Intellectual Disabilities Mental Retardation Waiver Eligibility Verification Options

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Intellectual Disabilities/Mental Retardation
WaiverEligibility Verification Options
CMS-1500 Billing GuidelinesJuly August
2008www.dmas.virginia.gov

• Department of Medical Assistance Services

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• This presentation is to facilitate training of
  the subject matter in Chapter V of the Virginia
  Medicaid Mental Retardation Community Services
  Manual
• This training contains only highlights of this
  manual and is not meant to substitute for or take
  the place of the Mental Retardation Community
  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
• Identify and transfer ICD-9 diagnosis codes from
  the patient file to claims

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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

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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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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)
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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
3180
1.
3.
319
2.
4.
May enter up to 4 codes
Omit decimals
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ICD-9 Diagnosis Codes

• All claims submitted to DMAS will require a
  current ICD-9 diagnosis code for payment
  processing.
• Some 3-digit diagnosis codes are valid
• 317 (mild mental retardation) is a valid 3-digit
  DX code
• 319 (mental retardation) is a valid 3-digit DX
  code

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ICD-9 Diagnosis Codes

• If the current year ICD-9 book indicates the
  diagnosis code requires 4-5 digits, the code
  listed on the claim submission must include 4-5
  digits
• 318 (other specified mental retardation) requires
  an additional 4th digit to be a valid diagnosis
  code 3180, 3181 or 3182
• Claims submitted without a valid diagnosis code
  will be denied

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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 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 Dates of Service
24. A.
DATE(S) OF SERVICE
From
To
MM DD YY
MM DD YY
08
08
05
01
05
01
1
05
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
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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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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Block 24D Procedure Codes
D.
PROCEDURES, SERVICES, OR SUPPLIES
(Explain Unusual Circumstances)
CPT/HCPCS
MODIFIER
97535

97537 U1
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Block 24E Diagnosis Code
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY
3180
1.
3.
319
2.
4.
E.
DIAGNOSIS
POINTER
1
Enter the identifier of the ICD-9 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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Medicaid Memo- 06/18/08- Rates

• Providers with a Dept. of Rehab Services (DRS)
  approved rate, will be reimbursed the DRS rate
  for DMAS payment of agency-directed individual
  supported employment services.
• Medicaid RA reason code 0670 (Pricing by Provider
  Procedure Rate) will identify procedures paid
  based on the DRS rate.
• Providers without the DRS approved rate will
  continue to receive the DMAS fee-for-service rate.

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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
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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 10
  digit 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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DMAS Service Types May Require A Taxonomy Code
on Claims
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Rendering Provider ID Block-24J

• The red shaded area will contain the 10 digit
  Atypical Provider Identifier (API)
• OR
• The white open area will contain the NPI of the
  provider rendering the service.

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Block 24I ID. Qualifier 24J Rendering Provider
ID Atypical Provider Identifier (API)
I. ID. QUAL
J. RENDERING PROVIDER ID.
1D
0012345670
NPI
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Block 24I ID. Qualifier 24J Rendering Provider
ID National Provider Identifier (NPI)
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 29 Amount Paid

• Patient pay amount is taken from services billed
  in Block 24A line 1
• If multiple services are provided on the same
  date of service, another form must be completed.
  Only one line per claim form 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)
29. 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 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 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 10 digit API in the
  red shaded area of 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 10 digit API in the
  red shaded area of 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, Mental Retardation Community 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