Department of Medical Assistance Services

1
Department ofMedical Assistance Services
Outpatient Psychiatric Services Medicaid
Eligibility and Billing

• November - December 2007
• www.dmas.virginia.gov

2
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

3
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

4
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 through
Medicaid by MediCall or the Automated Response
System (ARS).
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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
6
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 Amerigroup, Carenet, Optima
Family Care, Healthkeepers Plus, or Virginia
Premier Health Plan.
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Eligibility Verification

• MediCall
• ARS- Web-Based Medicaid Eligibility

8
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

9
MediCall

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

10
Automated Response System (ARS)

• Web-based eligibility verification option
• Free of Charge.
• Information received in real time.
• Secure
• Fully HIPAA compliant

11
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)

12
User Administration Console

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

13
Automated Response System- Registration

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

14
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

15
Important Contacts

• Provider Call Center
• Provider Enrollment
• Electronic Billing

16
Provider Call Center

• Claims, covered services, billing inquiries
• 800-552-8627
• 804-786-6273
• 830am 430pm (Monday-Friday)
• 1100am 430pm (Wednesday)

17
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

18
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]

19
Billing on the CMS-1500
20
MAIL CMS-1500 FORMS

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

21
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

22
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

23
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)

24
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
25
Block 1
GROUP
CHAMPVA
FECA
OTHER
BKL LUNG
HEALTH PLAN
(ID)
(SSN or ID)
(SSN)
(Member ID)
TDO or ECO CLAIM
25
26
Block 1a Recipient ID Number
1a. INSURED'S I.D. NUMBER (FOR PROGRAM
IN ITEM 1)
123456789014
(Be sure to include all 12 digits)
26
27
Block 2 Patient's Name
2. PATIENT'S NAME (Last name, First Name, Middle
Initial)
Smith, Sam
5. PATIENT'S ADDRESS (No., Street)
27
28
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
28
29
Is There Another Health Benefit Plan?Block 11d

• 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
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31
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
31
32
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

33
KePRO Contacts

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

34
Block 23 Prior Authorization Number - Conditional
23. PRIOR AUTHORIZATION NUMBER
34
35
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

36
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

37
Block 24A TPL Dates of Service
24. A.
DATE(S) OF SERVICE
From
To
MM DD YY
MM DD YY
TPL27.08
06
06
03
01
03
01
1
04
01
06
04
16
06
2
Both FROM and TO dates
must be completed
37
Dates must be within same calendar month
38
TPL Information Block 24A

• DMAS will set COB code based on the information
  given in locator 11d.
• No, or nothing indicated no other insurance on
  the system-claim processes as primary
• 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-claim processes as
  secondary

39
TPL Information Block 24A

• DMAS will set COB code based on the information
  given in locator 11d.
• Yes, and 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

40
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

41
Block 24A NDC Dates of Service
24. A.
DATE(S) OF SERVICE
From
To
MM DD YY
MM DD YY
N400026064871
06
06
03
01
03
01
1
04
01
06
04
16
06
2
41
42
TPL, NDC Dates of Service
24. A.
DATE(S) OF SERVICE
From
To
MM DD YY
MM DD YY
TPL27.08N400026064871
06
03
01
03
01
06
1
N400026064871TPL24.08
06
04
01
06
04
16
2
When both the NDC and TPL information must be
given on the same line you may place them in any
order
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43
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.
43
44
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

45
Block 24C EMG
C. EMG
Y
Medicaid will accept a Y in this Locator to
indicate that the procedure was an emergency
45
46
Block 24D Procedure Codes
D.
PROCEDURES, SERVICES, OR SUPPLIES
(Explain Unusual Circumstances)
CPT/HCPCS
MODIFIER
22
90805
46
47
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
47
48
Block 24 F Charges
F.
CHARGES
Enter the usual
and customary charges
48
49
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
49
50
Block 24H EPSDT/Family Plan
H.
EPSDT Family Plan
1
1-EPSDT 2-Family Planning Service
50
51
ID.QUALBlock 24I

• Qualifier 1D is to be used in the red shaded
  area for claims being submitted using the
  Medicaid provider number or 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.

52
Rendering Provider ID Block 24J

• The shaded red area will contain the current
  Medicaid provider number or the 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
Medicaid Provider Identification Number OR API
1D
NPI
53
54
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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(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
• Additional taxonomy information
• www.wpc-edi.com/taxonomy/more_information

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Block 26 Patients Account Number (Optional)
26. PATIENT ACCOUNT NUMBER
12345678918765
Can not exceed 17 alphanumeric digits
57
58
Total ChargeBlock 28

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

59
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.
60
61
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

62
Service Facility Location InformationBlock 32a-b

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

63
CHANGE - Block 32 Service Facility Location
Information
32. SERVICE FACILITY LOCATION INFORMATION
a.
b.
NPI
63
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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

65
Billing Provider Info PH Block 33a-b

• Enter the 10 digit NPI number of the billing
  provider in 33a
• Enter 1D qualifier with the Medicaid PIN or API
  in 33b OR
• Enter ZZ qualifier with the taxonomy code if
  needed in 33b, when using the NPI in 33a

66
Block 33 Billing Provider Info PH
33. BILLING PROVIDER INFO PH
( )
a.
b.
NPI
66
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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