Medicaid 101 The Basics

1
Medicaid 101- The Basics
Department of Medical Assistance Services

• Hospital
• April - July 2006

www.dmas.virginia.gov
2
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.
• Bill any and all other third-party carriers.

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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
4
Medicaid Verification Options

• MediCall
• ARS- Web-Based Medicaid Eligibility

5
MediCall

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

6
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

7
Automated Response SystemARS

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

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ARS- Information Available

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

9
Automated Response System- Registration

• Registration
• virginia.fhsc.com
• Questions concerning registration process
• Web Support Helpline 800-241-8726

10
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

11
Copay Indicators

• Code A
• Under 21- No copay exists
• Code B
• Long Term Care, Home or Community Based Waiver
  Services, Hospice-No copay
• Code C
• All other clients collect all applicable copays

12
Copay Exemptions

• Enrollees in managed care may not have copays
• Pregnancy related/family planning services
• Emergency services

13
Copay Amounts

• Inpatient hospital 100.00 per admission
• Outpatient hospital clinic 3.00 per visit
• Clinic visit 1.00 per visit
• Physician office visit 1.00 per visit
• Other physician visit 3.00 per visit
• Eye examination 1.00 per examination

14
Provider Call Center

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

15
Billing Inquiries
Customer Service Department of Medical
Assistance Services 600 East Broad Street, Suite
1300 Richmond, VA 23219
16
Provider Enrollment

• New provider numbers, change of address, or
  Electronic Fund Transfer (EFT) requests
• First Health PEU
• P. O. Box 26803
• Richmond, VA 23261
• 888-829-5373
• 804-270-5105
• 804-270-7027 - Fax

17
National Provider Identifier (NPI)

• The NPI is a 10 digit number and the standard
  unique  identifier for health care providers.
• Many health plans, including Medicare, Medicaid,
  and private health insurance issuers, and all
  health care clearinghouses must accept and use an
  NPI in standard transactions by May 23, 2007. 

18
National Provider Identifier (NPI)

• After this compliance date, health care providers
  may use only their NPI to identify themselves in
  standard transactions, where the NPI is called
  for.  
• As a result of a Federal Mandate, DMAS will
  require all of its participating providers to
  obtain and use a National Provider Identifier
  (NPI) in lieu of your current Medicaid provider
  identification number(s) for all standard
  transactions, including paper claims.

19
National Provider Identifier (NPI)

• The Department of Medical Assistance Services is
  targeting First Quarter 2007 as the starting date
  for accepting either the NPI or Medicaid
  Identifiers in the transactions from trading
  partners.
• System changes must occur before an NPI can be
  accepted by DMAS. If an NPI is used in lieu of a
  Medicaid Provider ID in a claim prior to DMAS
  readiness announcement, it will be denied.

20
NPI/API

• Please visit the DMAS website for latest
  information-
• www.dmas.virginia.gov/hpa-npi-home.htm
• Questions regarding NPI/API can be sent to-
• NPI_at_dmas,virginia.gov

21
National Provider Identifier (NPI)

• For additional information visit
• https//nppes.cms.hhs.gov.
• For the specifications for the NPI
• http//www.cms.hhs.gov/NationalProvIdentStand/
• www.wedi.org/npioi/index.shtml

22
National Provider Identifier (NPI)

• National Plan and Provider Enumeration System
  (NPPES)
• 1-800-465-3203
• To complete an application online, please visit
• https//nppes.cms.hhs.gov/NPPES/Welcome.do

23
Requests for DMAS Forms and Manuals

• DMAS Order DeskCOMMONWEALTH MARTIN1700
  Venable StreetRichmond, Virginia 23222

Phone [phone] Emaildmas_at_cms-mpc.com
24
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]

25
DMAS Websitewww.dmas.virginia.gov

• Current, most up-to-date information on Virginia
  Medicaid programs
• Provider memos available for review
• Access to Medicaid manuals
• Top 50 Common Error Reason Codes with Resolutions
• Numeric Insurance Code List
• Primary Carrier Coverage Code List

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DMAS Websitewww.dmas.virginia.gov

• Financial Reason Code Description List
• State and Local Hospital (SLH) Program Balance
  Statement
• Hospital DRG Rates for Fiscal Year 2006
• Medicaid Forms
• Medicaid/FAMIS-PLUS Client Handbook

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(No Transcript)
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Medicaid Programs
29
Medicaid Programs

• Medicaid Fee-for-Service
• No Primary Care Physician (PCP)
• No mandatory referral from the PCP.

• Medallion
• Primary Care Physician who directs all care.
• PCP referral required for all non-emergency
  services.

30
Medallion II HMO ID Cards

• Issued by the Managed Care Organizations
• Client will have both HMO and Medicaid cards
• Eligibility verification is a REQUIREMENT

31
Medallion II HMO ID Cards

• The Anthem card for Medicaid clients indicates
  Anthem HealthKeepers Plus. (Plus identifies the
  Medicaid plan).
• The Optima Card for Medicaid clients indicates
  Optima Family Care. (Family Care
  identifies the Medicaid plan).
• Virginia Premier only has a contract for Medicaid
  HMO- anyone presenting a VAPremier Card is a
  Medicaid client.

32
Medallion II HMO ID Cards

• The Southern Health Services card for Medicaid
  clients indicates CareNet.
• AMERIGROUP Virginia, Inc. provides coverage for
  Medicaid clients.

33
Virginia Medicaid HMO Contacts
34
Managed Care Helpline

• Providers/recipients can also contact the
  Medicaid Managed Care Helpline for
  assistance
• 1-800-643-2273
• 830 am 600 pm
• Monday - Friday

35
Client Medical Management CMM

• Mandatory Primary Care Physician and/or
  Pharmacist who directs all care
• Responsibilities
• coordinating routine medical care
• making referrals to specialists as necessary
• arrange 24 hour coverage when not available
• explain to recipients all procedures to follow
  when office is closed or there is an urgent or
  emergency situation

36
Designated Physicians - CMM

• Services provided to CMM clients will be
  reimbursed only
• in a medical emergency/delay in treatment may
  cause death, lasting injury or harm
• on written referral from PCP using the
  Practitioner Referral Form (DMAS-70), includes
  covering physicians
• covered services excluded from CMM program
  requirements

37
CMM Referrals

• Recipient Monitoring Unit
• Telephone [phone]
• CMM Helpline 1-888-323-0589

38
Medicaid Programs

• FAMIS
• Medical program for children under 19.
• First 30 days coverage in the FAMIS
  fee-for-service program.
• Mandatory Managed Care Organization (where
  available) after initial 30 days.

• FAMIS MOMS
• For pregnant women above Medicaid income
  guidelines
• MCO guidelines same as FAMIS
• Apply thru CPU or DSS

39
ALIENS

• Section 1903v of the Social Security Act requires
  Medicaid to cover emergency services for
  specified aliens when the services are provided
  in an emergency room or inpatient hospital
  setting.
• Hospital outpatient follow-up visits or physician
  office visits are not included in the covered
  services.

40
Aliens

• Emergency medical treatment only
• Eligibility requests should be sent to the local
  DSS
• Emergency Medical Certification form required for
  claim submission

41
Aliens

• To be covered, the services must meet
• emergency treatment criteria and are
• limited to
• Emergency room care
• Physician services
• Inpatient hospitalization not to exceed limits
  established for other Medicaid recipients
• Ambulance service to the emergency room
• Inpatient and outpatient pharmacy services
  related to the emergency treatment

42
State and Local Hospital - SLH

• Covered Services
• Acute care inpatient hospital services (excluding
  rehab and free-standing psychiatric hospitals)
• Acute care outpatient services.
• Ambulatory surgical services.
• Department of Health Clinic Services.
• SLH claims should be submitted with the Medicaid
  provider number.

43
Temporary Detention Order - TDO

• ALL TDO claims must have the TDO form attached to
  the front of the claim.
• Claims submitted without the TDO form will be
  returned to the provider
• The TDO form must be signed by the law
  enforcement officer and dated to be valid.
• TDO is the payer of last resort. SLH is the
  exception, paying primary over TDO.

44
Temporary Detention Orders - TDO

• Mail all TDO claims to
• Department of Medical Assistance Services
• TDO- Payment Processing Unit
• 600 East Broad Street, Suite 1300
• Richmond, VA 23219

45
Medicaid Benefit Package
46
Qualified Medicare Beneficiaries- QMB

• Eligible only for payment of Medicare premiums,
  deductibles, and coinsurance.
• Medicaid will consider the Medicare deductibles
  and coinsurance for benefits.
• If Medicare does not cover the service, the
  service should not be billed to Medicaid.

47
Qualified Medicare Beneficiaries- QMB Extended

• This group is eligible for Medicaid coverage of
  premiums, deductibles, and coinsurance plus all
  other Medicaid-covered services.
• Medicaid will consider the Medicare deductibles
  and coinsurance for benefits.
• Clients are also eligible for all Medicaid
  covered services.

48
Medicaid Benefit Programs

• Special Low-Income Beneficiaries -This group is
  only eligible for Medicaid coverage of the
  Medicare Part B premium only.
• Family Planning Waiver Services-This group is
  eligible for Medicaid family planning related
  services only.

49
Clarification of Family Planning Waiver

• Any woman enrolled as a Medically Indigent
  pregnant woman, who received a pregnancy related
  service paid by Medicaid on or after 10/01/03 is
  automatically eligible for the waiver at the end
  of her Medicaid coverage.
• The Medicaid client should visit her local DSS to
  ensure she has been enrolled.
• Eligible clients are enrolled for up to 24 months
  following the end of pregnancy.

50
Clarification of Family Planning Waiver

• The Family Planning Waiver provides coverage for
  the following services only
• Annual gynecological exams
• Family planning education and counseling
• Over-the-counter birth control supplies and
  prescription birth control supplies approved by
  the Federal Food and Drug Administration (FDA).

51
Clarification ofFamily Planning Waiver

• Family Planning Waiver covered services, contd.
• Sterilizations (excluding hysterectomies) and the
  required hospitalization
• Testing for sexually transmitted diseases (STDs)
  during family planning visits

52
Clarification of Family Planning Waiver

• Family Planning Waiver services are reimbursed on
  a fee-for-service basis.
• Please refer to the 11/05/04 Medicaid Memo for
  specific billing guidelines.
• Because Family Planning Waiver clients receive a
  limited benefit package, it is important to
  access each Medicaid participants eligibility
  and service limit status prior to providing
  services.

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Billing on the CMS-1450
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MAIL CMS-1450 FORMS TO

• Virginia Medical Assistance Program
• P. O. Box 27443
• 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 Eligibility
• Delayed Eligibility
• Denied Claims
• NO EXCEPTIONS
• Accident Cases
• Other Primary Insurance

56
TIMELY FILING

• Submit claims with documentation attached
  explaining the reason for delayed submission
• You must have the word Attachment in Locator 84.

57
Locator 1 Provider Name and Address
Provider NameStreet Address or Post Office
BoxCity, State, Zip CodePhone Number
57
58
Locator 3 Patient Control Number
Medicaid will accept an account number which
does not exceed 17 alphanumeric characters.
58
59
Locator 4 Type of Bill
OriginalBill

59
60
Locator 4 Enter the code as appropriate.
Valid codes for Virginia Medicaid -INPATIENT

• 111- Original Inpatient Hospital Invoice
• 112- Interim Inpatient Hospital Invoice
• 113- Continuing Inpatient Hospital Invoice
• 114- Last Inpatient Hospital Invoice
• 117- Adjustment Inpatient Hospital
• 118- Void Inpatient Hospital Invoice

60
61
The proper use of these codes will enable DMAS
to reassemble cycle-billed claims to form DRG
cases for purposes of DRG payment calculations
and cost settlement.
62
Locator 4 Type of Bill
OriginalBill

• 131- Original Outpatient Invoice
• 137- Adjustment Outpatient Invoice
• 138- Void Outpatient Invoice

62
63
TDO Bill Types

• 111-Original Inpatient
• 117-Adjustment Inpatient
• 118-Void Inpatient
• 131-Original Outpatient w/ER report
• 137-Adjustment Outpatient
• 138-Void Outpatient
• NOTE- Adjustments and Voids for TDO were
  effective 07/01/03.

64
SLH Bill Types

• 111-Original Inpatient
• 112-Interim Inpatient
• 113-Continuing Inpatient
• 114-Last Inpatient
• 117-Adjustment Inpatient
• 118-Void Inpatient

65
SLH Bill Types

• 131-Original Outpatient
• 137-Adjustment Outpatient
• 138-Void Outpatient

66
Locator 5 Federal Tax Number (TDO only)
Enter the number assigned to providers by the
federal government for tax reporting purpose.
(TIN or EIN)
66
67
Locator 6 Statement Covers Period
6 STATEMENT COVERS PERIOD
THROUGH
FROM
Must have FROM and THROUGH dates - Must be in
2-digit format.
67
68
Locator 6

• For hospital admissions on or after January 1,
  2000, the billing cycle for general medical
  surgical services has been expanded to the
  minimum of 120 days for both children and adults
  except for psychiatric services. Psychiatric
  services for adults remains limited to 21 days.
  Interim claims (bill types 112 or 113) submitted
  with less than 120 days will be denied. Bill type
  111 or 114 submitted with greater than 120 days
  will be denied.

69
TDO Requirement

• Enter the beginning and ending dates for the
  ACTUAL time span for TDO.
• Dates of service may overlap calendar months but
  may not cross over the fiscal year end.
• Claims submitted outside the TDO period will be
  returned.

70
SLH Requirements

• Enter the beginning and ending service dates
  (including covered and non-covered days).
• Use both from and to for a single day with
  the discharge status of 01.

71
SLH Requirements

• Interim claims (112 or 113) with less that 120
  days will be denied
• Bill type 111 or 114 with more than 120 days will
  be denied
• Psychiatric claim which exceed 21 day limitation
  will be denied.
• Billing may overlap calendar months

72
Overlapping Eligibility
73
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.
73
74
Locator 8 Non-Covered Days
8 N-CD.
Enter the days of care not covered for inpatient
only. Non-covered days are not included in
covered days.
74
75
Locator 12 Patient Name
Enter the patient's name - last, first, middle
initial
75
76
Locator 13 Patient Address
Enter the patients address. (Only required for
TDO if known)
76
77
Locator 14 Patient Birthdate
03181995
Enter the month, date, and full year(MMDDYYYY)
77
78
Locator 15 Sex
15 SEX
Enter the sex of the patient as recorded on the
date of admission, outpatient service, or start
of care.
78
79
Locators 17 - 20Admission Information
ADMISSION
17 DATE
18 HR
19 TYPE
20 SRC
Enter all admission information date, hour,
type, and source
79
80
Locator 17 Admission Date
ADMISSION
Enter the date of admission for inpatient care.
The date must be the same date for all claims
related to the same admission. Enter the date of
service for outpatient care.
DATE
NOSPACES
NOSLASHES
80
81
Locator 18 Admission Hour
ADMISSION
Enter the hour during which the patient
was admitted for inpatient or outpatient care.
81
82
Locator 19 Admission Type
For inpatient services only, enter the
appropriate code indicating the priority of
admission. A CODE 1 (emergency) indicates a
copay does not apply.
82
83
Locator 20 Admission Source
ER 7
Enter the appropriate code for the source of
admission. Code 7 (Emergency Room) indicates
copay does not apply.
83
84
TDO Requirements

• Locator 19 for TDO will always be 1.
• Locator 20 for TDO will always be 8.

85
Locator 21 Discharge Hour
Enter the hour the patient was discharged
from inpatient care.
85
86
Locator 21

• TDO-Enter the hour the patient appeared at the
  Involuntary Detention Hearing.
• SLH-Enter the hour the patient was discharged
  from inpatient care.

87
Locator 22 Patient Status
Enter for inpatient and outpatient
Enter status code as of ending date in Statement
Covers Period (Locator 6).
87
88
Locator 22 Patient Status
If the patient was a one-day stay, enter code
01. Correct reporting of patient status code
will facilitate quick and accurate determination
of DRG reimbursement. In particular, accurate
reporting of the values 01,02,05, and 30 will be
very important in DRG methodology.
89
TDO Requirement

• Code 01 discharged, NOT 30 still a patient,
  is to be used when the patient remains in the
  hospital after the TDO hearing.

90
Locator 23 Medical Record Number
23 MEDICAL RECORD NO.
Enter the Provider's Patient Record Number
90
91
Locators 24-30 Condition CodesRequired if
Applicable
CONDITION CODES
26
24
25
27
28
29
30

• A1 EPSDT
• A4 FAMILY PLANNING
• A7 INDUCED ABORTION DANGER TO LIFE
• A8 INDUCED ABORTION VICTIM RAPE/INCEST

91
92
Locators 36Occurrence Span Codes and Dates
OCCURRENCE SPAN
36
THROUGH
FROM
CODE
If code 71 is used, enter FROM/THROUGH
dates given by the patient for any hospital,
skilled nursing facility (SNF), or nursing
facility stay that ended within 60 days of this
hospital admission.
92
93
Locator 37 Internal Control Number/ Document
Control Number
37
Primary payer
A
Secondary payer
B
Tertiary payer
C
Adjustment/Voids - enter the 9 to 16 digit claim
reference number of the previously paid claim. Be
sure to use the appropriate type of bill (Locator
4) in combination with the reference number. A
brief explanation is required in Locator 84.
93
94
Locator 39 - 41 Value Codes and Amounts
82
83
85
Enter the appropriate code(s) and amount(s), if
applicable
94
95
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)
  other than Medicare Part A, code 83 must be
  entered, and the amount covered/paid by the
  primary carrier must be entered in the amount
  section of the locator.

96
Locator 39-41

• 85 Billed Not Covered/No Payment- primary
  insurance has excluded this service, applied the
  entire amount to the patients deductible,
  coverage has been terminated, or 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 the denial or non-coverage.

97
Locator 42 Revenue Code
Enter the appropriate revenue code(s) for the
service provided. Code must be four digits,
right justified, no leading zeros.
97
98
SLH Outpatient Revenue Codes

• 0450-Hospital Emergency Room
• 0510-Hospital Outpatient Clinic
• 0490-Hospital Ambulatory Surgery Suite

99
Locator 43 Revenue Description
Enter the revenue code description which can be
found in the Hospital Manual- Chapter V,
Exhibits.
99
100
Locator 44 HCPCS/Rates
Inpatient Enter accommodation
rate. Outpatient Enter the applicable HCPCS
code.
Ambulatory Surgical Centers must have a
surgical CPT code on the same line as revenue
code 0490.
100
101
Locator 45 SERV. DATE Required if Applicable
Enter the date the service was provided.
101
102
Locator 46 Units of Service
Inpatient Enter the total number of covered
accommodation days or ancillary units of service
where appropriate.
102
103
Locator 46 Units of Service
Outpatient Enter the units of service for
physical therapy, occupational therapy, or
speech- language pathology visit or session (1
visit 1 unit)
46 SERV. UNITS
103
104
Locator 47 Total Charges (by Revenue Code)
Enter the total charge(s) pertaining to the
related revenue code for the current billing
period as entered in the statement covers
period. Total charges must include only covered
charges.
104
105
Locator 47 Total Charges (by Revenue Code)
Note Use revenue code 0001 for TOTAL.
106
Locator 50 Payer Identification
Primary payer
Secondary payer
Tertiary payer
Enter "MEDICAID. When TDO or SLH is the only
payer, enter TDO or SLH on Line A.
106
107
Locator 51 Provider Number
A
Primary payer
B
Secondary payer
C
Tertiary payer
Enter the Provider ID Number on the appropriate
line corresponding with the payer name in Locator
50.
107
108
Locator 58 Insured's Name
Enter the client's last name, first name, and
middle initial.
108
109
Locator 59 Patient's Relationship to Insured
Enter the code indicating the relationship of the
insured to the patient. Refer to the CMS website
for codes.
109
110
Locator 60 Certificate/SSN/ HIC/ Identification
Number
Enter 12-digit Client ID Number
110
111
Locator 60

• TDO-DMAS staff will enter the enrollees ID
  number after eligibility has been determined
• SLH-Enter the unique SLH ID number assigned by
  the local Department of Social Services.

112
Locator 63 Treatment Authorization Code
Enter the number indicating that the treatment is
authorized by the payer. Enter the
preauthorization number assigned for the
appropriate inpatient and outpatient services.
112
113
Locator 63 Treatment Authorization Code (TDO
Only)
Enter the number indicating the treatment was
authorized, this will be the actual TDO number on
the form.
113
114
PREAUTHORIZATION REQUIRED

• MATERNITY CLAIMS/Baby delivered elsewhere
• When delivery occurred outside of hospital
  preauthorization from the Medicaid Prior
  Authorization Contractor is required.

115
Medicare Exhaust Days

• MEDICARE PRIMARY/Days Exhausted
• Preauthorization from the Medicaid Prior
  Authorization Contractor is required.
• Proof of exhausted Medicare days must be
  submitted with preauthorization if requested.

116
Medicare Exhaust Days

• All days must be billed.
• Initial stay less than 120 days, bill type 111.
• First 120 days bill type 112 next 120 days bill
  type 113 continue bill type 113 for any
  additional 120 day periods.
• Final bill type 114.

117
Medicare Exhaust Days

• Providers should list the amount Medicare paid on
  the 112 bill type (less than 120 days list
  payment on 111 bill type).
• Medicare payment should be listed in Block 39a
  and use COB code 83 (billed and paid).

118
Medicare Exhaust Days

• DO NOT WRITE the word CROSSOVER in Block 11
  (Medicare is exhausted and the days billed to
  Medicaid were not paid by Medicare)
• Block 84- providers MUST put write a statement
  MEDICARE DAYS EXHAUSTED or attach something
  showing Medicare are exhausted (Medicare EOB).

119
Medicare Exhaust Days

• If Medicaid has considered a crossover claim for
  deductible and coinsurance on days Medicare paid
  or any Part B charges-
• If the provider keeps all charges on the claim
  submitted for Medicare Exhaust days, all payments
  must be listed.
• If the provider deletes Part B charges, do not
  list any Part B payment amounts.

120
Special Note

• If the Medicaid recipient does not have Part A
  coverage, the COB code should be 82 (No Other
  Coverage).

121
Locator 67 Principal Diagnosis Code
NO DECIMALS
Enter the ICD-9-CM code that describes the
principal diagnosis.
121
122
Locator 76 Admitting Diagnosis Code
NO DECIMALS
Enter the ICD-9-CM diagnosis code provided at
admission as stated by the physician.
122
123
Locator 79 Procedure Coding Method Used
5 - HCPCS 9 - ICD-9-CM
9
Enter the code identifying the coding method
used in FL 80, 81
123
124
Locator 80 Principal Procedure Code and Date
NO DASHES NO SLASHES
NO DECIMALS
Enter the ICD-9-CM code for the major procedure
performed during the billing period.
124
125
Locator 80 Principal Procedure Code and Date

• For outpatient claims, a procedure code must
  appear in this locator when revenue codes
  0360-0369, 0420-0429, 0430-0439, and 0440-0449
  (if covered by Medicaid) are used in locator 42
  or the claim will be rejected.

126
Locator 80 Principal Procedure Code and Date

• For inpatient claims, a procedure code or one of
  the diagnosis codes of V64.1-V64.3 must appear in
  this locator (or on FL 67) when revenue codes
  0360-0369 are used in FL 42 or the claim will be
  rejected.

127
Locator 80 Principal Procedure Code and Date

• Procedures that are done in the Emergency Room
  (ER) one day prior to the client being admitted
  for an inpatient hospitalization from the ER may
  be included on the inpatient claim.

128
SLH

• For outpatient ambulatory surgical center claims,
  a CPT procedure code must appear on the same line
  as the revenue code 0490 in Locator 42 or the
  claim will be denied.

129
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.
129
130
Locator 82 Attending Physician
Physician Name
Inpatient Enter the nine-digit number assigned
by Medicaid for the physician attending the
patient. Outpatient Enter the number assigned
by Medicaid for the physician who performs the
principal procedure.
130
131
Locator 83 Other Physician ID
MEDALLION PCP
MEDALLION Physician Name

OTHER PHYS. ID
Physician Name
131
132
Locator 84 Remarks
a
b
Additional information necessary to adjudicate
the claim
c
d
132
133
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)
133
134
Locator 86 Date
Enter the date on which the bill is being
submitted to Medicaid (required for paper claims
only).
134
135
Medicaid Claims Correction vs. Appeals

• Claims submitted to VA Medicaid which have been
  denied for these claim issues do not meet our
  definition of an appeal
• Claim form not completed correctly
• Incorrect procedure/diagnosis codes
• Additional information required and not submitted
  with claim
• Authorization not listed or incorrect
• Provider should correct the information and
  resubmit as a brand new claim.

136
Medicaid Claims Correction VS. Appeals

• Claims submitted to Medicaid which have been
  denied for
• Service not covered by Medicaid
• Authorization denied or service not authorized
  within specified Medicaid guidelines
• Service denied as not being medically necessary
• Repayment of identified overpayments
• Services denied for these reasons can be
  appealed.

137
Medicaid Appeal Guidelines

• Specific Medicaid appeal guidelines can be found
  the Hospital Manual.

138

• TDO Tips

139
TDO Tips

• Make sure that the TDO order is attached to every
  claim, a copy is acceptable
• Make sure the provider number is in Locator 51
• Make sure the revenue codes are 4 digit codes

140
TDO Tips

• When using COB code 83 in Locator 39 make sure
  the dollar amount listed as paid from the primary
  carrier is for the TDO period ONLY, not the
  entire paid amount
• Locator 46 and 7 should always be the same

141
TDO Tips

• The TDO period shall not exceed 48 hours, if the
  48 hrs ends on a Sat. Sun. or legal holiday it
  will end on the next work day which is not a
  Saturday
• Bill type 131 MUST have the ER Report attached to
  the claim

142

• SLH Tips

143
SLH Tips

• Claims will no longer pend for reason code 0737-
  SLH Hospital Review
• M codes ended as of 12/31/03.
• Claims can only be adjusted within the same
  fiscal year

144
SLH Tips

• If an earlier claim was submitted with
  documentation you may indicate in Locator 84 that
  documents were already submitted and indicate the
  ICN of that claim rather than attaching
  documentation again.

145
Error Reason Code 0291 Claim Pending for Budget
(SLH Funds)

• Error Reason Code 0291 may be identified when
  checking the status of SLH claims via the
  MediCall or ARS system.
• Claims received after SLH funds are exhausted
  will be pended with Code 0291-
• Claim Pended for Budget (SLH Funds)
• This information is currently reported on your
  Remittance Advice (RA).

146
Error Reason Code 0291 Claim Pending for Budget
(SLH Funds)

• If there are no SLH funds available, claims are
  placed in the pended status until the end of the
  program year (SLH Program year runs May 1 April
  30).
• If the localitys funds are exhausted, and a
  previously approved claim payment is retracted,
  the funds will be made available to be paid on
  the next claim- from the pended group.

147
Medicare Primary

• Crossover Claims

148
Medicare Primary Billing Instructions for
CMS-1450

• 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.

149
Medicare Primary Billing Instructions for
CMS-1450

• 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

150
Medicare Primary Blocks 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).

151
Medicare Primary Billing Instructions for
CMS-1450

• 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.

152
Medicare Primary Billing Instructions for
CMS-1450

• 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.

153
Medicare Primary Billing Instructions for
CMS-1450

• 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.

154
Hospital Claims

• In order to avoid claim denials for outpatient
  hospital services over 20,000 and inpatient
  hospital services over 500,000, these claims
  should be submitted to Medicaid on paper instead
  of electronically.
• The paper claim will pend and the attachments to
  the claim will be reviewed for justification of
  the charges.

155
Outpatient Surgery

• For elective outpatient surgical procedures which
  require Preauthorization by Medicaid Medical
  Support (Physicians Manual, Chap. IV, pgs.
  89.1-99), submit paper claim.
• Contact the surgeon and request a copy of his PA
  letter ( the facility services do not required
  preauthorization).
• Attach a copy of the PA letter to the back of
  your claim form.
• Do not put the Physicians PA on your claim.

156
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.

157
REMITTANCE VOUCHERSections of the Voucher

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

158
THANK YOU

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