Department of Medical Assistance Services

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Department ofMedical Assistance Services
Outpatient Psychiatric Services Training PART
II Medicaid Eligibility and Billing

• February-March 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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Eligibility Medicaid or Medallion II HMO
Clients enrolled in the Medicaid Program will be
identified by a Virginia Medicaid Eligibility
Card. Eligibility can be verified by MediCall,
ARS, or other system options.
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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
• 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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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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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

• DMAS Order DeskCOMMONWEALTH MARTIN1700
  Venable StreetRichmond, Virginia 23222

Phone [phone] Emaildmas_at_cms-mpc.com
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Billing on the CMS-1500
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MAIL CMS-1500 FORMS

• Dept. of Medical Assistance Services
• Practitioner
• P. O. Box 27444
• Richmond, VA 23261

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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-1500 FORMUse ONLY the originalRED and
WHITE InvoicePhotocopies are not acceptable!
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Block 1 Check Medicaid
MEDICAID
CHAMPUS
1. MEDICARE
(Medicare )
(Medicaid )
(Sponsor's SSN)
2. PATIENT'S NAME (Last Name, First Name, Middle
Initial)
CHECK MEDICAID BLOCK ONLY
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Block 1a Client 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
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 10D
10d. RESERVED FOR LOCAL USE
ATTACHMENT
You MUST use the word "ATTACHMENT"
if you attach anything to the CMS form.
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Block 21 Diagnosis Codes
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY
3090
1.
3.
29630
2.
4.
May enter up to 4 codes
Omit decimals
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Block 23 Prior Authorization Number
(Conditional)
23. PRIOR AUTHORIZATION NUMBER
Enter the PA number assigned by DMAS for the
approved service.
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Block 24A Dates of Service
24. A
DATE(S) OF SERVICE
From
To
MM DD YY
MM DD YY
04
04
01
01
01
31
1
01
04
31
31
04
01
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 Block 24C Type of
Service
B
C
Type
Place
of
of
Service
Service
11
1
11- Office
1- Medical Care

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Block 24D Procedure Codes
D
PROCEDURES, SERVICES, OR SUPPLIES
(Explain Unusual Circumstances)
CPT/HCPCS
MODIFIER
90853
22
90801
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Block 24E Diagnosis Code
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY
3090
1.
3.
29630
2.
4.
E
DIAGNOSIS
CODE
1
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.
1,2
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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
Enter the number of times or hours the procedure,
service, or item was provided during the service
period.
DAYS
OR
UNITS
1
2

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32
Block 24I EMG
I
EMG
1-Emergency
If not emergency-
related, leave
blank
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33
24J COB Other Insurance 24K Other Insurance
Paid
J
K
RESERVED FOR
LOCAL USE
COB
Attach denial from other carrier Attachment in
10d required
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Block 26 Patients Account Number (Optional)
26. PATIENT ACCOUNT NUMBER
XXXXXXXXXXXXXXXXX
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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 33 Provider ID and Address
33. PHYSICIAN'S, SUPPLIER'S BILLING NAME,
ADDRESS, ZIP CODE
PHONE
00765432 1
PIN
GRP
Be sure to put the MEDICAID
9-digit ID number!
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Block 22 Adjustments and Voids
22. MEDICAID RESUBMISSION
CODE
ORIGINAL REF. NO.
1026
XXXXXXXXXXXXXXXX
Adjustment or
From original
Void
remittance
Resubmission
Code
37
(See CMS instructions for list of codes)
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Problems being encountered withCMS-1500 Claims
Submission
BLOCK
PROBLEM AREA
Block 1
Incorrect block checked
Block 1a
Incorrect Client's ID
Block 10d
Incorrect information entered
All of Block 24
Comments entered in blocks
Block 24E
Diagnosis code written out
Blocks 24 J K
(J) left blank (K) incorrect info.
Block 33
Not entering Provider ID by "PIN"
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BILLING MEDICAREDEDUCTIBLE AND COINSURANCE
TITLE XVIII (DMAS-30 R 6/03)
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Medicare Primary

• The Medicare Program Part B Carriers serving
  Virginia and the Virginia Medicaid Program have
  developed a system whereby these carriers will
  send to Virginia Medicaid the Medicare
  Explanation of Benefits (EOB) for identified
  Virginia clients.

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Medicare Primary

• This information will be used by the Program to
  pay Medicare coinsurance and deductible amounts
  determined by the carrier.
• Do not bill Virginia Medicaid directly for
  services rendered to clients who are also covered
  by Medicare Program Part B carriers serving
  Virginia. (Medicaid Memo 10/28/03)

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Medicare Primary

• If the Medicare Part B carrier is one of these,
  bill Medicare directly on the appropriate form.
• Upon receipt of the Medicare EOB, Virginia
  Medicaid will process payment automatically to
  participating providers when the clients
  Medicare number and the providers Medicare
  vendor/provider number are in Medicaids file.

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Medicaid Primary

• If problems are encountered, the DMAS-30 invoice
  form should be completed and forwarded to

Practitioner Department of Medical Assistance
Services P. O. Box 27444 Richmond, VA 23261-7444
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Title XVIII Common Mistakes

• Locator 7 - Other Coverage
• Locator 8 - Type Coverage
• Locator 17- Charges to Medicare
• Locator 18- Allowed By Medicare
• Locator 19- Paid By Medicare
• Locator 20- Deductible
• Locator 21- Coinsurance
• Locator 22- Paid By Carrier Other Than Medicare
• Locator 23- Patient Pay Amount (LTC Only)

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Title XVIII- Block 7
7
PRIMARY CARRIER INFORMA-TION OTHER THAN
(MEDICARE) 2 NO OTHER COVERAGE 3 BILLED
AND PAID 5 BILLED NO COVERAGE
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Title XVIII- Block 8
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Block 8 Type Coverage (Medicare)- Mark type of
coverage B.
TYPECOVERAGE(MEDICARE)
A B
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Title XVIII- Block 17
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CHARGES TO MEDICARE
Block 17 Charges to Medicare- Enter the total
charges submitted to Medicare.
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Title XVIII- Block 18
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ALLOWED BY MEDICARE
Block 18 Allowed by Medicare- Enter the amount
of the charges allowed by Medicare.

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Title XVIII- Block 19
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PAID BY MEDICARE
Block 19 Paid by Medicare- Enter the amount paid
by Medicare (taken from the EOB).
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Title XVIII- Block 20
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DEDUCTIBLE
Block 20 Deductible- Enter the amount of the
deductible (taken from the Medicare EOB).
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Title XVIII- Block 21
21
COINSURANCE
Block 21 Coinsurance - Enter the amount of the
coinsurance (taken from the Medicare EOB).
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Title XVIII- Block 22
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PAID BY CARRIER OTHER THAN MEDICARE
Block 22 Paid by Carrier Other Than Medicare-
Enter the payment received from the primary
carrier (other than Medicare). If Code 3 is
marked in Block 7, enter an amount in this block.
(Do not include Medicare payments.)
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Title XVIII- Block 23
PATIENT PAY AMOUNT
23
LTC ONLY
Block 23 Patient Pay Amount, LTC Only- Leave
Blank.
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TITLE XVIII- Adjustment InvoiceDMAS-31

• Block 1 Adjustment/Void
  Check the appropriate block
• Block 2 Provider Identification Number Enter
  the 7-digit number assigned by DMAS
• Block 2A Reference Number Enter
  the ICN number taken from the Title XVIII
  Deductible and Coinsurance Remittance Voucher for
  the line of payment needing adjustment.

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TITLE XVIII- Adjustment Invoice

• Blocks 3-20
  Refer to instructions for the DMAS-31 for the
  completion of these blocks.
• Remarks
  This section of the invoice should be used to
  give a brief explanation of the change needed.
• Signature
  Signature of the provider or agent and the date
  signed.

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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.

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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 Youwww.dmas.virginia.gov
THE END