Medicaid Eligibility Verification Options

1
Medicaid Eligibility Verification Options
CMS-1450 (UB-04) Billing Guidelines

• October - December 2008
• www.dmas.virginia.gov
• Department of Medical Assistance Services

2

• This presentation is to facilitate training of
  the subject matter in Chapter V of the Virginia
  Medicaid Psychiatric Services Manual.
• This training contains only highlights of this
  manual and is not meant to substitute for or take
  the place of the Psychiatric 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 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
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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 Process

• Go 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
• 804-786-6273
• 830am 430pm (Monday-Friday)
• 1100am 430pm (Wednesday)

13
Provider Enrollment

• New provider enrollment, Electronic Fund
  Transfer (EFT) 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 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-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
• Other Primary Insurance

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TIMELY FILING

• Submit claims with documentation attached to the
  back of the form, explaining the reason for
  delayed submission
• You should have the word Attachment in the
  Remarks field, Locator 80

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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

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CMS-1450 CLAIM FORM
Use ONLY the ORIGINAL RED WHITE UB-04
Invoice Photocopies are not Acceptable Computer
generated claims must match NUBC uniform standards
21
Locator 1 Providers Name, Address and Phone
Number

• Enter the providers name, complete mailing
  address and telephone number of the provider that
  is submitting the bill and which payment is to be
  sent.
• NOTE DMAS will need to have the 9 digit zip code
  on line four, left justified for adjudicating the
  claim.

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Locator 1 Provider Name, Address and Phone
Number
1
Our Place Facility
121 Friendly Street
Any Town
VA
12345-6456 8049781234
22
23
Locators 3a and 3b

• 3a Patient Control Number - Enter the patients
  unique financial account number which does not
  exceed 20 alphanumeric characters.
• 3b Medical/Health Record - Enter the number
  assigned to the patients medical/health record
  by the provider. This number cannot exceed 24
  alphanumeric characters.

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Locators 3a- Patient Control Number 3b-
Medical/Health Record Number
3a PAT. CNTL
123456789ABCDEFGH012
b. MED REC.
987654321HGFEDCBA1234567
Patient Control Number and Medical/Health Record
Number are required for all UB-04 claim
submissions.
24
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Locator 4 Type of Bill

• Enter the code as appropriate.
• The Type of Bill field has been increased from
  three digits to four digits by adding a leading
  zero.
• Claims submitted without the required four digit
  bill type will be denied.

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Locator 4 Type of Bill

• 0161 Original Residential Treatment Invoice
• 0162 First Interim Residential Treatment
  Invoice
• 0163 Subsequent Residential Treatment
  Invoice (s)
• 0164 Final Residential Treatment Invoice
• 0167 Adjustment Residential Treatment
  Invoice
• 0168 Void Residential Treatment Invoice

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Locator 4 Type of Bill
InterimBill

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Locator 6 Statement Covers Period

• STATEMENT COVERS PERIOD
• FROM THROUGH

093008
090108
Enter the beginning and ending service dates
reflected by this invoice (include both covered
non-covered days). Use both from and to for
a single day.
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29
Locator 8 Patient Name/Identifier
8 PATIENT NAME
a

b
Last First M
Enter the last name, first name and middle
initial of the patient.
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Locator 10 Patient Birthdate
10 BIRTHDATE
10011995
Enter the date of birth of the patient using
the following format - MMDDYYYY.
30
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Locator 11 Sex
11 SEX
F
Enter the sex of the patient as recorded at
admission, outpatient or start of care. M
Male F Female U Unknown
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Locator 12 Admission/Start of Care

• The start date for this episode of care. For
  inpatient services this is the date of admission.
  For all other services, the date the episode of
  care began
• Residential Treatment Facility - Admission or
  re-admission date

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Locator 12 Admission/Start of Care
ADMISSION 12 DATE
030508

33
34
Locator 13 Admission Hour
ADMISSION 13 HR
14
Enter the hour during which the patient was
admitted to the facility. Medicaid will allow a
default time for Residential Facility
patients. NOTE Military time is used as defined
by NUBC.
34
35
Locator 14 Priority Type of Visit

• Appropriate PRIORITY TYPE codes accepted
  by DMAS are

35
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Locator 14 Priority (Type) of Visit
ADMISSION 14 TYPE
3
Enter the code indicating the priority of this
admission /visit.
36
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Locator 15 Source of Referral/Admission
9
Information Not Available
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Locator 15 Source of Referral for Admission
Visit
15 SRC
6
Enter the code indicating the source of
the Referral for this admission or visit.
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39
Locator 17Patient Discharge Status

• Appropriate codes accepted by DMAS in claims
  processing

39
40
Locator 17 Patient Discharge Status
Appropriate codes accepted by DMAS in claims
processing
40
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Locator 17 Patient Discharge Status
17 STAT
30
Enter the code indicating the disposition or
Discharge status of the patient at the end for
the Service period covered on this bill
(Statement Covered Period, Locator 6).
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42
Locators 18-28 Condition Codes

• These codes are used by DMAS in the adjudication
  of claims

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Locators 18-28 Condition Codes (Required if
Applicable)
Condition Codes 18 19 20 21 22 23 24 25
26 27 28
A1
Enter the code (s) in alphanumeric sequence Used
to identify conditions or events related to this
bill that may affect adjudication. NOTE A1 is a
required Condition Code for all Residential
Facility Claims submitted to DMAS.
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Locators 39-41 Value Codes and Amount

• Note DMAS will be capturing the number of
  covered or non-covered day (s) or units for
  outpatient services with these required value
  codes
• 80 Enter the number of covered days for
  inpatient facility.
• 81 Enter the number of non-covered days for
  facility.

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Locators 39-41 Value Codes and Amount

• Enter the appropriate code (s) to relate amounts
  or values to identify data elements necessary to
  process this claim.
• One of the following codes must be used to
  indicate coordination of third party insurance
  carrier benefits
• 82 No Other Coverage
• 83 Billed and Paid (enter amount paid by
  primary carrier)
• 85 Billed Not Covered/No Payment

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Locators 39-41Value Codes and Amount

• VALUE CODES
• CODE AMOUNT

• VALUE CODES CODE AMOUNT

795 29
80 30
83
a
b
c
d
46
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Locator 42 Revenue Code

• Enter the appropriate revenue code (s) for the
  service provided. Note
• Multiple services for the same item, providers
  should aggregate the service under the assigned
  revenue code and then total the number of units
  that represent those services
• DMAS has a limit of five pages for one claim
• The Total Charge revenue code (0001) should be
  the last line of the last page of the claim

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Locator 42 Revenue Code
42 REV. CD.
1
0120
0001
2

3
4
Revenue codes are four digits, leading zero,
left justified and should be reported in
ascending numeric order.
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Locator 43 Revenue Description
43 DESCRIPTION
RB-Semi-Pvt-2 Bed-General
Total Charge

Enter the standard abbreviated description of
the related revenue code categories included on
this bill.
49
50
Locator 44 HCPCS/Rates/HIPPS
Rates Codes
44 HCPCS / RATE / HIPPS CODE
Inpatient Enter the accommodation rate.
50
51
Locator 45 Service Date (Required if
Applicable)
45 SERV. DATE
080108
51
52
Locator 46 Service Units
46 SERV. UNITS
30

Inpatient Enter total number of covered
accommodation days or ancillary units of service
where appropriate.
52
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Locator 47 Total Charges
47 TOTAL CHARGES
46 SERV. UNITS
1755 75
TOTALS
Enter the total charge(s) for the primary payer
during the statement covers period including
both covered and non-covered charges. Note
Use code 0001 for TOTAL.
53
54
Locator 48 Non-Covered Charges (Required if
Applicable)
48 NON-COVERED CHARGES
75
00
To reflect the non-covered charges for the
primary payer as it pertains to the
related revenue code.
54
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Locator 50 Payer Name A-C

• Enter the payer from which the provider may
  expect some payment for the bill.
• When Medicaid is the only payer, enter Medicaid
  on line A.
• If Medicaid is the secondary or tertiary payer,
  enter on lines B or C.

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Locator 50 Payer Name A-C
50 PAYER NAME
MEDICAID
A Primary Payer B Enter the secondary
payer identification, if
applicable. C Enter the tertiary
payer if applicable.
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Locator 56 National Provider Identification
(NPI)

• Providers must share their NPI with the DMAS
  Provider Enrollment Unit (PEU).
• Once your NPI is on file with the PEU, providers
  will bill their NPI in this field.

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Locator 56 NPI
56 NPI
1234567890
10 digit NPI should be listed in this field.
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Locator 58 Insureds Name
58 INSUREDS NAME
Virginia J. Recipient
A B C
Enter the name of the insured person covered
by the payer in locator 50. The name on the
Medicaid line must correspond with the enrollee
name when eligibility is verified.
59
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Locator 59 Patients Relationship to Insured

• Note appropriate codes accepted by DMAS are

60
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Locator 59 Patients Relationship to Insured
52 REL. INFO
18
Enter the code indicating the relationship of
the insured to the patient.
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Locator 60 Insureds Unique Identification
60 INSUREDS UNIQUE ID
012345678910
For lines A-C, enter the unique identification
number of the person insured that is assigned by
the payer organization shown on lines A-C,
Locator 50. NOTE The Medicaid recipient ID
number is 12 numeric digits.
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Locator 63 Treatment Authorization Codes
63 TREATMENT AUTHORIZATION CODES
A B
12345678910
Enter the 11 digit preauthorization number
assigned by KePro for the appropriate services
to be billed to Virginia Medicaid.
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64
Locator 64Document Control Number (DCN)

• This locator is to be used to list the original
  Internal Control Number (ICN) for APPROVED claims
  that are being submitted to adjust or void the
  original claim.

64
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Locator 64Document Control Number
(Required if Applicable)
64 DOCUMENT CONTROL NUMBER
2007363123456701
The control number assigned to the original
bill by Virginia Medicaid as part of their
internal claims reference number.
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Locator 66 Diagnosis and Procedure Code
Qualifier (ICD Version Indicator)
66 DX
9
The qualifier that denotes the version of
the International Classification of Diseases.
Qualifier 9 for the Ninth Revision. NOTE
Virginia Medicaid will only accept a 9 in this
locator.
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67
Locators 67A-Q Principal Diagnosis Code
Present on Admission (POA) Indicator

• The eighth digit of the Principal, Other
  and External Cause of Injury Codes are to
  indicate if
• the diagnosis was know at the time of admission,
  or
• the diagnosis was clearly present, but not
  diagnosed, until after the admission took place
  or
• was a condition that developed during an
  outpatient encounter

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Locator 67 A-Q POA Indicator

• The POA indicator should be listed in the shaded
  area. Reporting codes are
• CODE DEFINITION
• Y YES
• N NO
• U No information in the record
• W Clinically undetermined

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Locator 67 Principal Diagnosis Code
67
A
B
C
I
J
K
L
Enter the diagnosis codes corresponding to
all conditions that coexist at the time of
admission, that develop subsequently, or that
affect the treatment received and/or the length
of stay. NOTE Do not use decimals.
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Locator 69 Admitting Diagnosis

• ADMIT
• DX

2963
Enter the diagnosis code describing the
patients diagnosis at the time of
admission. NOTE Do not use decimals.
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Locator 76 Attending Provider
76 ATTENDING
NPI 1234567890
Enter NPI for the physician who has overall
responsibility for the patients medical care and
treatment reported on this claim..
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Locator 80 Remarks Field
80 REMARKS
Enter additional information necessary to
adjudicate the claim. Enter a brief description
of the reason for the submission of the
adjustment or void. If there is a delay in
filing, indicate the reason for the delay here
and include an attachment.
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Locator 81 Code-Code Field

• DMAS previously assigned different provider
  numbers for each type of service performed.
• Medicaid payment was then issued based on the
  type of service billed.
• DMAS will be using this field to capture a
  taxonomy code for claims that are submitted for
  one NPI with multiple business types or locations
  (e.g., Residential or Psychiatric units within
  an acute care facility).

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Locator 81 Code-Code Field

• The taxonomy code will be required for providers
  who do not have a separate NPI for each different
  service billed to VA Medicaid.
• The taxonomy code will also be required for
  providers who have one NPI for multiple business
  locations.
• Code B3 is to be entered in the first small space
  and the provider taxonomy code is to be entered
  in the second large space. The third space should
  be blank.

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Locator 81 Code-Code Field
81CC a b c d
B3 323P00000X
Enter the provider taxonomy code for the billing
provider when the adjudication of the claim is
known to be impacted.
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DMAS Services That May Require Taxonomy Codes on
Claims
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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.

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REMITTANCE VOUCHERSections of the Voucher

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

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THANK YOU
Department of Medical Assistance Services

• www.dmas.virginia.gov