Department of Medical Assistance Services Eligibility Verification Options & CMS-1450 (UB-04) Billing Guidelines For Home Health Services June 2007 www.dmas.virginia.gov ************ This presentation is to facilitate training of the subject matter in portions of the Virginia Medicaid manual on Home Health Services . This training contains only highlights of those manuals and is not meant to substitute for or take the place of the Home Health Services manual. 2 Objectives 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 3 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: 05/09/1964 F CARD# 00001 Important Contacts • MediCall • ARS- Web-Based Medicaid Eligibility • Provider Call Center • Provider Enrollment • DMAS Website • WebEx MediCall 800-884-9730 800-772-9996 804-965-9732 804-965-9733 6 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 7 Automated Response System ARS • Web-based eligibility verification option – Free of Charge. – Information received in “real time”. – Secure – Fully HIPAA compliant Automated Response System (ARS) • March 26, 2007 DMAS implemented a new 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) 9 User Administration Console (UAC) • The UAC will: – Allow providers to manage their own ARS access for one or more users – Allow the provider to assign a Delegated Administrator for its office or facility – Enable access to the ARS for anyone in the provider‟s office or facility with a business need to information on the provider‟s behalf 10 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 enroll and establish your new access to use the ARS beginning May 23, 2007. • Web Support Helpline: 800-241-8726 11 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‟ 12 UAC Registration Process • 3-Step Process – Step One – Request PIN (will be mailed) – Step Two – Register with a PIN – Step Three – Activate your user login ID and password • After this process you will need to log onto the UAC, in order to assign your access privileges to the ARS, set up additional local administrators and assign roles and providers to administrators 13 WebEx Presentation • To view an ARS pre-recorded presentation developed by First Health Services use this link: https://dmas.webex.com/mw0302l/mywebex/default.do?s iteurl=dmas – Click on: • Attend a session, recorded session • Select - NPI: Automated Response System/UAC • View or download presentation 14 NPI Training and Education • Comprehensive NPI section of the DMAS website – http://www.dmas.virginia.gov/npi- home_page.htm • For training opportunities – DMAS Learning Network http://www.dmas.virginia.gov/LNupcoming_events.h tm 15 NPI and DMAS • Virginia Medicaid Providers having questions related to the DMAS NPI implementation schedule –please contact: NPI@dmas.virginia.gov 16 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) 17 Provider Enrollment To enroll providers with a NPI 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 Billing on the CMS-1450 (UB-04) 19 MAIL UB-04 FORMS TO: DEPARTMENT OF MEDICAL ASSISTANCE SERVICES P. O. Box 27444 Richmond, Virginia 23261 20 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 21 TIMELY FILING • Submit claims with documentation attached to the back of each claim form explaining the reason for delayed submission • Indicate information is attached in Locator 80- REMARKS. 22 Locator 1: Provider‟s Name, Address and Phone Number • Enter the provider‟s name, complete mailing address and telephone number of the provider that is submitting the bill and which payment is to be sent. • NOTE: DMAS will need to have the 9 digit zip code on line four, left justified for adjudicating the claim. 23 Locator 1: Provider Name, Address and Phone Number 1 Neighborhood Home Health 121 Friendly Street Any Town VA 123456456 8049781234 24 Locators 3a and 3b • 3a Patient Control Number - Enter the patient‟s unique financial account number which does not exceed 20 alphanumeric characters. • 3b Medical/Health Record - Enter the number assigned to the patient‟s medical/health record by the provider. This number cannot exceed 24 alphanumeric characters. 25 Locators 3a- Patient Control Number & 3b- Medical/Health Record Number 3a PAT. CNTL # 123456789ABCDEFGH012 b. MED REC. # 987654321HGFEDCBA1234567 Patient Control Number and Medical/Health Record Number are required for all UB-04 claim submissions. 26 Locator 4 :Type of Bill • Enter the code as appropriate. • The Type of Bill field has been increased from three digits to four digits by adding a leading zero. • Claims submitted without the required four digit bill type will be denied. 27 Locator 4: Type of Bill Type of Bill 4 TYPE OF BILL 0333- Original Bill 0336- Adjustment Invoice 0338- Void Invoice 0333 *Only “Approved” claims can be Adjusted or Voided. 28 Locator 6: Statement Covered Period • Enter the beginning and ending service dates reflected by this invoice (include both covered and non-covered days). • Use both “from” and “to” for a single day. • If the total days of service exceed 31 days, use additional billing invoices. • Claims submitted which exceed the 31 day limitation will be denied. 29 Locator 6: Statement Covers Period 6 STATEMENT COVERS PERIOD FROM THROUGH 030507 030507 Enter the beginning and ending service dates reflected by this invoice (include both covered non-covered days). Use both “from” and “through” for a single day. 30 Locator 7: Reserved for Assignment NOT REQUIRED 7 NOTE: This locator on the UB-92 contained the covered days of care. Locators 39-41 on the UB-04, are the appropriate fields to enter covered and non-covered days. 31 Locator 8: Patient Name/Identifier 8 PATIENT NAME a b Last First M Enter the last name, first name and middle initial of the patient. 32 Locator 10: Patient Birthdate 10 BIRTHDATE 10011980 Enter the date of birth of the patient using the following format - MMDDYYYY. 33 Locator 11: Sex 11 SEX F Enter the sex of the patient as recorded at admission, outpatient or start of care. M = Male; F = Female; U = Unknown 34 Locator 12: Admission/Start of Care ADMISSION 12 DATE 030507 Please enter the start date of this episode of care. 35 Locator 13: Admission Hour ADMISSION 13 HR 14 Enter the hour during which the patient was admitted for outpatient care. Home Health Agencies may use a default time for all patients. NOTE: Military time is used as defined by NUBC. 36 Locator 14: Priority Type of Visit Appropriate PRIORITY TYPE codes accepted by DMAS are: CODE DESCRIPTION 1 Emergency 2 Urgent 3 Elective 5 Trauma 9 Information not available 37 Locator 14: Priority (Type) of Visit ADMISSION 14 TYPE 3 Enter the code indicating the priority of this admission /visit. 38 Locator 15: Source of Referral for Admission or Visit Appropriate codes accepted by DMAS are: Code Description 1 Physician Referral 2 Clinic Referral 4 Transfer from Another Acute Care Facility 5 Transfer from a Skilled Nursing Facility 6 Transfer from Another Health Care Facility 7 Emergency Room 8 Court/Law Enforcement 9 Information not available Locator 15: Source of Referral for Admission Visit 15 SRC 1 Enter the code indicating the source of the Referral for this admission or visit. 40 Locator 17: Patient Discharge Status Appropriate codes accepted by DMAS in claims processing: Code Description 01 Discharge to Home 02 Discharged/transferred to Short Term General Hospital for Inpatient Care 03 Discharged/transferred to SNF 04 Discharged/transferred to ICF 05 Discharged/transferred to Another Facility not Defined Elsewhere 41 Locator 17: Patient Discharge Status Appropriate codes accepted by DMAS in claims processing: Code Description 07 Left Against Medical Advice/Discontinued Care 20 Expired 30 Still a Patient 50 Hospice – Home 51 Hospice – Medical Care Facility 42 Locator 17: Patient Discharge Status Appropriate codes accepted by DMAS in claims processing: Code Description 61 Discharge/transfer to Hospital Based Medicare Approved Swing Bed 62 Discharged/transferred to an Inpatient Rehabilitation Facility 43 Locator 17: Patient Discharge Status 17 STAT 01 Enter the code indicating the disposition or Discharge status of the patient at the end for the Service period covered on this bill (Statement Covered Period, Locator 6). 44 Locators 18-28: Condition Codes Codes used by DMAS in the adjudication of claims: Code Description A1 EPSDT A5 Disability 45 Locators 18-28: Condition Codes (Required if Applicable) Condition Codes 18 19 20 21 22 23 24 25 26 27 28 A1 A5 Enter the code (s) in alphanumeric sequence Used to identify conditions or events related to this bill that may affect adjudication. NOTE: DMAS limits the number of codes to a maximum of 8 on one claim. 46 Locator 29: Accident State (Conditional) 29 ACDT STATE VA Enter if known, the state ( two digit Postal State Code abbreviation) where the motor vehicle accident occurred. 47 Locators 31-34: Occurrence Code and Dates (Required if Applicable) 31 OCCURRENCE CODE DATE a A3 030107 b Enter the code and associated date defining a significant event relating to this bill. Enter codes in alphanumeric sequence. 48 Locators 35-36: Occurrence Code and Span Dates (Required if Applicable) 35 OCCURRENCE SPAN CODE FROM THROUGH a b Enter the code and related dates that identify an event that relates to the payment of the claim. Enter codes in alphanumeric sequence. 49 Locator 37: Adjustment Reason Codes • This field previously was used to identify the ICN of the approved claim to be adjusted or voided. That information will now be listed in Locator 64. • Providers can use this locator to list the 4 digit adjustment/void code when correcting an approved claim. • A complete list of adjustment and void codes can be found in Chapter V of the Home Health Services manual. 50 Locators 39-41:Value Codes and Amount • Note: DMAS will be capturing the number of covered day (s) or units for outpatient services with these required value codes: 80 Enter the number of days for re-occurring outpatient claims. All claim submissions must have number listed. 51 Locators 39-41: Value Codes and Amount • Enter the appropriate code (s) to relate amounts or values to identify data elements necessary to process this claim. • One of the following codes must be used to indicate coordination of third party insurance carrier benefits: 82 No Other Coverage 83 Billed and Paid (enter amount paid by primary carrier) 85 Billed Not Covered/No Payment 52 Locators 39-41:Value Codes and Amount • For Part A Medicare Crossover Claims, the following codes must be used with one of the third party insurance carrier codes: A1 Deductible from Part A A2 Coinsurance from Part A Other codes may be used if applicable. 53 Locators 39-41: Value Codes and Amount 39 VALUE CODES 40 VALUE CODES CODE AMOUNT CODE AMOUNT a 80 15 83 225 00 b c d 54 Locator 42: Revenue Code Enter the appropriate revenue code (s) for the service provided. Note: • Multiple services for the same item, providers should aggregate the service under the assigned revenue code and then total the number of units that represent those services • DMAS has a limit of five pages for one claim • The Total Charge revenue code (0001) should be the last line of the last page of the claim. 55 Locator 42: Revenue Code 42 REV. CD. 1 0550 2 0551 3 0421 4 0441 Revenue codes are four digits, leading zero, left justified and should be reported in ascending numeric order. 56 Locator 43: Revenue Description 43 DESCRIPTION Skilled Nursing Assessment Skilled Nursing Follow-Up PT Follow-Up Visit Enter the standard abbreviated description of the related revenue code categories included on this bill. 57 Locator 44: HCPCS/Rates/HIPPS Rates Codes 44 HCPCS / RATE / HIPPS CODE 58 Locator 45: Service Date (Required if Applicable) 45 SERV. DATE 030507 Enter the date the outpatient service was provided. 59 Locator 46: Service Units 46 SERV. UNITS 6 12 Outpatient: Enter the unit (s) of service for physical therapy, occupational therapy or speech-language pathology visit or session (1 visit = 1 unit, even if more than 1 modality is done). 60 Locator 47: Total Charges 46 SERV. UNITS 47 TOTAL CHARGES 1755 75 TOTALS Enter the total charge(s) for the primary payer during the „statement covers period‟ including both covered and non-covered charges. Note: Use code “0001” for TOTAL. 61 Locator 50: Payer Name A-C • Enter the payer from which the provider may expect some payment for the bill. • When Medicaid is the only payer, enter “Medicaid” on line A. • If Medicaid is the secondary or tertiary payer, enter on lines B or C. 62 Locator 50: Payer Name A-C 50 PAYER NAME MEDICAID A Primary Payer B Enter the secondary payer identification, if applicable. C Enter the tertiary payer if applicable. 63 Locator 51: Health Plan Identification 51 HEALTH PLAN ID Note: DMAS will no longer use this locator to capture the Medicaid provider number. Refer to locators 56 and 57. 64 Locator 56: National Provider Identification (NPI) • DMAS will send a confirmation letter once a provider‟s NPI has been successfully added by the Provider Enrollment Unit (PEU) to VAMMIS. • Providers may submit their NPI in this field. 65 Locator 56: NPI 56 NPI 1234567890 Once the DMAS Dual Use Period is completed, the NPI will be required for all claims submissions. 66 Locator 57A-C: Other Provider Identifier • Enter the nine-digit Medicaid PIN number in this field April 1, 2007 – Memo notification of the end of the Dual Use Period. • For providers who are given an Atypical Provider Identifier (API) Number, the API will be listed in this locator. 67 Locator 57A-C: Other Provider Identifier 57 001234567 OTHER PRV ID Enter the Medicaid PIN in this locator during the Dual Use Period only. Atypical Provider Number (API) will also be listed in this field. 68 Locator 58: Insured’s Name 58 INSURED‟S NAME A Virginia J. Recipient B C Enter the name of the insured person covered by the payer in locator 50. The name on the Medicaid line must correspond with the enrollee name when eligibility is verified. 69 Locator 59: Patient’s Relationship to Insured • Note: appropriate codes accepted by DMAS are: Code Description 01 Spouse 18 Self 19 Child 21 Unknown 39 Organ Donor 40 Cadaver Donor 53 Life Partner 70 Locator 59: Patient’s Relationship to Insured 52 REL. INFO 18 Enter the code indicating the relationship of the insured to the patient. 71 Locator 60: Insured’s Unique Identification 60 INSURED‟S UNIQUE ID 012345678910 For lines A-C, enter the unique identification number of the person insured that is assigned by the payer organization shown on lines A-C, Locator 50. NOTE: The Medicaid recipient ID number is 12 numeric digits. Locator 63: Treatment Authorization Codes 63 TREATMENT AUTHORIZATION CODES A 12345678910 B Enter the 11 digit preauthorization number assigned by KePro for the appropriate outpatient services to be billed to Virginia Medicaid. 73 Locator 64: Document Control Number (DCN) • This locator is to be used to list the original Internal Control Number (ICN) listed on your Remittance Advice (RA) for APPROVED claims that are being submitted to adjust or void the original claim. • This information was previously required in Locator 37 of the UB-92. 74 Locator 64: Document Control Number (Required if Applicable) 64 DOCUMENT CONTROL NUMBER 2006363123456701 The control number assigned to the original bill by Virginia Medicaid as part of their internal claims reference number. 75 Locator 66: Diagnosis and Procedure Code Qualifier (ICD Version Indicator) 66 DX 9 The qualifier that denotes the version of the International Classification of Diseases. Qualifier = 9 for the Ninth Revision. NOTE: Currently, Virginia Medicaid will only accept a 9 in this locator. 76 Locator 67: Principal Diagnosis Code Locators 67A-Q: Other Diagnosis Codes 67 A B C I J K L Enter the diagnosis codes corresponding to all conditions that coexist at the time of admission, that develop subsequently, or that affect the treatment received and/or the length of stay. 77 Locator 69: Admitting Diagnosis 69 ADMIT DX 82101 Enter the diagnosis code describing the patient‟s diagnosis at the time of admission. NOTE: Do not use decimals. 78 Locator 72: External Cause of Injury (Required if Applicable) b 72 ECI E895 c Enter the diagnosis code pertaining to external causes of injuries, poisoning, or adverse effect. 79 Locator 74: Principal Procedure Code and Date • Note: for outpatient claims, a procedure code must appear in this locator when revenue codes 0360-0369, 0420-0429, 0430-0439, and 0440-0449 (if covered by Medicaid) are used in Locator 42 or the claim will be rejected. 80 Locator 74a-e: Other Procedure Codes and Date (Required if Applicable) a. OTHER PROCEDURE CODE DATE 9339 030507 Enter the ICD-9-CM procedure codes identifying all significant procedures other than the principal procedure and the dates on which the procedures were performed. Report those that are most important for the episode of care and specifically any therapeutic procedures closely related to the principal diagnosis. 81 Locator 76: Attending Provider and Identifier • Outpatient: Enter qualifier 82 and the 9- digit number assigned by Medicaid for the physician who has overall responsibility for the patient‟s medical care and treatment reported on this claim, April 1, 2007 - Memo notification of the end of the Dual Use Period. • The NPI may be entered in the field identified as “NPI” beginning April 1, 2007. 82 Locator 76: Attending Provider 76 ATTENDING NPI 1234567890 Accepted for claims submitted April 1, 2007 and after. QUAL 82 001234567 Accepted - April 1, 2007 – Memo Notification of the end of the Dual Use Period. 83 Locators 78-79: Other Provider Name and Identifiers • This field will be used to list the ID number for the Primary Care Physician (PCP) who authorized the outpatient visit. • For MEDALLION patients referred to the Home Health Agency, enter the ID number for the PCP who authorized the treatment. • This information is required for all MEDALLION patients treated for non- emergency services. 84 Locators 78-79: Other Provider Name and Identifiers • For Client Medical Management (CMM) patients referred to the Home Health Agency by the PCP, enter the provider‟s ID number and attach the Practitioner Referral Form (DMAS-70). • Enter the qualifier DN and the nine digit number assigned by Medicaid for the PCP, April 1, 2007- Memo Notification of the End of the Dual Use Period. • The NPI may be entered in the field identified as “NPI”. 85 Locators 78-79: Other Provider Name and Identifier 78 OTHER NPI 1234567890 Accepted for claims submitted April 1, 2007 and after. QUAL DN 001234567 Accepted April 1, 2007 – Memo Notification of the End of the Dual Use Period 86 Locator 80: Remarks Field 80 REMARKS Enter additional information necessary to adjudicate the claim. Enter a brief description of the reason for the submission of the adjustment or void. If there is a delay in filing, indicate the reason for the delay here and include an attachment. 87 Locator 81: Code-Code Field • DMAS previously assigned different provider numbers for each type of service performed. • Medicaid payment was then issued based on the type of service billed. • DMAS will be using this field to capture a taxonomy code for claims that are submitted for one NPI with multiple business types (e.g., Home Health Agency also providing Personal Care Services). 88 Locator 81: Code-Code Field • The taxonomy code will be required for providers who do not have a separate NPI for each different service billed to VA Medicaid. • Code B3 is to be entered in the first small space and the provider taxonomy code is to be entered in the second large space. The third space should be blank. 89 Locator 81: Code-Code Field 81CC a B3 251E00000X b c d Enter the provider taxonomy code for the billing provider when the adjudication of the claim is known to be impacted. 90 DMAS Service Types May Require A Taxonomy Code on Claims Taxonomy Codes Service Type Description Taxonomy Code Durable Medical Equipment 332B00000X Home Health 251E00000X Personal Care 3747P1801X Private Duty Nursing 163WC2100X Respite 385H00000X 91 REMITTANCE VOUCHER Sections 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. 92 REMITTANCE VOUCHER Sections of the Voucher FINANCIAL TRANSACTION EOB DESCRIPTION ADJUSTMENT DESCRIPTION/REMARKS- STATUS DESCRIPTION REMITTANCE SUMMARY- PROGRAM TOTALS 93 Department of Medical Assistance Services THANK YOU www.dmas.virginia.gov
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