Medicaid Biller Training

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Medicaid Biller Training

• For Out-of-state Providers

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Resources

• New Providers
• Refer to Michigan Medicaid website, Provider
  Enrollment
• MI Eligibility Verification System 1-888-696-3510
• Prior Authorization (All Non Emergency Services
  require PA)
• MA eligibility 517-335-5198
• CSHCS eligibility 517-335-9440
• Michigan Uniform Billing Manual
• Phone [phone] Fax  [phone]
• www.michigansubc.org
• Health Claim Form Association 1500
• Refer to Michigan Medicaid website, Medicaid
  Provider Manual, BILLING REIMBURSEMENT FOR
  PROFESSIONALS, section 3.
• Website www.michigan.gov/mdch gtgt PROVIDERS gtgt
  INFORMATION FOR MEDICAID PROVIDERS
• Medicaid Provider
• Explanation codes, Reason Remark codes
• Provider Specific Information (Fee-Screens)
• Provider Support
• Phone [phone]
• Email ProviderSupport_at_michigan.gov

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PROVIDERS
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Information for Medicaid Providers
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Provider Enrollment

• When to contact Provider Enrollment
• New Providers
• Refer to Michigan Medicaid website, Provider
  Enrollment for the enrollment form
• When any information associated with your Trading
  Partners Agreement changes
• Tax ID/Affiliation
• Addresses
• License (renewed, restored, additional)
• Specialties
• Billing Agents
• NPI

• PROVIDER ENROLLMENT UNIT
  
• MEDICAID PAYMENTS DIVISION ProviderEnrollment_at_m
  ichigan.gov
• MEDICAL SERVICES ADMINISTRATION
• MICHIGAN DEPARTMENT OF COMMUNITY HEALTH
• PO BOX 30238
  ?Phone [phone]
• LANSING, MI 48909 Fax [phone]
•  

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National Provider Identifier (NPI)

• Providers may now apply for their NPI through CMS
• Must have NPI by May 23, 2007
• MI Medicaid does not currently require NPI but
  greatly encourages applying now
• More NPI Information
• https//nppes.cms.hhs.gov
• 1-800-465-3203 (NPI Toll-Free)
• customerservice_at_npienumerator.com

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MMIS

• Coming Soon
• Online Provider Enrollment
• Online Eligibility
• Online Claims Submission
• Online Claim Status
• And More, All Direct from MDCH

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Eligibility Verification

• Automated Voice Response System (AVRS) Free
  (1-888-696-3510) Need Provider Type/ID and
  beneficiary information
• WebDenis - Free (www.bcbsm.com/providers)
• Medifax - for a fee (www.medifax.com)
• Healthcare Data Exchange (HDX) - for a fee
  (www.hdx.com )

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Eligibility Verification

• Scope/Coverage
• Level of Care (LOC)
• Third Party Liability (TPL)

• Scp/Cvrg 2-digit alpha/numeric code indicating
  which Medical Assistance Program the beneficiary
  is enrolled (i.e. Medicaid, CSHCS, ABW, MOMS,
  etc.)
• LOC A modifier to the patients Scope/Coverage
  indicating other circumstances (i.e. nursing
  facility or hospice patient, enrolled in HMO,
  beneficiary is incarcerated, etc.)
• TPL Any other payers preceding Medicaid
  Medicaid is always the payer of last resort.

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Eligibility Verification

• Common Scope Code
• 1 - Medicaid
• 2 - Medicaid
• 3 - Adult Benefit Waiver
• 4 - Refugees and Repatriates

• Scope/Coverage
• 0 (zero) - No Medicaid eligibility/coverage
  (Deductible / Spend-down)
• E - Emergency or urgent Medicaid coverage only
• F - Full Medicaid coverage
• G - Adult Benefit Waiver

• Common Level of Care Code
• Blank (No LOC code) - fee-for-service (FFS).
• 02 - nursing facility services
• 11 - Adult Benefit Waiver (CHP)
• 07 - Medicaid Health Plan (MHP)
• 10 Patient Pay amount
• 16 - hospice

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Eligibility Policies

• Beneficiary Eligibility Chapter, Medicaid
  Provider Manual (Eligibility Code Descriptions)
• Adult Benefits Waiver Chapter, Medicaid Provider
  Manual (Coverages and Limitations)
• Childrens Special Health Care Services Program
  Chapter, Medicaid Provider Manual
• Medicaid Health Plans, Medicaid Provider Manual
  (HMO responsibilities)
• MI CHILD www.michigan.gov/mdch gtgt Health Care
  Coverage gtgt Children and Teens (NOT MEDICAID)
• Third Party Liability (TPL) at MDCH
• Medicare Buy-In Unit at MDCH

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Third Party Liability (TPL)

• To remove or update other insurance information
  from Third Party Liability (TPL) file
• Phone [phone] (option 4)
• Fax [phone]
• Email TPL_Health_at_Michigan.gov

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Medicare Buy-In Unit (MDCH)

• Lewis Cass Building Phone [phone]
• 320 South Walnut Fax [phone]
• Lansing, MI 48913 Email BuyInUnit_at_Michigan.g
  ov

• The Medicare Buy-In Unit is responsible for
• Processing Medicare premium payments for eligible
  Medicaid beneficiaries.
• Other Insurance Coding for Medicare on the
  Medicaid system.
• Alien information for Medicaid beneficiaries that
  are age 65 or over, must have the date of entry
  forwarded to the Buy-In Unit if the beneficiary
  has not been in the US for over 5 consecutive
  years.
• The Medicare Buy-In unit will not be able to
  address questions from the beneficiaries.

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Medicaid Billing Limitations

• 12 month limitation from Date of Service (DOS)
• Inpatient admission- 12 month from discharge date
• Continuous Activity Within 120 days from last
  rejection
• Documentation is needed for
• Claim replacements when Previously billed with
  incorrect
• Provider ID Number
• Beneficiary ID Number

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Claim Submission

• PAPER
• No confirmation until CRN appears on RA
• 30-60 days to appear on Medicaid RA
• Must attach EOB
• No paper clips, white out or dot matrix printers

• ELECTRONIC
• 997 Acknowledgement receipt from Medicaid
• 7-14 days to appear on Medicaid RA
• No EOB needed
• A list of approved billing agents is posted at
  Electronic Billing website

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Electronic Billing

• Shopping for an Electronic Billing Agent
• Billing Agent Authorization Form
• 835/277U Request Form
• Billing Agents responsibilities
• Billing And Reimbursement Chapters, Medicaid
  Provider Manual
• AutomatedBilling_at_michigan.gov

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Electronic Claims

• Medicaid accepts electronic Primary, Secondary
  and Tertiary claims
• EOBs are not needed when submitting
  secondary/tertiary claims electronically
• CAS Codes are required
• Complete Loop 2400 and 2430 for claim Procedure
  Code and Modifier (Professional)
• Professional claims only need to be sent on paper
  when attachments (besides EOBs) are needed

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Crossover Claims(Special Services)

• Medicaid is accepting crossover claims from WPS
  and AdminaStar
• Bulletin All Provider 04-05, issued June 1, 2004
• Bulletin MSA 05-02, issued January 1, 2005
• Provider ID must be included in Loop 2010AA
• Example REF1D108888888
• Medicaid will soon allow the Provider ID in Loop
  2310B, Rendering Billing Provider ID
• FAQs posted at Provider Updates webpage

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Crossover Claims(Special Services)

• Troubleshooting Crossover
• Medicare EOB says that the Claim was forwarded
  to MDCH for Reimbursement but claim never
  appears on Medicaid Remittance Advice
• This means that your Medicaid Provider Type and
  ID were not in the proper provider identifying
  field within your electronic claim
• See your vendor for correction
• Rebill to Medicaid any crossover claims that do
  not appear within 30 days of Medicare EOB
• Groups of providers who submit batches of claims
  under one Medicare group ID but more than one
  Medicaid Provider ID should not attempt to
  crossover until further notice

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835 Electronic Remittance Advice

• The 835 is the only electronic format available
• Paper is still available
• 835 reports all paid and rejected claims
• 277U will report pended claims
• MDCH edits no longer exist
• Nationally recognized Reason/Remark codes
• Posted electronically and on paper RA
• Crosswalk available at website
• www.michigan.gov/mdch gtgt Providers gtgt Information
  for Medicaid Providers gtgt Electronic Billing

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Remittance Advice
Checks and Remittance Advice (EOB) mailed
separately

• MSA
• Remittance Advice
• Payment Information by beneficiary
• Issued by MDCH
• Date, Provider Type/ID, Amounts match Warrant
  Date, Provider Type/ID, Amounts
• One RA issued to each Provider ID

• State of Michigan Remittance Advice
• Attached to the Check
• Check and RA (AKA Warrant)
• Payment information by Provider Type/ID and Tax
  ID
• Issued by Department of Treasury
• 39S 391 MDCH/Medicaid
• One RA issued to each Tax ID

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Replacement

• Examples of when a claim may need to be
  replaced
• To return an overpayment (report "returning
  money" in Remarks section)
• To correct information submitted on the original
  claim (other than to correct the Provider ID
  number and/or the beneficiary ID number). Refer
  to the Void/Cancel subsection below
• To report payment from another source after MDCH
  paid the claim (report "returning money" in
  Remarks section) and/or
• To correct information that the scanner may have
  misread (state reason in Remarks section).

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Replacement

• To replace a previously paid claim,
• UB-92-
• indicate 7 (xx7) as the third digit in the Type
  of Bill Form locator frequency.
• enter the 10-digit Claim Reference Number (CRN)
  of the last approved claim being replaced
• the reason for the replacement in Remarks. The
  Provider ID number and beneficiary ID number on
  the replacement claim must be the same as on the
  original claim.
• Refer to Michigan Medicaid manual, BILLING
  REIMBURSEMENT FOR INSTITUTIONAL, section 3.1

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Replacement

• To replace a previously paid claim,
• HCFA 1500-
• Report code 7 in the left side of Item 22
• Report the ten-digit Claim Reference Number (CRN)
  of the previously paid claim in the right side of
  Item 22
• State reason in the Remarks section
• NOTE If the resubmission code of 7 is missing
  the claim cannot be processed as a replacement
  claim.
• If all service lines of a claim were rejected,
  the services must be resubmitted as a new claim,
  not a replacement claim.
• Refer to Michigan Medicaid manual, BILLING
  REIMBURSEMENT FOR PROFESSIONALS, section 4.1

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Void/Cancel

• If a claim was paid under the wrong provider or
  beneficiary ID Number,providers must void/cancel
  the claim.
• UB-92
• indicate an 8 in the Type of Bill (xx8) as the
  third digit frequency.
• enter the 10-digit CRN of the last approved claim
  or adjustment being cancelled and
• enter in Remarks Section the reason for the
  void/cancel.
• A new claim may be submitted immediately using
  the correct provider or beneficiary ID number.
• A void/cancel claim must be completed exactly as
  the original claim.
• Refer to Michigan Medicaid manual, BILLING
  REIMBURSEMENT FOR INSTITUTIONAL, section 3.2

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Void/Cancel

• If a claim was paid under the wrong provider or
  beneficiary ID Number,providers must void/cancel
  the claim.
• HCFA 1500
• Report code 8 in the left side of Item 22
• Report the ten-digit Claim Reference Number (CRN)
  of the previously paid claim in the right side of
  Item 22
• complete one service line and enter zero dollars
• (000) in all money fields.
• State reason in the Remarks section
• Refer to Michigan Medicaid manual, BILLING
  REIMBURSEMENT FOR PROFESSIONALS, section 4.2

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Prior Authorization

• All out of state services that have been prior
  authorized must
• indicate in Remarks (F.L. 19) OUT OF STATE
• prior authorization number in prior authorization
  field

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Appeals

• Claim is submitted to MDCH (PO Box 30043)
• Claim is denied
• If necessary, correct claim information indicated
  as insufficient/incorrect on RA and resubmit
• If corrected claim is rejected contact Provider
  Support Hotline for counsel
• (1-800-292-2550)

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Appeals

1. Hotline advice is followed, but claim is still
   processed improperly
2. Send paper claim with letter explaining
   situation/history and request for action to
   Special Payments Research and Analysis (PO Box
   30731)
3. Research and Analysis either denies request or
   processes but system still rejects

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Appeals

• If all requirements have been satisfied and all
  instruction followed but claim continues to
  reject, MDCH Administrative Tribunal should be
  contacted
• MDCH Administrative Tribunal Appeals Division
• PO Box 30763
• Lansing, MI 48909
• Phone [phone]