Level 2 NM Medicaid Billing Basics January 2010

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					         Level 2
 NM Medicaid Billing Basics
      January 2010

          Presented by
Erminia Reynaga & Carlos Trujillo
 Provider Field Representatives
 ACS Helpdesks

   Call 505-246-0710 or 800-299-7304 - to directly
    reach all provider help desks including Provider
    Relations, Provider Enrollment, the HIPAA/EMC
    help desk and TPL.




January 2010                                           2
              ACS Info
   For all contact, Claims, and Correspondence Addresses
    information go to the following link on the New Mexico
    Medicaid Web Portal:

       https://nmmedicaid.acs-
        inc.com/nm/general/loadstatic.do?page=ContactUs.htm




     January 2010                                             3
Important State Websites
  STATE  WEBSITE:
  PROGRAM POLICY MANUAL

      http://www.hsd.state.nm.us/mad/policymanual
       .html
  BILLING INSTRUCTIONS

      http://www.hsd.state.nm.us/mad/billinginstruc
       tions.html
  REGISTERS AND SUPPLEMENTS:

      http://www.hsd.state.nm.us/mad/registers/




January 2010                                           4
         ACS Field
         Representatives
Provider Field Representative:
 Carlos Trujillo – (505) 246-9988 Ext. 221;
  (800) 282-4477 Ext 221
       E-mail: Carlos.Trujillo@acs-inc.com


   Erminia Reynaga – (505) 246-9988 Ext. 104;
    (800) 282-4477 Ext 104
       E-mail: Erminia.Reynaga@acs-inc.com



January 2010                                     5
IMPORTANT UPDATE!
Electronic Funds Transfers (EFT)
   Electronic Funds Transfers (EFT) is part of the ongoing
    effort by MAD and ACS to transform Medicaid program
    capabilities into efficient electronic processes.
   To implement EFT, we will build on the capabilities of
    ACS’ NM Medicaid web portal that providers currently
    use for other electronic activities.
   We recognize that there is a need for increased security
    regarding EFT so access to this web function will be
    limited to the Master Administrator for your
    organization’s account on the web portal.
   Currently providers are able to sign up for EFT for
    electronic payments.

January 2010                                                   6
IMPORTANT UPDATE!
Electronic Funds Transfers (EFT)
    All information will be verified and validated
     against the information ACS already has for the
     provider.
    While registering for EFT using the web portal,
     the Master Administrator will be asked to supply
     an e-mail address for receipt of notifications. This
     e-mail address will also provide a security purpose
     for EFT because a provider will be notified
     whenever a change is made to the banking
     information associated with EFT.
    January 2010                                        7
The Billing Process

     I.        Check eligibility
     II.       Get Prior Authorization (only if required)
     III.      Submit the Claim
     IV.       Claim follow up




January 2010                                                8
Eligibility Check List
    Date of Service – Make sure client is eligible
     on DOS
    Is the Client Fee for Service, SALUD!, or
     COLTS?
    Limited Benefits – Check Category of Eligibility
    TPL or Medicare, Medicare Replacement Plans
     -There may be a payer primary to Medicaid
    The client may be required to pay a co-pay



January 2010                                            9
  Eligibility Resources
         On-Line Eligibility Inquiry—Web Portal
          https://nmmedicaid.acs-inc.com/

         Automatic Voice Response System (AVRS)
          (505) 246-2219 or (800) 820-6901

         Eligibility Help Desk – (505) 246-2056, (800)
          705-4452



January 2010                                          10
Eligibility Inquiry




                      The “SSN-style” ID
                      number




January 2010                               11
Eligibility Inquiry




January 2010          12
Checking Eligibility
        Eligibility denials are the most common
         denials for all provider types!
        Due to month end timing issues for the
         eligibility file from ISD, it is suggested
         providers wait until the 2nd of each month
         to check monthly eligibility, if possible. This
         will assure you an accurate accounting of
         the client’s eligibility.



January 2010                                               13
 Eligibility Denials

     What do I do if I receive a denial pertaining
      to the patient’s eligibility?
     Verify the information on the Web Portal.
     You may need to correct the patient’s ID,
      DOB, Name, attach an authorization (CMS
      309), or bill to another insurance company.




January 2010                                          14
           Categories of Eligibility
           with Limited Benefits




January 2010                           15
    029 - Family Planning Waiver
   Which services are covered?
   Medical Claims and Institutional Claims:
   The system examines the revenue code,
    procedure code, and any related diagnosis codes
    on the line. The service is covered by the Family
    Planning Waiver if a combination of the following
    code sets are used to identify the service:
        Procedure Code and the diagnosis code are on the
         following approved code lists.



    January 2010                                            16
         Approved FPW Procedure Code List




January 2010                                17
           Pregnancy Prevention Diagnoses




January 2010                                18
029 - Family Planning Waiver

   Which services are covered? (continued)
   Institutional Claims only:
       The revenue code and diagnosis are on the following
        approved code lists.
       Diagnosis code V25.2 (Sterilization Diagnosis) is found
        on the claim.




January 2010                                                  19
Revenue Codes Related to Family Planning




January 2010                               20
           Pregnancy Prevention Diagnoses




January 2010                                21
029 - Family Planning Waiver

   Which services are NOT covered by this COE?
       Any service that is not listed as one of the
        aforementioned covered services.




January 2010                                           22
0029 – Service not Family
Planning Related
   Why does this denial occur when the service was
    actually for Family Planning?
       Procedure code, diagnosis code, or revenue code not
        recognized as family planning related. If rendered
        service is family planning related, resubmit claim using
        alternate codes from approved list available. Do not bill
        Medicaid client for services that can be billed using an
        alternate approved codes.
       If you are not able to locate a suitable alternative code
        for your service but feel the service should be paid
        under this benefit package please contact the FPW
        Program Manager at MAD.
January 2010                                                   23
035 – Pregnancy Related (non-
presumptive) Covered Services
   Which services are covered?
   Medical Claims and Institutional Claims:
   The system examines the revenue code,
    procedure code, and any related diagnosis codes
    on the line. The service is covered by Pregnancy
    Related Services Only (PRSO) if a combination of
    the following code sets are used to identify the
    service:
        Procedure Code and the diagnosis code are on the
         following approved code lists.

    January 2010                                            24
        Approved PRSO Procedure Code List




January 2010                                25
        Approved PRSO Procedure Code List




January 2010                                26
               Pregnancy Related Diagnoses




January 2010                                 27
035 – Pregnancy Related (non-
presumptive) Covered Services
   Which services are covered? (continued)
   Institutional Claims only:
        The revenue code and diagnosis are on the following
         approved code lists.




 January 2010                                                  28
          Revenue Codes Related to PRSO




January 2010                              29
               Pregnancy Related Diagnoses




January 2010                                 30
035 – Pregnancy Related (non-
presumptive) Non-Covered
Services
   Which services are NOT covered by this COE?
        Any service that is not listed as one of the
         aforementioned covered services.




 January 2010                                           31
0707 – Pregnancy Related (non-
presumptive) Non-Covered
Services
   Why does this denial occur when the service was
    actually for Pregnancy Related?
        Procedure code, diagnosis code, or revenue code not
         recognized as family planning related. If rendered service is
         family planning related, resubmit claim using alternate
         codes from approved list available. Do not bill Medicaid
         client for services that can be billed using an alternate
         approved codes.
        If you are not able to locate a suitable alternative code for
         your service but feel the service should be paid under this
         benefit package please contact the FPW Program Manager
         at MAD.
    January 2010                                                 32
041, 044 – Qualified
Medicare Beneficiary (QMB)
      MEDICAID covers the co-insurance and
       deductible on MEDICARE covered services
       only after MEDICARE has paid.
      If service is not covered by Medicare,
       MEDICAID WILL NOT PAY.




January 2010                                     33
Categories of Eligibility
with Co-pays
      071 FM 1– SCHIP (State Children’s Health
       Insurance Program)
      074 – WDI (Working Disabled Individuals)
      Clients with these COEs may owe co-pays
       for some services




January 2010                                      34
071-SCHIP Copayment
Schedule
    Service                Co-       Comments
                           payment
    Outpatient Physician   $5.00
    Visit
    Urgent Care Visit      $5.00
    Outpatient Therapy     $5.00
    Visit
    Other Practitioner     $5.00
    Visit
    Dental Office Visit    $5.00     Co-pay does not apply if service
                                     is preventive, diagnostic, or
                                     orthodontic.



January 2010                                                            35
071-SCHIP Copayment
Schedule
   Service                 Co-payment   Comments

   Emergency Room Visit    $15.00       Co-pay does not apply if
                                        patient is admitted to the
                                        hospital.
   Inpatient Hospital      $25.00
   Admission
   Pharmacy Prescription   $5.00        Co-pay does not apply to
                                        medical supplies.
   Missed Appointment      $5.00        If the client does not contact
                                        the provider to cancel the
                                        appointment.



January 2010                                                             36
074-WDI Copayment
Schedule
 Service                      Co-payment   Comments

 Prescriptions                $5.00        Includes covered prescription
                                           and non-prescription items.

 Outpatient visit, other      $7.00
 practitioner visit, clinic
 visit, urgent care visit,
 outpatient therapy
 sessions


 Dental Office Visit          $7.00

 Emergency Room Visit         $20.00

 Inpatient Hospital           $30.00
 Admission


January 2010                                                               37
               Other Categories of
               Eligibility




January 2010                         38
CMS (Children’s Medical
Services)
         CMS is like billing for a Medicaid client
          with the following differences:
              Always use the 14 digit CMS client ID
               number that begins with 07
              Always enter the PA number in box 23 of the
               CMS-1500 form (If the PA number is 8
               digits, add 2 zeroes in front of it.)



January 2010                                           39
Premium Assistance for
Maternity (PAM) Eligibility
         Premium Assistance for Maternity (PAM)
          claims are covered by Fee for Service
          and has the same benefits as Category
          of Eligibility 035 - Pregnancy Related
          (non-presumptive) Services.




January 2010                                       40
Premium Assistance for
Kids (PAK) Eligibility
          Premium Assistance for Kids (PAK) claims
           are not covered by Fee for Service, they
           are paid by the MCO health plan the
           client is enrolled in.




January 2010                                          41
Statewide Coverage
Insurance (SCI) Eligibility
         Statewide Coverage Insurance (SCI) claims
          are not covered by Fee For Service, they
          are paid by the health plan the client is
          enrolled in.




January 2010                                          42
               Complete list of
               Categories of Eligibility

        http://www.hsd.state.nm.us/mad/pdf_
        files/GeneralInfo/Eligpamphlet.pdf




January 2010                                  43
The Billing Process

     I.        Check eligibility
     II.       Get Prior Authorization (only if required)
     III.      Submit the Claim
     IV.       Claim follow up




January 2010                                                44
 Prior Authorization
 Requirements
         How do you determine if/when a Prior Authorization
          (PA) is required?
         Call Molina TPA (Third Party Assessor) at
         (505) 348-0311 ( in Albuquerque)
         (866) 916-3250 (Toll free)
         They can tell you if a PA is required and the
          procedures for getting a PA.
         Also, consult the Medicaid program and policy
          manuals and billing manuals for prior authorization
          requirements.
         Authorizations for EMSA contact Molina TPA
January 2010                                                45
  Prior Authorization
  Requirements
       All claims for Waiver and PCO providers
        require an authorization.
              Waiver providers – Contact your case Manager to
               obtain or follow up on a Prior Authorization.
              PCO providers –Contact Molina TPA (Third Party
               Assessor)
              (505) 348-0311 ( in Albuquerque)
              (866) 916-3250 (Toll free)



January 2010                                                     46
          Utilization Review (UR)

   As of August 1, 2009 Dental Providers will need
    to submit your requests for prior approval to:
       Doral Dental USA, LLC 12121 North Corporate
        Parkway Mequon, WI 53092.
   If you have questions or concerns, regarding
    your prior approval requests that have been
    submitted to Doral Dental for review, Please
    contact Doral Customer Service at:
       1-800-417-7140 (Toll free)


January 2010                                          47
   Prior Authorization
   Requirements
       All claims for Children’s Medical Services
        (CMS) clients must have the CMS prior
        authorization number entered on the claim.
       CMS claims can be submitted electronically.
        However, if the claims denies for eligibility,
        submit the claim on paper and attach the
        paper authorization issued by CMS, which is
        either the CMS 309 form.


January 2010                                             48
      Pharmacy Claim/CMS PA

         If a CMS PA for a pharmacy service is not on
          file, the provider needs to first contact the
          Point of Sale helpdesk and then fax the CMS
          PA to them:
           ACS Point of Sale Helpdesk

             800-365-4944




January 2010                                          49
What do I do if I get a denial
pertaining to a Prior authorization?
        Check the Web Portal’s Prior Authorization
         inquiry to verify the PA/Claim discrepancy
         the denial pertains to.
        Make claim corrections or follow up with
         your respective authorizing agency to have
         PA information changed/corrected.




January 2010                                          50
    Prior Authorization Inquiry




January 2010                      51
Prior Authorization Detail




January 2010                 52
The Billing Process

     I.        Check eligibility
     II.       Get Prior Authorization (only if required)
     III.      Submit the Claim
     IV.       Claim follow up




January 2010                                                53
Electronic Claim Submission

         You may submit Fee For Service claims
          electronically within 120 days from the
          initial date service.




January 2010                                        54
Three Ways to Submit
Claims Electronically
        Payerpath – Free HIPAA Compliant web-
         based claims entry system. The URL to the
         registration form for Payerpath is:
     http://www.hsd.state.nm.us/mad/hipaa.
       html




January 2010                                         55
Three Ways to Submit Claims
Electronically - Continued
         TIE (Transaction Interface Exchange) –
          the State of NM’s HIPAA translator. If
          you have software that will generate a
          HIPAA compliant file you can directly
          submit the file to NM Medicaid via TIE.
          TIE is another free service.
         Through a Clearinghouse




January 2010                                        56
Three Ways to Submit Claims
Electronically - Continued
        The URL to the registration form for TIE is:
         http://www.hsd.state.nm.us/mad/hipaa.html
         Fill out the Trading Partner agreement and Medicaid
         Provider Billing Agent application and mail it to the
         NMHSD.




January 2010                                                 57
Timely Filing Limits
     Original Claims - 120 days from the initial
      date of service. (For DRG hospital inpatient
      claims ONLY – 120 days from last date of
      service.)
     Resubmissions - 6 months from the date of
      the previous denial. Include a copy of the
      page of the RA(s) where the claim denied
      and/or other proof of timely filing.




January 2010                                         59
  Timely Filing Limits
        Adjustments – 6 months from the date of the
         incorrect payment (include a copy of the
         page of the RA(s) where the claim paid).
        TPL - 365 days from the initial date of service
         (remember to include a copy of the EOB
         from the insurance carrier, plus a copy of the
         explanation page).




January 2010                                           60
  Timely Filing Limits

        Medicare - 6 months from the date that
         Medicare either paid or denied the claim
         (remember to include a copy of the EOMB
         along with the explanation page).
        Final Limit - all payments must be finalized
         within 2 years of the date of service.




January 2010                                            61
Timely Filing Denials

   What do I do if I get a denial pertaining to
    Timely Filing?
       If the claim is within 2 years from the DOS and you
        have an explanation of benefits that proves timely,
        attach a copy of a valid Proof of Timely Filing to the
        claim and resubmit to ACS.
       If the claim is beyond 2 years from the DOS, the claim
        is past the final filing limit.




January 2010                                                 62
Timely Filing Denials

   What is considered valid proof of timely filing?
       A copy of the page of the RA the claim denied/paid in
       A copy of the claim status page from the web portal
        where the claim denied
       A copy of the 120 day enrollment letter
       A copy of the RTP form attached to the paper claim if
        was returned to you




January 2010                                                63
      Claim Form Requirements




January 2010                    64
 Where to get a copy of claim
 form instructions


                    Click on Provider Information




January 2010                                 65
         Where to get a copy of claim
         form instructions
                                 Scroll down


                           Open file




January 2010                                   66
CMS-1500 Claim Form
Requirements
     All claims that do not require an
      attachment for payment must be
      submitted electronically.
     Professional claims are submitted on the
      837P electronically and the CMS-1500 on
      paper.
     MAD requires that all paper CMS-1500
      claim forms be on the original red claim
      forms.
     Photocopies of claim forms are returned
      to your billing office.
January 2010                                     67
   UB-04 Claim Form Requirements

     All claims that do not require an
      attachment for payment must be
      submitted electronically.
     Professional claims are submitted on the
      837I electronically and the UB-04 on
      paper.
     MAD requires that all paper UB-04 claim
      forms be on the original red claim forms.
     Photocopies of claim forms are returned
      to your billing office.

January 2010                                      68
ADA 2006 Claim Form
Requirements
     All claims that do not require an
      attachment for payment must be
      submitted electronically.
     Professional claims are submitted on the
      837D electronically and the ADA 2006 on
      paper.
     MAD requires that all paper ADA 2006
      claim forms be on the original red claim
      forms.
     Photocopies of claim forms are returned
      to your billing office.
January 2010                                     69
The Billing Process

     I.        Check eligibility
     II.       Get Prior Authorization (only if required)
     III.      Submit the Claim
     IV.       Claim follow up




January 2010                                                70
Claim follow up
        Check for claim status on the Web Portal.
              Claim specific search capability is available using
               the web portal to locate specific claims quickly.




January 2010                                                         71
 Claims Status Inquiry




January 2010             72
Claims Summary




January 2010     73
Claim Detail - Codes




January 2010           74
Claim follow up
        The Remittance Advice may also be used for
         claims status.
              Contains summary of that week’s payment
               information.




January 2010                                             75
Reading the Remittance
Advice (RA)
    The Remittance Advice, also known as an
     EOB, is produced weekly. The RA lists claims
     ACS has processed for a particular provider,
     explaining which claims are pending, paid, or
     denied, and the reason for any denials. A
     financial summary is also included in the RA.




January 2010                                         76
   Reports and Data Files




January 2010                77
Reports and Data Files




January 2010             78
What is a Transaction Control
Number (TCN)?
   The TCN is a unique number assigned to
    each and every claim. This number
    contains information about the claim and
    can be used to identify your claim when
    calling provider services


               30832300085000001

January 2010                                   79
        What will a TCN tell you?
                              30832300085000001

 The first digit indicates                            Batch number
 what the claim “media” is:
 2 = electronic crossover
 3 = other electronic claim   The last two                                The claim number within
                              digits of the    The numeric                the batch.
 4 = system generated         year the         day of the
 claim or adjustment          claim was        year.
 8 = paper claim              received




                                This is the Julian Date - this represents the date the claim
                                was received by ACS: this claim - the 323rd day of 2008,
                                or November 18, 2008


January 2010                                                                                        80
       Follow these billing procedures and
        you will be a happy, successful biller.




January 2010                                      81
January 2010   82
           Thank you for attending!




January 2010                          83