Department of Medical Assistance Services

1
Department ofMedical Assistance Services
Outpatient Psychiatric and Substance Abuse
Services Eligibility and Billing

• July - August 2008
• www.dmas.virginia.gov

2

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

2
3
Training Objectives

• Upon completion of this training participants
  should be able to
• Verify Medicaid Eligibility
• Correctly complete a claim on the new CMS-1500
  (08-05)
• Have a clear understanding of the guidelines
  required for the proper submission of forms, i.e.
  timely filing and adjustments/voids

4
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

5
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.
6
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
7
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, Optima Family Care,
Healthkeepers Plus, Amerigroup, or Virginia
Premier Health Plan.
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Eligibility Verification

• MediCall
• ARS- Web-Based Medicaid Eligibility

9
MediCall/ARS- Information Available

• Medicaid client eligibility/benefit verification
• Service limit information
• Claim status
• Prior authorization
• Provider check log
• Primary Payer Information
• Medallion Participation
• Managed Care Organization Assignment

10
MediCall

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

11
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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Automated Response System (ARS)

• NPI Compliant ARS Web Site will allow
• Access to claims status for bills submitted using
  an NPI
• Access to claims status for bills submitted by a
  Group Practice
• Enhanced delegated administration capability
  provided by the User Administration Console (UAC)

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User Administration Console

• No longer will providers have the limitation of
  only one ARS user associated to an individual
  Provider Identification Number
• Providers were required to re-enroll and
  establish their new access to use the ARS
  beginning December 3, 2007.

14
Automated Response System- Registration

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

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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

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Important Contacts

• Provider Call Center
• Provider Enrollment
• Electronic Billing

17
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 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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Electronic Billing

• Mailing Address
• EDI Coordinator-Virginia OperationsFirst Health
  Services Coordinator4300 Cox RoadRichmond, VA
  23060
• E-mail edivmap_at_fhsc.com
• Phone [phone]
• Fax [phone]

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Billing on the CMS-1500
21
MAIL CMS-1500 FORMS

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

22
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

23
TIMELY FILING

• Submit claims with documentation attached
  explaining the reason for delayed submission
• You must use modifier 22 in Locator 24D to
  ensure review of attached documentation

24
Block 1

• The locator will now be used to indicate if the
  claim is Medicaid, TDO, or ECO
• Enter an X in the MEDICAID box for the Medicaid
  Program
• Enter an X in the OTHER box for Temporary
  Detention Order (TDO) or Emergency Custody Order
  (ECO)

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Block 1
TRICARE
MEDICAID
CHAMPUS
1. MEDICARE
(Medicare )
(Medicaid )
(Sponsor's SSN)
2. PATIENT'S NAME (Last Name, First Name, Middle
Initial)
MEDICAID CLAIM
24
26
Block 1
GROUP
CHAMPVA
FECA
OTHER
BKL LUNG
HEALTH PLAN
(ID)
(SSN or ID)
(SSN)
(Member ID)
TDO or ECO CLAIM
25
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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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28
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?
WV
YES
NO
c. OTHER ACCIDENT?
NO
YES
You MUST check YES or NO for a, b c
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Is There Another Health Benefit Plan?Block11d

• Providers should only check yes if there is other
  third party coverage
• If there is no other coverage check no or leave
  blank

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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
DMAS does not require items 9 a-d to be
completed.
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Block 21 Diagnosis Codes
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY
3441
1.
3.
2963
2.
4.
May enter up to 4 codes
Omit decimals
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33
Prior Authorization NumberBlock 23

• If service requires prior authorization, enter
  the eleven digit PA number assigned by KePro
• Enter the number preassigned to the TDO or ECO
  form that is obtained from the magistrate
  authorizing the TDO/ECO

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KePRO Contacts

• Questions
• KePRO - 888.827.2884
• Via email at ProviderIssues_at_kepro.org or
  PAUR06_at_dmas.virginia.gov

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Block 23 Prior Authorization Number - Conditional
23. PRIOR AUTHORIZATION NUMBER
32
36
NPI Compliance

• A Prior Authorization (PA) obtained with a
  Legacy Medicaid PIN that spans over May 23, 2008,
  must be billed using the NPI for claims received
  by DMAS on or after May 22, 2008.
• A crosswalk is in place to match claims submitted
  with an NPI to PAs obtained with a Legacy
  Medicaid PIN.

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NPI Compliance

• All PAs should be requested using the Rendering
  (Servicing) Providers NPI.
• The PA should not be requested using the Group
  Practice organization NPI and claims will deny
  if it is obtained with a Group NPI.

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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

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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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Block 24A Dates of Service
24. A.
DATE(S) OF SERVICE
From
To
MM DD YY
MM DD YY
TPL27.08
08
08
03
31
03
31
1
04
01
08
04
16
08
2
Both FROM and TO dates
must be completed
35
Dates must be within same calendar month
41
TPL Information Block 24A

• DMAS will set COB code based on the information
  given in locator 11d.
• No, or nothing indicated-no other
• 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

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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, attachment required
• Yes, and TPL qualifier with payment in 24a red
  area-other carrier billed and paid

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NDC Information Block 24A

• Qualifier N4 is used followed by the National
  Drug Code (NDC) whenever a HCPCS J-code is
  submitted in 24D.
• No spaces between the qualifier and the NDC
  number
• Must be left justified
• The HCPCS code, J8499 (unclassified
  non-chemotherapeutic drug, oral administration)
  may also be used to bill for the opioid drug.

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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
03
31
03
31
1
N400026064871
04
01
08
04
16
08
2
Both FROM and TO dates
must be completed
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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 21- Inpatient
11
Medicaid accepts the same 2 digit CMS Place of
Service codes as Medicare.
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46
Emergency IndicatorBlock 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
Y
Medicaid will accept a Y in this Locator to
indicate that the procedure was an emergency
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48
Block 24D Procedure Codes
D.
PROCEDURES, SERVICES, OR SUPPLIES
(Explain Unusual Circumstances)
CPT/HCPCS
MODIFIER
22
90804
90804
HF
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J Code Mandate Block 24D

• When billing a J Code the red shaded area must
  have the unit of measurement (UOM) qualifier.
• Valid qualifiers
• F2 international unit
• ML milliliter
• GR gram
• UN unit
• The numeric quality of the drug (greater than
  zero) administered to the patient must be entered
  after the qualifier.

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J-Code Mandate Block 24D

• Enter the actual metric decimal quantity (units)
  administered to the patient
• If reporting a fraction of a unit, use the
  decimal point
• The maximum number of bytes allowed for the
  quantity is 13, including the decimal point.

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Block 24D Procedure Codes
D.
PROCEDURES, SERVICES, OR SUPPLIES
(Explain Unusual Circumstances)
CPT/HCPCS
MODIFIER
GR0.0004
J0881


J0881 constitutes 1mcg of a drug, the quantity
given was 400 mcg which converts to 0.0004 grams
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Block 24E Diagnosis Code
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY
34431
1.
3.
2963
2.
4.
E.
DIAGNOSIS
POINTER
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
1,2
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Block 24 F Charges
F.
CHARGES
Enter the usual
and customary charges
45
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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
400
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Block 24H EPSDT/Family Plan
H.
EPSDT Family Plan
1
1-EPSDT 2-Family Planning Service
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ID.QUALBlock 24I

• Qualifier 1D is to be used in the red shaded
  area for claims being submitted using the 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 current API
• The open area will contain the NPI of the
  provider rendering the service

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Block 24I ID. Qual. 24J Rendering Provider ID

J. RENDERING PROVIDER ID.
I. ID. QUAL
1234567890-API
1D
NPI
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Block 24I ID. Qual. 24J Rendering Provider ID

J. RENDERING PROVIDER ID.
I. ID. QUAL
Taxonomy (if needed)
ZZ
12345647890
NPI
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DMAS Service Types May Require A Taxonomy Code on
ClaimsTaxonomy Codes
61
(No Transcript)
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Taxonomy Codes

• A complete list of the taxomony codes accepted by
  DMAS can be found at
• http//www.dmas.virginia.gov/downloads/pdfs/npi_
• DMAS_TaxonomyCodeSummary.pdf
• If you have a question related to Taxonomy please
  email DMAS at
• NPI_at_dmas.virginia.gov

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Block 26 Patients Account Number (Optional)
26. PATIENT ACCOUNT NUMBER
12345678918765
Can not exceed 17 alphanumeric digits
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Total ChargeBlock 28

• DMAS now requires this locator to be completed
• Enter the total charges for the services in 24F
  lines 1-6.

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Block 28 Total Charges
28. TOTAL CHARGE

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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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Service Facility Location InformationBlock 32

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

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Service Facility Location InformationBlock 32a-b

• Enter the 10 digit NPI number of the service
  location in 32a
• Enter 1D qualifier with the API in 32b OR
• Enter ZZ qualifier with the taxonomy code if
  needed in 33b, when using the NPI in 32a

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

• 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 billing
  provider in 33a
• Enter 1D qualifier with the API in 33b
• DO NOT use taxonomy codes when submitting group
  NPIs

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NPI Compliance

• Group Practices were required to begin billing as
  groups as of May 23, 2008.
• Providers must submit the Groups organization
  Type-2 NPI as the Billing Provider and the
  practitioners individual Type-1 NPI as the
  Rendering (Servicing) Provider on all claim
  submissions
• Groups billing incorrectly will have their claims
  denied effective May 23, 2008.

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Block 33 Billing Provider Info PH
33. BILLING PROVIDER INFO PH
( )
a.
b.
NPI
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NPI Compliance

• A taxonomy code should never be sent for the
  Billing Provider when the billing provider is a
  Group Practice.
• If sent, the taxonomy code should be associated
  with the Rendering (Servicing) Provider.
• Sending a taxonomy code for a Group Practice
  provider on an electronic claim will result in
  the rejection of the claim(s).

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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, Medicaid Physicians Manual has code
list.
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THANK YOU