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									  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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