TOTAL. This
revenue code must be the last code entered in
Locator 42.
119
120
Locator 50 Payer Identification
Primary payer
Secondary payer
Tertiary payer
When Medicaid is the only payer, enter Medicaid
on line A. If Medicaid is secondary or tertiary
payer, enter on Lines B or C.
120
121
Locator 51 Provider Number
Primary payer
Secondary payer
Tertiary payer
Enter the Medicaid Provider I.D. Number on the
appropriate line corresponding with the payer
name in locator 50.
121
122
Locator 58 Insured's Name
Enter the name of the insured person covered by
the payer in Locator 50. The name on the Medicaid
line must correspond with the name given when
eligibility is confirmed.
122
123
Locator 59 Patient's Relationship to Insured
Enter the code indicating the relationship of the
insured to the patient. Refer to the State UB-92
Manual for codes.
123
124
Locator 60 Certificate/SSN/ HIC/ Identification
Number
Enter the Medicaid Enrollee 12 digit I. D. Number
125
Locator 63 Treatment Authorizaton Codes
Enter the number indicating that the treatment is
authorized by the payer. Intensive rehab stays
(inpatient) must be preauthorized.
126
Locator 67 Principal Diagnosis Code
NO DECIMALS
Enter the ICD-9-CM code that describes the
principal diagnosis.
126
127
Locator 68-75 Other Diagnosis Code
OTHER DIAG. CODES
NO DECIMALS
Enter the codes for diagnoses other than
principal if any.
127
128
Locator 76 Admitting Diagnosis Code
NO DECIMALS
Enter the ICD-9-CM diagnosis code provided at
admission as stated by the physician.
128
129
Locator 79 Procedure Coding Method Used
5 - HCPCS 9 - ICD-9-CM
9
Enter the code identifying the coding method used
in Locators 80 and 81 as listed above.
129
130
Locator 80 Principal Procedure Code and Date
REQUIRED IF APPLICABLE
NO DASHES NO SLASHES
NO DECIMALS
Enter the ICD-9-CM code for the major procedure
performed during the billing period.
130
131
Locator 81 Other Procedure Codes and Dates
NO DASHES NO SLASHES
NO DECIMALS
Enter the code(s) identifying all significant
procedures other than the principal procedure
(and the dates) on which the procedures were
performed.
131
132
Locator 82 Attending Physician
Physician Name
Enter the nine-digit number assigned by Medicaid
for the physician attending the patient.
132
133
Locator 83 Other Physician ID
Physician Name ID

OTHER PHYS. ID
Physician Name
133
134
Locator 83 Other Physician ID
Enter the provider number assigned by Medicaid
for the Primary Care Physician (PCP) who
authorized the inpatient stay or outpatient
visit. This is required for all MEDALLION
patients even though the PCP may be listed in
Locator 82. Enter the PCP number for all
inpatient stays. THE PCP MUST BE IN LOCATOR
83-A
135
Locator 84 Remarks
a
Enter a brief description of the reason for the
submission of the adjustment or void (refer to
Locator 37). If there was a delay in filing,
indicate the reason for delay here and include
an attachment. Also, provide any other
information necessary to adjudicate the claim.
b
c
d
135
136
Locator 85 Provider Representative
Enter the authorized signature indicating that
the information on this bill is in conformance
with the certifications on the back of the bill.
(Required for paper claims only)
136
137
Locator 86 Date
Enter the date on which the bill is being
submitted to Medicaid. (Required for paper
claims only)
137
138
Medicare Crossover Claims
139
Medicare Primary Billing Instructionsfor
CMS-1450 (UB-92)

• The word CROSSOVER must be entered in Block 11
  of the UB-92 to identify Medicare crossover
  claims.
• Coordination of Benefits (COB) codes 83 and 85
  must be accurately printed in Blocks 39-41 of the
  UB-92.

140
Medicare Primary Billing Instructionsfor
CMS-1450 (UB-92)

• The first occurrence code 83 indicates that
  Medicare paid and there should always be a dollar
  value associated with this code.
• The A1 indicates Medicare deductible and code A2
  indicates Medicare coinsurance.

141
Medicare PrimaryBlocks 39-41

• Line a 83 Billed and Paid (enter amount paid by
  Medicare or other insurance).
• Line a A1 Deductible Payer A. (enter Medicare
  Deductible Amount on the EOMB).
• Line a A2 Co-Insurance Payer A. (enter Medicare
  Co-Insurance amount on the EOMB).

140
142
Medicare Primary Billing Instructionsfor
CMS-1450 (UB-92)

• Note Complete all information in Locators 39a
  through 41a first (payments by Medicare or
  payments by other insurance) before entering
  information in 39b through 41b locators etc.

143
Medicare Primary Billing Instructionsfor
CMS-1450 (UB-92)

• COB code 85 is to be used when another insurance
  carrier is billed and there is no payment from
  that carrier.
• For the deductibles and co-insurance due from any
  other carrier(s) (not Medicare) the code for
  reporting the amount paid is B1 for the
  deductibles and B2 for the coinsurance.

144
Medicare Primary Billing Instructionsfor
CMS-1450 (UB-92)

• Block 77 on the UB-92 is not required. The
  10/28/03 Medicaid Memo erroneously listed this as
  a required field.
• Block 80 must be left blank for UB-92 Medicare
  Part B paper claims. If applicable, an ICD-9-CM
  procedure code should be entered in Block 80 for
  Medicare Part A claims.

145
REMITTANCE VOUCHERSections of the Voucher

• APPROVED - for payment.
• PENDING - for review of claims.
• DENIED - no payment allowed.
• DEBIT (DR)-Adjusted claims creating a
  positive balance.
• CREDIT (CR) - Adjusted/Voided claims
  creating a negative balance.

145
146
REMITTANCE VOUCHERSections of the Voucher

• FINANCIAL TRANSACTION
• EOB DESCRIPTION
• ADJUSTMENT DESCRIPTION/REMARKS- STATUS
  DESCRIPTION
• REMITTANCE SUMMARY- PROGRAM TOTALS.

145
147
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