Department of Medical Assistance Services Medicaid Eligibility Verification Options

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Department of Medical Assistance
ServicesMedicaid Eligibility Verification
Options CMS-1500 (08-05) Billing Guidelines

• Community Mental Health Rehabilitative Services
• For Adults
• September-October 2008
• 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 Community Mental Health Rehabilitative
  Services Manual
• This training contains only highlights of this
  manual and is not meant to substitute for or take
  the place of the Community Mental Health
  Rehabilitative 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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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 05/09/1994 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-
• 800-241-8726

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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 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-1500
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MAIL CMS-1500 FORMS TO

• DEPARTMENT OF MEDICAL ASSISTANCE
• SERVICES
• PRACTITIONER
• P. O. Box 27444
• Richmond, Virginia 23261

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TIMELY FILING

• ALL CLAIMS MUST BE SUBMITTED AND PROCESSED WITHIN
  ONE YEAR FROM THE DATE OF SERVICE
• EXCEPTIONS
• Retroactive/Delayed Eligibility
• Denied Claims
• NO EXCEPTIONS
• Accident Cases
• Other Primary Insurance

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TIMELY FILING

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

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Block 1
TRICARE
MEDICAID
CHAMPUS
1. MEDICARE
(Medicare )
(Medicaid )
(Sponsor's SSN)
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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
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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?
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
Please indicate NO for recipients who have
no other insurance coverage. DMAS does not
require providers to complete Blocks 9 a-d.
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Block 21 Diagnosis Codes (Current ICD.9 Code)
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY
3139
1.
3.
2963
2.
4.
May enter up to 4 codes
Omit decimals
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Block 23 Prior Authorization Number
(Conditional)
23. PRIOR AUTHORIZATION NUMBER
24
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Blocks 24A thru 24J

• These blocks have been divided into open areas
  and a shaded red line area
• The shaded area is ONLY for supplemental
  information
• Instructions will be given on when the use of the
  shaded area is required for claims processing

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TPL Information Block 24A

• Qualifier TPL will be used followed by
  dollars/cents amount whenever an actual payment
  is made by a third party carrier
• No spaces between the qualifier and dollars and
  no symbol used
• Decimal between dollars and cents is required to
  read paid amount correctly
• Must be left justified

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TPL Information Block 24A

• DMAS will set COB code based on the information
  given in locator 11d.
• No, or nothing indicated-no other carrier-old COB
  code 2
• No, or nothing indicated/system has other
  insurance-claim will deny bill other insurance
• No, or nothing indicated/TPL qualifier with
  payment in 24a red area-old COB code 3

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TPL Information Block 24A

• DMAS will set COB code based on the information
  given in locator 11d.
• Yes, but nothing in 24a red area-other carrier
  billed and made no payment-old COB code 5
• Yes, and TPL qualifier with payment in 24a red
  area-other carrier billed and paid-old COB code 3

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Block 24A Dates of Service
24. A.
DATE(S) OF SERVICE
From
To
MM DD YY
MM DD YY
TPL27.08
08
08
08
01
08
01
1
08
01
08
08
31
08
2
Both FROM and TO dates
must be completed
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
11-Office location 12- Patients Home 53
Community Mental Health Center
of
Service
11
Medicaid accepts the same 2 digit CMS Place of
Service codes as Medicare.
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Emergency Indicator-24C

• This locator will be used to indicate whether the
  procedure was an emergency
• DMAS will only accept a Y for yes in this
  locator
• If there was no emergency leave blank

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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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Procedure Codes

• Crisis Intervention Services - H0036
• Crisis Stabilization - H2019
• Intensive Community Treatment - H0039
• Mental Health Support Services - H0046
• Mental Health Case Management - H0023

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Block 24D Procedure Codes
D.
PROCEDURES, SERVICES, OR SUPPLIES
(Explain Unusual Circumstances)
CPT/HCPCS
MODIFIER
H0046

H0023
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Block 24E Diagnosis Code
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY
3139
1.
3.
2963
2.
4.
E.
DIAGNOSIS
POINTER
1
Enter the identifier of the ICD-9-CM diagnosis
code listed in Locator 21. To identify more than
one diagnosis code, separate the indicators with
a comma.
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
1
31
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ID.QUAL Block-24I

• Qualifier 1D is to be used in the red shaded
  area for claims being submitted using the
  Atypical Provider Identifier (API).
• Qualifier ZZ is to be used to indicate the
  taxonomy code-only when the NPI is used and only
  if necessary to adjudicate the claim.

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Rendering Provider ID Block-24J

• The shaded red area will contain the API
• OR-
• The open area will contain the NPI of the
  provider rendering the service.

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Block 24I ID. Qualifier 24J Rendering
Provider ID
J. RENDERING PROVIDER ID.
I. ID. QUAL
Atypical Provider Identifier (API)
1D
NPI
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Block 24I ID. Qualifier 24J Rendering
Provider ID
I. ID. QUAL
J. RENDERING PROVIDER ID.
1D
001234567
NPI
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Block 24I ID. Qualifier 24J Rendering
Provider ID
I. ID. QUAL
J. RENDERING PROVIDER ID.
ZZ
Taxonomy (if needed)
1234567890
NPI
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Block 26 Patients Account Number
26. PATIENT ACCOUNT NUMBER
12345678918765
Can not exceed 14 alphanumeric digits
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Block 28 Total Charges
28. TOTAL CHARGE

Please list the total all charges in Block 28.
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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 32Service Facility Location Information

• Enter information for the location where services
  were rendered
• First line-Name
• Second line-Address
• Third line-City, State, 9 digit zip code
• No punctuation in the address
• Space between city and state
• Include hyphen for the 9 digit zip code

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Block 32Block 32, contd.Service Facility
Location Information

• Providers with multiple offices/locations - the
  zip code must reflect the office/ location where
  services were rendered
• Enter the 10 digit NPI number of the service
  location in 32a.
• OR-
• Enter 1D qualifier with the API in 32b

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

• Enter the information to identify the provider
  that is requesting to be paid
• First line-Name
• Second line-Address
• Third line-City, State, 9 digit zip code
• No punctuation in the address
• Space between city and state
• Include hyphen for the 9 digit zip
• Phone number is to be entered in the area to the
  right of the field title, no hyphen or space used

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Billing Provider Info PH -Block-33a-b

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

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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, Community Mental Health
Rehabilitative Services Manual has resubmission
code list.
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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