Individual and Family Developmental Disabilities Support Waiver Services Case Managers Workshop

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Individual and Family Developmental Disabilities
Support Waiver ServicesCase Managers Workshop

• Medicaid Eligibility Verification Options
• Billing
• January 2009
• www.dmas.virginia.gov

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• This presentation is to facilitate training of
  the subject matter in Chapter V of the Virginia
  Medicaid Individual and Family Developmental
  Disabilities Waiver Services Manual.
• This training contains only highlights of this
  manual and is not meant to substitute for or take
  the place of the Individual and Family
  Developmental Disabilities Waiver Services
  Manual.
• Providers are responsible for reviewing and
  adhering to the Individual and Family
  Developmental Disabilities Waiver Services Manual
  requirements.

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Training Objectives

• Upon completion of this training participants
  should be able to
• Verify Medicaid Eligibility
• Correctly complete a claim on the new CMS-1500
  (08-05)
• Have a clear understanding of the guidelines
  required for the proper submission of forms, i.e.
  timely filing and adjustments/voids

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As A Participating ProviderYou Must-

• Determine the patients identity.
• Verify the patients age.
• Verify the patients eligibility.
• Accept, as payment in full, the amount paid by
  Virginia Medicaid.

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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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Medicaid Verification Options

• MediCall
• ARS- Web-Based Medicaid Eligibility

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MediCall/ARS- Information Available

• Medicaid client eligibility/benefit verification
• Service limit information
• Claim status
• Prior authorization
• Provider check log
• 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 SystemARS

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

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UAC Registration Process

• https//uac.fhsc.com/uac/pages/unsecured/common/h
  ome.jsf
• 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-
• 800-241-8726

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ARS User Guide Available

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

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Provider Call Center

• Claims, covered services, billing inquiries
• 800-552-8627
• 804-786-6273
• 830am 430pm (Monday-Friday)
• 1100am 430pm (Wednesday)

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Provider Enrollment

• New provider numbers, change of address or
  Electronic Fund Transfer (EFT)
• 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
  OperationsElectronic Claims Coordinator4300 Cox
  RoadGlen Allen, VA 23060
• E-mail edivmap_at_fhsc.com
• Phone [phone]
• Fax [phone]

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Billing on the CMS-1500
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Claims AddressConsumers Eligible for Medicaid
Department of Medical Assistance
Services Practitioner P. O. Box 27444 Richmond,
VA 23261-7444
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Claims Address
For use by Case Managers Only For services
rendered to consumers who are not yet enrolled in
the DD Waiver and do not have a Medicaid ID
number.
Supervisor Behavioral Health Developmental
Disabilities Unit Department of Medical
Assistance Services 600 East Broad Street, 10th
Floor Richmond, VA 232119
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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

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TIMELY FILING

• Submit claims with documentation attached
  explaining the reason for delayed submission

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CMS-1500 CLAIM FORM
Use ONLY the ORIGINAL RED WHITE Invoice Photo
copies are not Acceptable Computer generated
claims must match NUBC uniform standards
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Block 1
TRICARE
MEDICAID
CHAMPUS
1. MEDICARE
(Medicare )
(Medicaid )
(Sponsor's SSN)
2. PATIENT'S NAME (Last Name, First Name, Middle
Initial)
MEDICAID CLAIM
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Block 1a Recipient ID Number
1a. INSURED'S I.D. NUMBER (FOR PROGRAM
IN ITEM 1)
123456789014
(Be sure to include all 12 digits)
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Block 2 Patient's Name
2. PATIENT'S NAME (Last name, First Name, Middle
Initial)
Smith, Sam
5. PATIENT'S ADDRESS (No., Street)
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Block 10 Accident Related

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

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Block 10 Accident-Related
10. IS PATIENT'S CONDITION RELATED TO
a. EMPLOYMENT? (CURRENT OR PREVIOUS)
YES
NO
PLACE (State)
b. AUTO ACCIDENT?
WV
YES
NO
c. OTHER ACCIDENT?
NO
YES
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?

If yes, return to and complete item 9 a-d.
NO
YES
DMAS does not require items 9 a-d to be
completed. Please indicate NO for
recipients who have no other insurance coverage.
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Block 21 Diagnosis Codes
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY
3441
1.
3.
2963
2.
4.
May enter up to 4 codes
Omit decimals
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Block-23 Prior Authorization Number

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

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Block 23 Prior Authorization Number - Conditional
23. PRIOR AUTHORIZATION NUMBER
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Blocks 24A thru 24J

• These blocks have been divided into open areas
  and a shaded red line area
• The shaded red 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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Block 24A Shaded Red Area TPL Information
Block 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

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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
• 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

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TPL Billing Scenarios

• Primary carrier does not pay
• Policy us 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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Block 24A Dates of Service
24. A.
DATE(S) OF SERVICE
From
To
MM DD YY
MM DD YY
08
08
12
01
12
01
1
12
01
08
12
31
08
2
Both FROM and TO dates
must be completed
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Dates must be within same calendar month
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Block 24B Place of Service
Note Type of Service is no longer required
B.
Place
of
Service
11-Office location 12 Patients Home
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Medicaid accepts the same 2 digit CMS Place of
Service codes as Medicare
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24C Emergency Indicator

• 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

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Block 24C EMG
C. EMG
Medicaid will accept a Y in this Locator to
indicate that the procedure was an emergency
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Block 24D Procedure Codes
D.
PROCEDURES, SERVICES, OR SUPPLIES
(Explain Unusual Circumstances)
CPT/HCPCS
MODIFIER
T2023
41
42
Special Billing Instructions

• Chapter V- Billing Instructions- of the IFDDS
  Waiver Service Manual, lists all billing codes
  Medicaid accepts for DD Waiver services.
• If the National Code also has a modifier listed,
  the modifier must be included on the claim
  submission.

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Block 24E Diagnosis Code
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY
34431
1.
3.
2963
2.
4.
E.
DIAGNOSIS
POINTER
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.
1
1,2
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Block 24 F Charges
F.
CHARGES
Enter the usual
and customary charges
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Block 24G Days or Units
G.
DAYS
OR
Enter the number of times or hours the procedure,
service, or item was provided during the service
period.
UNITS
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Blocks-24I-JID Qualifier and Rendering Provider

• Qualifier 1D is to be used in 24I the shaded
  red area for claims being submitted using
  Atypical Provider Identifier (API).
• The shaded red area of 24J will contain the API.

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Blocks -24I-J ID Qualifier and Rendering
Provider-NPI

• The open area of 24J will contain the NPI of the
  provider rendering the service.
• Qualifier ZZ is to be used in the shaded red
  area of 24J to indicate the taxonomy code-only
  when the NPI is used and only if the taxonomy
  code is necessary to adjudicate the claim.

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Taxonomy Codes

• A complete list of the taxonomy codes accepted by
  DMAS can be found at
• http//www.dmas.virginia.gov/downloads/pdfs/npi_DM
  AS_TaxonomyCodeSummary.pdf
• If you have a question related to Taxonomy please
  email DMAS at
• NPI_at_dmas.virginia.gov

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Block 24I ID. Qualifier and 24J Rendering
Provider ID
J. RENDERING PROVIDER ID.
I. ID. QUAL
1D
Atypical Provider Identifier
NPI
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Block 24I ID. Qualifier and 24J Rendering
Provider ID- NPI
J. RENDERING PROVIDER ID.
I. ID. QUAL
Taxonomy (if needed)
ZZ
12345647890
NPI
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Block 26 Patients Account Number
26. PATIENT ACCOUNT NUMBER
12345678918765
Can not exceed 17 alphanumeric digits
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Block 28Total Charge

• DMAS now requires this locator to be completed
• Enter the total charges for the services in 24F
  lines 1-6.

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Block 28 Total Charges
28. TOTAL CHARGE

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Block 29Amount Paid(Personal/Waiver
Services ONLY)

• 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

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Block 29 Amount Paid (Personal and Waiver
Services ONLY)
28. AMOUNT PAID

Enter the Patient Pay amount as indicated on the
DMAS-122
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Block 31 Signature Date
31. SIGNATURE OF PHYSICIAN OR SUPPLIER
INCLUDING DEGREES OR CREDENTIALS
(I certify that the statements on the reverse
apply to this bill and are made a part thereof.)
SIGNED
DATE
If there is a signature waiver
on file, you may stamp, print,
or computer-generate the signature
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Block 32 Service 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
• 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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Block 32a-b Service Facility Location
Information

• Enter the 10 digit NPI number of the service
  location in 32a OR
• Enter 1D qualifier with API in 32b

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Block 32 Service Facility Location Information
32. SERVICE FACILITY LOCATION INFORMATION
a.
b.
NPI
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Block 33Billing 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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Block 33a-b Billing Provider Info PH

• Enter the 10 digit NPI number of the service
  location in 33a, OR
• Enter 1D qualifier with the API in 33b

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Block 33 Billing Provider Info PH
33. BILLING PROVIDER INFO PH
a.
b.
NPI
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Block 22 Adjustments and Voids
22. MEDICAID RESUBMISSION
CODE
ORIGINAL REF. NO.
1032
xxxxxxxxxxxxxxxx
From original
Adjustment or
remittance
Void
Resubmission Code
Chap. V, Medicaid Individual and Family
Developmental Disabilities Waiver Services
Manual has code list.
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THANK YOU

• Department of Medical Assistance Services
• www.dmas.virginia.gov