Children's Mental Health

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• Department of Medical Assistance Services

Children's Mental Health

Eligibility Verification Billing
Guidelines For Treatment Foster Care
April May 2006 www.dmas.virginia.gov
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OBJECTIVE-Upon completion of this
training,participants should be able to

• Verify Medicaid eligibility
• Properly submit claims
• Understand timely filing guidelines
• Including submission of adjustment/voids
• Resolve rejected/denied claims
• Interpret Medicaid Remittance Advice

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As A Participating ProviderYou Must-

• Determine the patients identity.
• Verify the patients age.
• Verify the patients eligibility.
• Accept, as payment in full, the amount paid by
  Virginia Medicaid.
• Bill any and all other third-party carriers.

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Important Contacts

• Provider Enrollment
• MediCall
• ARS- Web-Based Medicaid Eligibility
• DMAS Website
• Provider Call Center
• Customer Service

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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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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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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 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

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

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ARS- Information Available

• ARS Users Guide- located on the DMAS web-site
  under Provider Services section
• Medicaid client eligibility/benefit verification
• Service limit information
• Claim Status
• Prior authorization
• Provider check log

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(No Transcript)
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DMAS Website

• Current, most up-to-date information on Virginia
  Medicaid programs
• Provider memos available for review
• Access to Medicaid manuals
• Numeric Insurance Code List
• Primary Carrier Coverage Code List

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DMAS Website

• Financial Reason Code Description List
• Top 50 Error Reason Denial Codes and Resolutions
  
• Virginia Medicaid Error Code Crosswalk Listing
• 2005 Medicaid/FAMIS-PLUS Client Handbook

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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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Billing Inquiries

• Customer Service
• Department of Medical Assistance Services
• 600 East Broad Street, Suite 1300
• Richmond, VA 23219

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National Provider Identifier (NPI)

• The NPI is a 10 digit number and the standard
  unique  identifier for health care providers.
• Many health plans, including Medicare, Medicaid,
  and private health insurance issuers, and all
  health care clearinghouses must accept and use
  NPIs in standard transactions by May 23, 2007. 

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Atypical Provider

• Entities that do not provide health care (e.g.
  transportation services, waiver service
  providers, etc.) are not eligible to be assigned
  NPIs because they do not meet the CMS definition
  of health care provider.
• DMAS considers these non-health care providers as
  Atypical Providers.

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Atypical Provider Identifier (API)

• DMAS will determine-
• Whether we can assign you an API number
• Direct you to a third party who will assign an
  API number for you
• Or add an additional character to your existing
  ID number
• DMAS will make this determination well in advance
  of any deadline for submission and inform you in
  writing.

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NPI/API

• After the mandatory compliance dates, health care
  providers may use only their NPIs to identify
  themselves in standard transactions, where the
  NPI is called for.  
• As a result of a Federal Mandate, DMAS will
  require all of its participating providers to
  obtain and use a National Provider Identifier
  (NPI) or Atypical Provider Identifier (API) in
  lieu of your current Medicaid provider
  identification number(s) for all standard
  transactions, including paper claims.

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NPI/API

• The Department of Medical Assistance Services is
  targeting January 2007 as the starting date for
  accepting either the NPI/API or Medicaid
  Identifiers (current Medicaid Provider ID) in the
  transactions from trading partners.
• DMAS plans to notify providers six months in
  advance of the actual starting date of the
  transition implementation.

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NPI/API

• System changes must occur before an NPI/API can
  be accepted by DMAS. If an NPI/API is used in
  lieu of a Medicaid Provider ID in a claim prior
  to DMAS readiness announcement, it will be
  denied.

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NPI/API

• Please visit the DMAS website for latest
  information-
• www.dmas.virginia.gov/hpa-npi-home.htm
• Questions regarding API can be sent to-
• NPI_at_dmas,virginia.gov

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National Provider Identifier (NPI)

• For additional information, please visit-
  https//nppes.cms.hhs.gov."
• For the specifications for the NPI
  http//www.cms.hhs.gov/NationalProvIdentStand/
• www.wedi.org/npioi/index.shtml

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National Provider Identifier (NPI)

• National Plan and Provider
• Enumeration System (NPPES)
• 1-800-465-3203
• To complete an application online, please visit
• https//nppes.cms.hhs.gov/NPPES/Welcome.do

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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 Eligibility
• Delayed Eligibility
• Denied Claims
• NO EXCEPTIONS
• Accident Cases
• Other Primary Insurance

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TIMELY FILING

• Submit claims with documentation attached
  explaining the reason for delayed submission
• You must have the word Attachment in Locator
  10d and use modifier 22 in Locator 24D

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Reimbursement Rate Certification

• Required for claims submitted for Treatment
  Foster Care Case Management.
• Claims submitted without the required information
  will deny.
• For providers who choose to submit claims
  electronically, CLAIM ATTACHMENT FORM (DMAS-3)
  should be used to send the Reimbursement Rate
  Certification.
• The DMAS-3 should be sent to the same mailing
  address used for paper claim submission.

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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 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
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 1500 form.
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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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Block 23 Prior Authorization Number
23. PRIOR AUTHORIZATION NUMBER
For services requiring prior authorization, enter
PA number assigned by the DMAS PA contractor
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Block 24A Dates of Service
24. A
DATE(S) OF SERVICE
From
To
MM DD YY
MM DD YY
06
06
03
01
03
01
1
03
06
01
31
06
03
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-Office location 12- Home
11
1
1- Medical Care
Medicaid accepts the same Place of Service and
Type of Service as Medicare.
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Block 24D Procedure Codes
D
PROCEDURES, SERVICES, OR SUPPLIES
(Explain Unusual Circumstances)
CPT/HCPCS
MODIFIER
T1016
22
T1016
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Block 24E Diagnosis Code
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY
34431
1.
3.
2963
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
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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44
24J COB Other Insurance 24K Other Insurance
Paid
J
K
RESERVED FOR
LOCAL USE
COB
Attach denial from other carrier
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Block 26 Patients Account Number (Optional)
26. PATIENT ACCOUNT NUMBER
12345678918765432
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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
123456789
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.
1032
xxxxxxxxxxxxxxxx
From original
Adjustment or
remittance
Void
Resubmission Code
Chap. V, Medicaid Psychiatric Manual has 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
THE END
THE END
THE END

• Department of Medical Assistance Services
• www.dmas.virginia.gov