Mental Retardation Waiver Eligibility Verification Options _ CMS

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Mental Retardation Waiver Eligibility Verification Options _ CMS Powered By Docstoc
					Department of Medical Assistance Services

Intellectual Disabilities/ Mental Retardation Waiver Eligibility Verification Options & CMS-1500 Billing Guidelines July – August 2008 www.dmas.virginia.gov

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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
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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

999999999999
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
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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
8:30am – 4:30pm (Monday-Friday)

11:00am – 4:30pm (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 Corporation Virginia Operations Electronic Claims Coordinator 4300 Cox Road Glen Allen, VA 23060
E-mail: edivmap@fhsc.com

Phone: (800) 924-6741
Fax: (804) 273-6797
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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
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

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
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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
Photocopies are not Acceptable
Computer generated claims must match NUBC uniform standards
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Block 1

1. MEDICARE
(Medicare #)

MEDICAID
(Medicaid #)

TRICARE CHAMPUS
(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
b. AUTO ACCIDENT?

NO
PLACE (State)

YES
c. OTHER ACCIDENT?

NO

YES

NO

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?
YES NO

If yes, return to and complete item 9 a-d.

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 1.

3180
319

3.

2.

4.

May enter up to 4 codes Omit decimals
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ICD-9 Diagnosis Codes
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 

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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
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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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

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Block 24A: Dates of Service
24. A. DATE(S) OF SERVICE

From MM DD YY

MM

To DD YY

1

05 01 08 05 01 08

2

05 01 08 08 31 08

Both FROM and TO dates must be completed Dates must be within same calendar month

Block 24B: Place of Service
B. Place of Service

11-Office location 12- Patient’s Home

Note: Type of Service is no longer required

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Medicaid accepts the same 2 digit CMS Place of Service codes as Medicare.

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Emergency Indicator-24C

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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 32 emergency

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 1.

3180 319

3.

2.

4.

E. DIAGNOSI S POINTER

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 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
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Providers with a Dept. of Rehab Services (DRS) approved rate, will be reimbursed the DRS rate for DMAS payment of agencydirected 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 36 rate.

Block 24G: Days or Units
G. DAYS OR UNITS

1 31

Enter the number of times or hours the procedure, service, or item was provided during the service period.

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ID.QUAL Block-24I
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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

Service Type Description
Mental Health-Mental Retardation Community Services MR Waiver Services Case Management Services

Taxonomy Code
251C00000X 261QM0801X 320900000X 251B00000X

Rendering Provider ID # Block-24J

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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
NPI

0012345670

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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)
NPI

1234567890
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Block 26: Patient’s 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
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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 32 Service 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, cont’d. Service Facility Location Information
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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.

NPI

b.

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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
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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.

NPI

b.

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Block 22: Adjustments and Voids
22. MEDICAID RESUBMISSION CODE

ORIGINAL REF. NO.

1032 xxxxxxxxxxxxxxxx From Adjustment original remittanc or Void e Resubmission Code
Chap. V, Mental Retardation Community Services Manual has resubmission code list.
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REMITTANCE VOUCHER Sections of the Voucher
   

APPROVED PENDING DENIED DEBIT (+)

For payment. For review of claims. No payment allowed. Adjusted claims creating a positive balance.



CREDIT (-)

Adjusted/Voided claims creating a negative balance.
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REMITTANCE VOUCHER Sections of the Voucher
  

FINANCIAL TRANSACTION EOB DESCRIPTION ADJUSTMENT DESCRIPTION/REMARKSSTATUS DESCRIPTION REMITTANCE SUMMARY- PROGRAM TOTALS



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THANK YOU
Department of Medical Assistance Services

www.dmas.virginia.gov


				
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