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					                                           Billing DSHS for Medical Services 095




Billing DSHS for Medical Services

Making Medicaid Easier
This Training Is Designed to Prepare You to:

               Confirm that a patient is eligible for Medical Assistance.

               Find out if a service is covered under a Medical Assistance program.

               Determine who to bill.

               Recognize when prior authorization is required.

               Increase your success submitting claims and billing Medicare Crossover Claims.

               Find out what you have been paid for.

               Determine when and how to re-bill a denied claim or submit an adjustment.

               Quickly navigate DSHS’s websites to locate policy references, exclusions, and
                limitations in program specific billing instructions.

               Anticipate some of the changes coming with the new DSHS Billing System -
                ProviderOne.


Who Will Benefit From This Training?

This training is designed for new billing staff, billing DSHS fee-for-service and staff who:

               Schedule patient appointments or check in patients on the day they receive services or

               Post and reconcile DSHS payments.

We assume participants are already familiar with standard billing practices and coding.
 NOTE: This training does not include billing in the pharmacy POS system.




An Introduction to Medical Assistance
 What is Medical Assistance?

Washington’s Medical Assistance programs provide healthcare coverage for low-income residents who
meet certain eligibility requirements. These include, but are not limited to age, pregnancy, disability,
blindness, and old age. Special rules exist for those living in a nursing home and disabled children
living at home. Eligibility for Medical Assistance is determined at the local Community Service
Office.

Washington State has a number of programs dedicated to providing health care coverage to low-
income residents. The largest single source for this coverage is Medicaid. There are also other
programs that offer more limited benefits. Washington’s Medical Assistance programs provide
healthcare coverage for our most vulnerable residents.

The Health and Recovery Services Administration (HRSA) of the Department of Social and
Health Services (DSHS) operates Medicaid and several associated health and recovery programs
including the state’s Mental Health programs, chemical dependency and prevention treatment
programs, and family planning.

Medicaid patients receive healthcare services either through enrollment in a managed care
program or on a fee-for-service basis. Current client participation is divided about 50-50 between
the two different methods.

 For managed care, HRSA contracts with licensed health insurance carriers to provide a defined
set of services to enrolled members. Fee-for-service care is delivered by licensed or certified health
care providers like yourself who have a contract with DSHS to serve our patients.


 Who Are Medical Assistance Clients?

Approximately one million Washington residents, nearly two thirds of them children, depend on
Medical Assistance programs for their healthcare. Those covered by medical assistance might surprise
you.

Medical Assistance covers one in three children living in Washington State including:
                            children receiving foster care
                            children of working parents unable to afford health care coverage
                            disabled children living at home

                           Other examples of clients include:
                               Working disabled adults
                               Elderly citizens who can continue to live in their home with assistance
                               Elderly low-income seniors living in nursing homes


        Every effort has been made to ensure this Guide’s accuracy. However, in the unlikely event of an actual or apparent   1
        conflict between this document and a department rule, the department rule controls.
DSHS appreciates our providers. They deliver medically necessary services to our state’s most
vulnerable citizens. As you know, these clients may be a coworker, friend, neighbor or family member.

Under their agreement with DSHS, providers can choose to serve as few or as many clients as your
business can comfortably accommodate. Most providers find they are able to serve some level of
clients receiving medical assistance as part of their payor mix.


 How does Medicaid Compare to Other Payors?

In many ways, Medicaid is similar to other payors. There are some distinct differences between
Medicaid and other insurance plans, including Medicare. These include:
     Providers who are contracted with Medicaid cannot bill a patient for a covered service with the
       following exceptions (WAC 388-502-0160):
            o A patient chooses to receive and pay for a non-covered service AND sign a waiver
                before the service occurs.
            o A patient is responsible for a “spenddown liability” which they must incur before the
                client becomes eligible for medical benefits.
            o The provider has documentation that the client represented himself/herself as a private
                pay client.
            o The client refuses to complete and sign insurance forms, billing documents, or other
                forms necessary for the provider to bill insurance for the service.
     Provider must accept Medicaid’s payment as payment in full. Clients are not responsible to
       pay any remaining balance after Medicaid has made a payment.
     Medicaid is almost always the payor of last resort, which means Medicare and commercial
       private insurance companies must be billed first.
     Other payors process paper “corrected claims” for providers who want to make changes to a
       paid claim. DSHS requires providers to fill out an adjustment form (DSHS form 525-109) if
       changes need to be made to a paid claim. Providers can submit electronic corrected claims.


 How Is Medicaid Different From Medicare?

Although their names are similar, Medicaid and Medicare are very different programs. Medicare is an
entitlement program funded entirely at the federal level. It is a health insurance program for people age
65 or older, people under age 65 with certain disabilities, and people of all ages with end stage renal
disease. The Medicare Program provides:
      Medicare Part A, which covers inpatient hospital services
      Medicare Part B, which covers professional, outpatient hospital, and vendor services
      Medicare Part C, which is a Managed Care version of Medicare, also called an Advantage
         Plan (HMO)and offered through private insurance companies
      Medicare Part D, which covers prescription drugs

Unlike Medicare, Medicaid is not an entitlement program. It is a needs-based program with
eligibility determined by income and covers a wider range of healthcare services than Medicare (i.e.
dental, glasses). Some individuals are eligible for both Medicaid and Medicare. They are known as
“dual eligibles”.

For more information on Medicare, you can find extensive material on the website for Centers for
Medicare and Medicaid Services (CMS) at http://www.cms.hhs.gov/MedicareGenInfo/ .

        Every effort has been made to ensure this Guide’s accuracy. However, in the unlikely event of an actual or apparent   2
        conflict between this document and a department rule, the department rule controls.
 DSHS Clients as Good Consumers Of Health Care Services

Like you, we strive to help clients be good consumers of health care services. DSHS offers guidance to
new clients and provide them with a publication for people getting services covering topics such as:
     Before you use a doctor, dentist, clinic, pharmacy or other provider, ask if they will take your
        Medical Assistance Identification card (MAID) and bill DSHS
     Help your healthcare provider give you the care you need. Bring your MAID to all
        appointments, tell your provider you have Medical Assistance, and help them get copies of
        your medical records
     Carry your MAID with you all the time. Show your MAID whenever you get medical care or
        services and when you get prescription medicines
     Be courteous about appointments, calling if you will miss an appointment or be late, so other
        patients can use the time that was reserved for you
     Let your provider know if you have other medical insurance besides Medical Assistance


 What are some of the benefits of being a Medicaid Provider?

       Enhanced payments are available for dental providers who provide access to baby and child
        dentistry (ABCD).
       Rural physician providers get a delivery extra rate.
       Medicaid pays promptly when claims are billed correctly.
       DSHS is introducing technology to make billing Medicaid easier.
       You determine how many Medicaid patients your payor mix and business can allow.

 What Resources are Available to Providers?

Program Specific Billing Instructions


        Billing Instructions are documents that explain billing guidelines, coverage, and limitations. There
        are many Billing Instructions that contain program specific policies. There is also a General
        Information Booklet. It covers rules that apply to all providers.


Fee Schedule


        The fee schedule helps providers look up procedure codes and determine if services are covered.
        You can also research the reimbursement rate of a service. The fee schedule also informs you of
        authorization requirements that correspond with that procedure code.



Trained Staff


        The Medicaid Assistance Customer Service Center (MACSC) is available to support providers
        Monday – Friday, 7:00a.m.-5:30p.m. You can contact MACSC at 1-800-562-3022, option 2, or by e-
        mailing your inquiry to providerinquiry@dshs.wa.gov .

        Every effort has been made to ensure this Guide’s accuracy. However, in the unlikely event of an actual or apparent   3
        conflict between this document and a department rule, the department rule controls.
        Table of Contents


Confirm Patient Is Eligible for Medical Assistance
       Why                                                                                       page 6
       How                                                                                       page 6

Determine If a Service Is Covered
       Why                                                                                       page 9
       How                                                                                       page 9

Bill DSHS
        Why                                                                                      page 13
        How                                                                                      page 13

Reconcile the Remittance Advice
       Why                                                                                       page 16
       How                                                                                       page 16

Appendixes

        WAMedWeb                                                                                 page 20

        Medical Assistance Customer Service Center (MACSC)                                       page 23

        Medical Assistance Identification Card (MAID)                                            page 24

        Covered Services Chart                                                                   page 26

        Expedited Prior Authorization (EPA)                                                      page 28

        Medicare Crossovers                                                                      page 29

        Remittance Advice (RA) /Claim Numbers (ICNs)                                             page 31

        Medical Assistance Programs                                                              page 32

        Adjustment Request Form                                                                  page 34

        Credit Balances                                                                          page 35




        Every effort has been made to ensure this Guide’s accuracy. However, in the unlikely event of an actual or apparent   4
        conflict between this document and a department rule, the department rule controls.
Providing Services for Patients on Medical Assistance



The Key Actions

1. Confirm Patient Is Eligible For Medical
  Assistance

2. Determine If A Service Is Covered

3. Bill DSHS

4. Reconcile the Remittance Advice




    Every effort has been made to ensure this Guide’s accuracy. However, in the unlikely event of an actual or apparent   5
    conflict between this document and a department rule, the department rule controls.
 Key Action


   1
Confirm Patient is Eligible for Medical
Assistance
 Why

            Many claims are denied because a patient was not eligible for coverage on the date of
            service. Confirming eligibility costs you nothing but can save you plenty – in both
            time and money.

            Confirming eligibility at check-in will:
                Ensure you deliver a service you can get reimbursed for
                Indicate who to bill first so payment is not delayed (Commercial insurance
                   carrier; Medicare; Medical Assistance)
                Determine if the patient is on a Managed Care Plan (HMO). For most services,
                   the plan is responsible for payment and DSHS is not secondary
                Help you identify any special limitations (such as a requirement to coordinate
                   care through a single Primary Care Physician)

            Confirming eligibility before the appointment can help you avoid having to turn away a
            patient at check in and lose an appointment time needed by another patient because:
                 You don’t accept their HMO plan
                 You are not an enrolled Medicare provider
                 You are not an enrolled provider with their commercial private insurance plan

            You can confirm eligibility with or without a Medical Assistance Identification Card
            (MAID) using no-cost methods outlined below in STEP 1 and STEP 4.

How

STEP 1: Check Medical Assistance Eligibility When Scheduling Appointment

            This step is optional but recommended for new clients. To assure coverage, providers
            should always check eligibility on the day the service is provided. The following methods
            will confirm patient eligibility:
                  Search for eligibility information on-line via the WAMedWeb (see Appendix A)
                          o Available 24 hours a day, 7 days a week
                  Call the Interactive Voice Response (IVR) if you have the patient’s SSN (see
                     Appendix B)
                          o Available 24 hours a day, 7 days a week
                  Call a customer service representative at 1-800-562-3022, option 2
                          o Available Monday through Friday between 7:00am and 5:30pm

       Every effort has been made to ensure this Guide’s accuracy. However, in the unlikely event of an actual or apparent   6
       conflict between this document and a department rule, the department rule controls.
            STEP 2: Ask Patient For Medical Assistance Identification (MAID) At Check In.

                          The MAID should be received by the patient at the beginning of each month they are
                          eligible for services. The card is good for one month and lists the people in the family or
                          household who are eligible for medical assistance. If family members are on different
                          Medical Assistance programs, or live at different addresses, they may have more than one
                          MAID. As long as family members have their Patient Identification Code (PIC) listed on
                          a MAID, they can receive services.

                          A patient might not have a MAID, but still be eligible. If a patient has recently been
                          approved for medical assistance and has not received their MAID, they may present a
                          letter from DSHS that says they have medical assistance. Patients can use this letter
                          instead of the MAID to get medical care while waiting for the MAID to come. If a patient
                          has recently moved or have misplaced their card, you can still check eligibility (See STEP
                          4).

            STEP 3: Verify The Patient’s Identification

                          Clients are advised that no one else may use their MAID. It is possible that the MAID
                          could be lost or stolen. It is important to know to whom you are providing services. It is
                          the responsibility of the provider to verify the patient’s identification. If the patient is not
                          known to you, you will want to ask for some form of identification in addition to the
                          MAID.

            STEP 4: Confirm Eligibility Using One of These Methods

                          DSHS offers several no cost methods for confirming eligibility. You can:
                              Search for eligibility information on line via the WAMedWeb (see Appendix A)
                                     o Available 24 hours a day, 7 days a week
   QUICK TIP
                              Review the dates of eligibility printed on the MAID (see Appendix C)
                                     o If patient does not have a card with them, select another method
Click HERE to view            Call the IVR at 1-800-562-3022 using the patient’s SSN (see Appendix B)
the WAMedWeb                         o Available 24 hours a day, 7 days a week
tutorial                      Call a customer service representative at 1-800-562-3022
                                     o Available Monday through Friday between 7:00am and 5:30pm

                          Note: Some offices contract with a Medical Eligibility Vendor (MEV). You will have a
                          separate set of instructions.

            STEP 5: Determine Who to Bill

                          Regardless of the source of information used to confirm eligibility, you will want to
                          identify who the primary payer is. DSHS is almost always the payer of last resort

                                    Check to see if the patient is in a Managed Care plan
                                        o If the patient is in managed care through Medical Assistance, most
                                             services are covered by the plan. Medicaid is not secondary in this
                                             scenario.


                     Every effort has been made to ensure this Guide’s accuracy. However, in the unlikely event of an actual or apparent   7
                     conflict between this document and a department rule, the department rule controls.
                      Check to see if the patient is covered by commercial plan, private insurance, or
                       Medicare
                          o Health insurance is indicated on the MAID or on information returned to
                               you when you checking eligibility.

                             o    Identify an insurance carrier using the list of Insurance Carrier Codes at
                                  http://maa.dshs.wa.gov/LTPR or call DSHS at 800.562.6136.

                      Bill DSHS only after first pursuing any potentially primary payors when:
                            o Health insurance is indicated on the medical ID card or inquiry;
                            o There is possible casualty claim and immediate funds available or;
                            o There is reason to believe insurance is available.

            Note: If you determine there is a possible casualty claim, please call the Casualty Unit at
            1-800-894-3754 (i.e. motor vehicle accident, Department of Labor and Industries claim,
            Injury diagnosis)

STEP 6: Keep a Copy of the Information Returned To You

                      Regardless of the method you choose to confirm eligibility, keep a copy of the
                       information returned to you as proof of eligibility
                           o Copies of the eligibility document can be submitted as claim back-up if
                               DSHS’s claim processing system is not updated.

            Note: IVR does not provide an eligibility document.


 Pitfalls

                 Entering the PIC incorrectly in your computer system at patient check-in can
                  later cause a claim to deny.
                 Billing DSHS when there is a primary payor will delay receipt of payment and
                  increase your workload.
                 Billing the wrong payer can put the provider at risk of meeting time limits for
                  other insurance carriers. Although the initial billing submission time limit for
                  DSHS is 365 days, an insurance carrier’s time limit on billing allowances may be
                  shorter.


   When ProviderOne goes live patients will receive a permanent plastic client “Services Card” instead of the
   MAID. Please see the Client Services Card Fact Sheet for more information. (link) Each family member
   will receive their own Services Card.




    The new Patient ID will be used instead of the current PIC and will have a simpler format which does not
    contain patient information. (i.e. 123456789WA).




       Every effort has been made to ensure this Guide’s accuracy. However, in the unlikely event of an actual or apparent   8
       conflict between this document and a department rule, the department rule controls.
 Key Action


   2
Determine if A Service is Covered
 Why

            If you have determined that DSHS is the right payer, it is important to verify that the
            service your office plans to provide is covered. DSHS provides a wide range of medical
            services. Not all programs cover all services.

            Some procedures may require that you satisfy certain conditions in order to be reimbursed
            for the service - such as determining whether a service requires prior authorization. These
            requirements should be researched before the service occurs to prevent possible
            interruptions to payment. If a service is not covered and the patient chooses to receive and
            pay for a specific service a waiver must be signed before the service occurs in order to
            collect from them.


 How

STEP 1: Determine What Service Will be Performed

                      Check to see what procedure is planned

STEP 2: Identify the Corresponding Procedure Code

                      Use your national coding books to identify the procedure and diagnosis code.
                       (i.e., CPT, HCPCS, ICD-9, and ADA dental books)

STEP 3: Confirm That the Type of Service is Covered Under the Patient’s Medical
Assistance Program

                      Locate the medical program identifier or medical program name that the patient
                       is covered under
                            o The medical program identifier or medical program name is located on
                                the MAID or eligibility inquiry

                      See Appendix H DSHS Medical Assistance Programs to review high level
                       Medical Program Descriptions

                      See Appendix D for an overview of services typically covered under each
                       program

                      Look up detailed service in the program specific Billing Instructions

       Every effort has been made to ensure this Guide’s accuracy. However, in the unlikely event of an actual or apparent   9
       conflict between this document and a department rule, the department rule controls.
At the beginning of every Billing Instruction, there is a section that outlines what Medical Assistance
programs are eligible for the services in that document. Please see the example below from the Vision
Care Billing Instructions:




This chart shows what programs are eligible for vision services. The program identifier can be found
in the lower right hand corner of the MAID. This information will also be returned to you if you verify
eligibility via the WAMedWeb or IVR.

    o   Look up special criteria and limitation details in your program specific Billing Instructions.
                         o Some payable procedure codes may still have special criteria such as:
                               Payable only when billed with a specific diagnosis code
                               A limitation. For example, an eye exam is covered for an adult
                                  Medical Assistance patient but limited to one every two years.

STEP 4: Determine if the Service is Allowable and/or Requires Authorization

                       Look up the procedure code in the appropriate fee schedule.
                           o The fee schedule will provide you with information about the procedure
                                code and reimbursement rate
                           o If there is a pound sign (#) next to the code, it is non-covered
                           o If there is a dollar amount, it is covered




        Every effort has been made to ensure this Guide’s accuracy. However, in the unlikely event of an actual or apparent   10
        conflict between this document and a department rule, the department rule controls.
                          The following is an example of a professional fee schedule:



Procedure code
11954 is not covered.                                                                                                     Mod=Modifier.
Procedure code                                                                                                            NFS=Non Facility Setting
11960 is covered                                                                                                          FS=Facility Setting
                                                                                                                          PA= Prior Authorization
                                                                                                                          Global Days= Post Op
                                                                                                                          Period



                                       Use the Fee Schedule to determine if there is an authorization requirement
                                           o The Fee Schedule might indicate PA, Prior Authorization. Consult with
                                                your program specific BI on requesting Prior Authorization instructions.
                                           o The Fee Schedule might indicate EPA, Expedited Prior Authorization –
                                                These are authorization numbers obtained from the Billing Instructions
                                                based on certain medical criteria where the formal prior authorization
                                                process is waived. For an example, see Appendix E.

                             Note: You can request an “Exception to Rule” for a non-covered service. DSHS will
                             review the medical justification and other required documentation to determine if the non-
                             covered service is medically necessary. (WAC 388-501-0160)

                                       Use the Fee Schedule to determine the reimbursement rate for the procedure
                                           o This step is optional. If you would like to know the reimbursement rate
                                                for a procedure, that dollar amount is listed in the fee schedule next to the
                                                procedure code. In the above example, the reimbursement rate for 11960
                                                is $503.61.
                                           o Facility setting maximum allowable fees (FS Fee) is paid when the
                                                provider performs the services in a facility setting (e.g., a hospital or
                                                ambulatory surgery center) and the cost of the resources are the
                                                responsibility of the facility
                                           o Non-facility setting maximum allowable fees (NFS Fee) is paid
                                                when the provider performs the service in a non-facility setting (e.g.,
                                                office or clinic) and typically bears the cost of resources, such as
                                                labor, medical supplies, and medical equipment associated with the
                                                service performed.

                             Note: For reimbursement information on inpatient services, please see the
                             Inpatient Hospital Services Billing Instructions.

              STEP 5: Have the Patient Sign a Waiver if the Service is Non-covered

                             Contracted Providers can bill a DSHS patient for non-covered services if the patient
                             signed a waiver before the service occurred. (WAC 388-502-0160)

                                       Use a waiver form that includes each of the following elements
                                            o A statement listing the specific service to be provided;
                                            o A statement that the service is not covered by Medical Assistance;
                                               and
                        Every effort has been made to ensure this Guide’s accuracy. However, in the unlikely event of an actual or apparent   11
                        conflict between this document and a department rule, the department rule controls.
                         o A statement that the patient choose to receive and pay for the service
                     Obtain patient’s signature on the waiver and keep for your records

           This information can also be located in the General Information Booklet.


Pitfalls

                If you have a patient sign a waiver and it is later found that the service was
                 covered by DSHS at the time it was provided, the patient is not obligated to
                 pay. This applies even if DSHS did not pay the provider because the
                 provider did not satisfy DSHS’s billing requirements.
                Failing to obtain prior authorization when required could result in a denied
                 claim. You would not be able to bill the patient in this situation.
                Failing to understand that prior authorization does not override eligibility could
                 cause your claim to deny. The patient must be eligible for Medical Assistance
                 the date the service occurs. You can bill a patient without a waiver if they are
                 not eligible the date the service occurs.



   When checking eligibilty, a Benefit Service Package will be returned to you, outlining what types of
   services are covered under the patient’s Medical Asisstance program.




      Every effort has been made to ensure this Guide’s accuracy. However, in the unlikely event of an actual or apparent   12
      conflict between this document and a department rule, the department rule controls.
             Key Action


                3
          Bill DSHS
            Why

                        If you have determined the client is eligible, the service is covered, and DSHS is the
                        primary payer you can proceed with billing DSHS after the service is rendered.

                        All the work up to this point will increase your success in billing DSHS and getting
                        reimbursed in a timely manner. Denied claims can result in rework to research, correct,
                        and follow up re-billing.


          How

          STEP 1: Determine What Billing Method You Will Use

                        DSHS encourages providers to submit electronically. You can receive quicker payments
                        using an electronic method. Paper claims can take up to 4-6 weeks to process and receive
                        payment. Information elements on the claim will remain the same regardless of what
                        methods you use.

                               Select one of the methods below:
                                    o WAMedWeb – With this tool, providers can check claim status, submit
           QUICK TIP                     claims, check patient eligibility, view weekly warrant amounts, and view
                                         your last 3 Remittance Advice online. (See Appendix A)
Claim templates can be created      o Electronic Claim Submission using your practice management software
in the WAMedWeb - eliminating            – Your software company uses companion guides to keep your software
the need to reenter all of your          up to date. Companion guides can be located at
claim information.                       http://www.acs-gcro.com/.
                                         Electronic claims are submitted to DSHS through a Billing Agent,
This is ideal for services your
office bills regularly. Click            Clearinghouse, or Software vendor. To conduct electronic transactions
HERE to learn how to create              with DSHS, a trading partner agreement must be completed. Enrollment
templates.                               forms can be located at http://www.acs-gcro.com/
                                    o Paper Claim Submission
                                                       Institutional (i.e. hospitals, nursing homes) claims are
                                                          submitted on a UB04 claim form.
                                                       Professional (i.e. physician) claims are submitted on a
                                                          CMS1500 claim form.
                                                       Dental claims are submitted on an ADA form. We are
                                                          currently only accepting the 1994, 1999, 2002/2004,
                                                          and 2006 ADA Dental Claim Forms. Effective 7-1-08,
                                                          DSHS will only accept the 2006 ADA Dental Claim
                                                          Form.

                   Every effort has been made to ensure this Guide’s accuracy. However, in the unlikely event of an actual or apparent   13
                   conflict between this document and a department rule, the department rule controls.
                             Note: Medicare Crossovers that are not electronically forwarded to DSHS from
                             Medicare must be submitted on paper, using the same claim form you used to bill
                             Medicare. Please see Appendix F for more information on Medicare Crossovers.


             STEP 2: Enter Your Claim Information

                             Regardless of the method you bill, the data elements needed are the same.

                                    Follow national claim standards
                                         o Instructions on how to complete and bill according to the official UB-04
          QUICK TIP
                                             Data Specifications Manual is available from the National Uniform
  Both individual and batch                  Billing Committee at: http://www.nubc.org/index.html.
  claims can be submitted via
  the WAMedWeb.                            o    Instructions for completing the CMS 1500 form can be located in the
                                                General Information Booklet on page H.13.
  Click HERE to learn how to
  submit indiv idual or batch              o    Instructions for completing the ADA claim forms can be found in section
  claims in the WAMedWeb.                       G of either Dental Billing Instruction.

                             Note: Adjustments and resubmitted claims are addressed under Key Step 4 - Reconcile
                             DSHS Remittance Advice.

                             Note: When billing DSHS after a commercial private insurance, indicate the insurance
                             PAID amount in the appropriate box on the claim form. Subtract the insurance paid
                             amount from the total billed amount and that balance is the estimated amount due.

             Step 3: Determine if Your Claim Needs Backup and Attach to Claim

                                    Your claim to Medical Assistance will need backup documents if the DSHS
                                     patient has:
                                         o Commercial Private Insurance
                                         o Medicare
                                         o Managed Medicare
                                         o Invoices
                                         o Operative Reports, if requested by DSHS

                                                                    Example: Posted in the Injectable Fee Schedule, J7192 has the
Some codes listed in the                                            “A.C.” indicator in the reimbursement field. Refer to your
fee schedule are denoted                                            billing instructions to verify if an invoice will be required as
with an “A.C.”                                                      back-up.
(Acquisition Cost)
indicator and may require
submittal of an invoice to
consider payment


                                    If your claim needs backup, submit the documentation to DSHS with your claim.

                                    If you are sending back-up documents to your electronic billing, attach a
                                     standard cover sheet to your back-up documents and send them to:
                     Every effort has been made to ensure this Guide’s accuracy. However, in the unlikely event of an actual or apparent   14
                     conflict between this document and a department rule, the department rule controls.
                             o    Electronic Claim Back-up Documentation (ECB)
                                  PO Box 45560, Olympia
                                  WA 98504-5560

            Note: If the original paid claim had required back-up, any adjustment made to that paid
            claim will also require you to resubmit the back-up with the adjustment form.

STEP 4: Submit Claim in a Timely Manner

                      Initial claims must be submitted to DSHS within 365 days of the date of service
                            o Providers may resubmit, modify, or adjust any timely initial claim for a
                                 period of 36 months from the date of service.
                            o You will need to reference the original claim number (Internal Control
                                 Number – ICN) on claims resubmitted after 365 days

                      Paper claims can be mailed to DSHS at the following addresses:

                             o    All Paper Claims
                                  PO Box 9248, Olympia, WA 98507-9248

            Note: See Appendix F for time limits on Medicare Crossover Claims.

            Note: Prescription drug claims must be resubmitted, modified, or adjusted within 15
            months of the date of service.

 Pitfalls

                 Not using current claim forms can result in having your paper claims mailed
                  back to you. DSHS will return all claims submitted on the CMS/HCFA-1500
                  claim form (version 12/90) and return all claims submitted on the UB-92 claim
                  form.
                 IF the PIC was entered in your computer system incorrectly at check-in, it can
                  cause your claim to deny.
                 Not billing Medicaid Crossovers to DSHS on the same claim form you used to
                  bill Medicare can cause your crossove r to deny. See Appendix F for more
                  information on Medicare Crossovers.



    You will no longer need to submit your 7 digit legacy Medicaid number on claims. Instead you will only
    use your NPI numbers and taxonomy on all claims.




    You will be able to attach back up documents electronically on individual claims.




       Every effort has been made to ensure this Guide’s accuracy. However, in the unlikely event of an actual or apparent   15
       conflict between this document and a department rule, the department rule controls.
Every effort has been made to ensure this Guide’s accuracy. However, in the unlikely event of an actual or apparent   16
conflict between this document and a department rule, the department rule controls.
 Key Action


   4
Reconcile the Remittance Advice
 Why

            The Medical Assistance Remittance and Status Report (RA) provides you with the
            information needed to check the status of your claims. You can apply payments to your
            patient accounts from the “Claim Paid” section, see what claims are in process, and
            investigate denied claims.

            DSHS makes payments to Medical Assistance providers weekly. Medical Assistance
            always pays on Monday each week. Claim submission cutoff in the payment system is
            Tuesday at noon to make payment the following Monday for a “clean” claim. Clean
            claims are claims that have all of the required data elements and do not conflict with
            DSHS program policies. Clean claims submitted after the cutoff timeframe will be paid
            the following payment cycle of the following Monday. DSHS sends out the RA weekly
            and it is always dated with Monday’s payment date.


How

STEP 1: Select Method to Retrieve Remittance Advice (RA)

                      Retrieve your RA via the WAMedWeb.
                           o Log onto the WAMedWeb
                           o Select View/Download Files from the Menu for the 835 RA or
                           o Select RA from the Menu for the PDF RA
                           o Select the appropriate submitter number from the drop down box and
                               click on submit
                           o Click on the file name of the RA you wish to view

                      If you are not set up to use the WAMedWeb, you will receive a paper copy of your
                       RA
                            o The paper RA’s are generated Monday of each week
                            o Paper versions of the RA are delivered to the USPS post office by
                                Tuesday

       NOTE: When you receive the paper RA it is subject to the delivery schedule of your local
       USPS post office. If you receive your RA electronically, it will be available Monday morning

STEP 2: Review the Remittance Advice

            Please see Appendix G for an RA example. The RA is structured in this order:

       Every effort has been made to ensure this Guide’s accuracy. However, in the unlikely event of an actual or apparent   17
       conflict between this document and a department rule, the department rule controls.
                                             Remittance Newsletter
                                                  o The newsletter contains important information regarding DSHS policies.
                                             Paid claims
                                                  o Lists the claims that have been paid.
                                             Denied claims
                                                  o Lists the claims that have been denied. Denial reason codes will be
                                                      posted on the far right of the page.
        QUICK TIP
                                             Claims in process
     You can search for
                                                  o Lists the claims that have been received and have not been finalized.
     claim status via the                    Adjustments paid
     WAMedWeb at                                  o Lists adjustments that have paid.
     any time, without                       Adjustments denied
     having to wait for                           o Lists adjustments that have denied. Denial reason codes will be posted on
     your RA.                                         the far right of the page
                                             Adjustments in process
     Click HERE to                                o Lists the adjustments that have been received and have not been
     learn how using                                  finalized.
     the WAMedWeb
                                             Explanation of EOBs
     tutorial
                                                  o This section describes the denial reason codes that posted within the RA.

                                   NOTE: Some paid claims may contain some services that denied.

                 STEP 3: Reconcile Payments and Review Claims in Process

                                             Review the Paid Claims section and apply payments to your patient accounts.
                                                  o There may be more than one “Paid Claims” section depending upon
                                                      what services have been reimbursed. For Example, if you billed for
                                                      EPSDT services there would be a “Paid Claims – EPSDT Claim” section
                                                      that would be separate from your “Paid Claims –Physician Claim”
      QUICK TIP
                                                      section. Be aware of that possibility to assure you account for all paid
To help you speed up the                              claims posted to an RA
reconciliation process for
paid claims, enter your            Note: Some paid claims may also contain denied service lines. Those denied service lines
practice management                will still be posted in the paid claims section within the specific paid claim.
software patient account
number on your paper or                      Review the “Claims in Process” section.
electronic claims, DSHS                           o There may be more than one “Claims in Process” section depending
will return that identifier                           upon what services you have billed. For Example, if you billed for
on your RA.                                           EPSDT services there would be a “Claims in Process – EPSDT Claim”
                                                      section that would be separate from your “Claims In Process – Physician
                                                      Claim” section. Be aware of that possibility to assure you account for all
                                                      claims in process posted to an RA.

                                   Note: On average, paper claims can take as long as 4-6 weeks to process from the date
                                   they were received. Electronic “clean” claims can take 7-10 days from the date they were
                                   submitted to process.

                 STEP 4: Research Denied Claims

                                             Review the Denied Claims section

                              Every effort has been made to ensure this Guide’s accuracy. However, in the unlikely event of an actual or apparent   18
                              conflict between this document and a department rule, the department rule controls.
                                             o    There may be more than one Denied Claims section depending upon
                                                  what type of services have been denied. Be aware of that possibility to
                                                  assure you account for all denied claims posted to an RA.
                                             o    For Example, if you billed for EPSDT services that were denied by
                                                  DSHS there would be a “Denied Claims – EPSDT Claim” section that
                                                  would be separate from your “Denied Claims –Physician Claim” section.

                                       Read EOB Codes
                                           o Refer to the Explanation of Benefits section at the end of the RA for
                                               further information on the denial codes posted to those claims or denied
                                               services.
                                           o Most EOB codes are self explanatory. If it is unclear, it should refer you
                                               to the right resource (i.e. Billing Instruction, coding books, fee schedule).
                                           o If you are still unable to understand the denial, a customer service
                                               representative can assist you at the Medical Assistance Customer Service
                                               Center at 1-800-562-3022. (See Appendix B)

                                        Note: For claim denials related to Private Insurance or for clarification on billing
                                        Medicaid secondary to Private insurance, please contact the Coordination of
                                        Benefits office at 1-800-562-6136

                                       Determine if you need to rebill or process an adjustment
                                            o Rebill when:
                                                      The entire claim is denied;
                                                      An individual line on a professional service, multiple-line claim
                                                         is denied. This line can be resubmitted as a new claim.
                                            o See step 6 for information on adjusting paid claims.

             STEP 5: Rebill When a Denied Claim Can be Corrected

                                       Make any necessary corrections based on the EOB code(s) on a copy of the claim
                                        or produce a new claim with the correct information
                                            o Line out or omit all previously paid lines on the claim before sending it
                                                back to DSHS.
                                            o Adjust the total

                                       Attach insurance information or other required documentation to the claim

                                       Send claim to DSHS
                                            o Providers billing electronically may rebill claims via the WAMedWeb
                                                applications

             STEP 6: Submit Adjustments When You Need to Change a Paid Claim

                                       Process an adjustment when:
                                            o The claim was paid and an error was made (i.e., wrong patient, billed
                                                amount, tooth number, etc.)
                                            o The claim contained multiple surgical procedure codes, and one of the
                                                procedures was denied or paid incorrectly
                                            o The claim was overpaid
           TIP
To avoid confusion you
                     Every
can attach a replacement effort has been made to ensure this Guide’s accuracy. However, in the unlikely event of an actual or apparent   19
claim form to your conflict between this document and a department rule, the department rule controls.
adjustment.
                    Complete adjustments on the Adjustment Request (525-109), DSHS form 13-715.
                        o See Appendix I for an example of the Adjustment
                        o Use only one adjustment request form per claim
                        o Submit multiple line corrections to a single claim on one adjustment
                            request form
                        o See special instructions on the following page if adjusting an
                            overpayment

                    Attach proper documentation to the adjustment request
                         o Include operative reports, insurance EOB’s, etc.

                    Send adjustment to DSHS
                         o Adjustments can be submitted electronically via the WAMedWeb. (See
                             Appendix A)
                         o DSHS will locate the claim to adjust. The entire original claim will be
                             credited back to DSHS to allow the adjustment to pay correctly. The
                             message CRE will appear in the EOB column on the RA. See Appendix
                             J for information on credit balances (CRE).

                    If you are adjusting an overpayment, Submit an adjustment
                          o DSHS will recoup your claim and deduct the excess amount from your
                              future remittance check(s) until the overpayment is satisfied;
                     OR

                    Issue a refund check payable to DSHS
                         o Attach a copy of the RA showing the paid claim and include a brief
                              explanation for the refund.
                         o Mail to DSHS
                                   DSHS Finance Division
                                      PO Box 9501
                                      Olympia WA 98507-9501



Pitfalls

               Misinterpreting adjustments on the RA. You may see the claim twice. The first
                time will be the “take back” or “CRE” and the second is the reprocessing of the
                claim. Some providers read this incorrectly and think we recouped the claim
                twice.
               Submitting an adjustment for overpayments AND sending in a refund by check.
                Do not adjust and refund for the same claim.
               Refunding claims you may rebill because of an error may cause your new claim
                to deny as a duplicate. Adjustments are preferred in this scenario.




     Every effort has been made to ensure this Guide’s accuracy. However, in the unlikely event of an actual or apparent   20
     conflict between this document and a department rule, the department rule controls.
                                                                                                      Appendix A
                       Getting signed up for the WAMedWeb
The WAMedWeb is an excellent online application provided to you at no cost by the state of
Washington Department of Social and Health Service (DSHS). With this tool providers can submit
claims, check claim status, submit claims, check patient eligibility, view weekly warrant amounts, and
view Remittance Advices (PDF and 835) online!

Step 1 –
Enrollment to become a Trading Partner is required for Medicaid providers who would like to access
the free WAMedWeb application. Enroll by completing the provider enrollment form and trading
partner agreement at http://www.acs-
gcro.com/Medicaid_Accounts/Washington_State_Medicaid/Enrollment/enrollment.htm
If you have questions about completing these forms, please call ACS at 1-800-833-2051.

Step 2 –
Fax or mail the forms to ACS. The fax and mailing information for ACS is located on the enrollment
forms. You will receive a welcome packet within 10 business days with all the information needed to
complete the WAMedWeb registration and gain access to the online application. If you do not receive
your welcome packet within 10 business days, please call ACS EDI Gateway at 1-800-833-2051.

Step 3 –
Please go to the following link and watch the WAMedWeb tutorial:
http://maa.dshs.wa.gov/wamedwebtutor/WAMedWeb%20Tutorial.html
This tutorial walks you through how to use the WAMedWeb and the registration process. If you have
additional questions on using the WAMedWeb after viewing the tutorial, please call the Medical
Assistance Customer Service Center at 1-800-562-3022.




        Every effort has been made to ensure this Guide’s accuracy. However, in the unlikely event of an actual or apparent   21
        conflict between this document and a department rule, the department rule controls.
                                    The tutorial is broken down into modules. You
                                    can click on the module(s) to view information
                                    that is of interest to you.




                                                                                              Appendix A
              Checking eligibility via the WAMedWeb
     o     Step 1 – Log onto the WAMedWeb
     o     Step 2 – Select “Eligibility Inquiry” from the inquiry menu
     o     Step 3 – Enter in your search criteria. Provider number and date of service are always
           required. There are four ways to search for eligibility in the WAMedWeb:
                PIC (Patient Identification Code)
                Last Name, First Name and SSN
                Last Name, First Name and Date of Birth
                SSN and Date of Birth
     o     Step 4 – When finished entering your search criteria, click on submit
     o     Step 5 – The patient’s eligibility information will be returned to you.

                                                                                    Only enter the first Date of Service with the
                                                                                    date of eligibility you are looking for. This will
                                                                                    return an accurate eligibility segment. If you
                                                                                    enter a single date, you can go back 3 years
                                                                                    from the current date to check eligibility.




Every effort has been made to ensure this Guide’s accuracy. However, in the unlikely event of an actual or apparent   22
conflict between this document and a department rule, the department rule controls.
       Note: Familiarizing yourself with the WAMedWeb now will help you prepare for the
        ProviderOne transition. ProviderOne will also we a web based application.

             Submitting an Adjustment via the WAMedWeb
             Step 1 – Log onto the WAMedWeb
             Step 2 – Select “Claim Admin” from the Submissions menu
             Step 3 – From the Create Claims menu, select the appropriate claim form.
             Step 4 – No matter what type of claim form you use, the first question asked by
                      WAMedWeb on the basic claim information page is “Are you resubmitting this
                      claim?”. Select the “Yes” button.
             Step 5 – From the Resubmission Type Code drop down menu, select
                      “7: Replacement/Adjustment”.
             Step 6 – In the ICN to Credit/Adjust field, enter the 17 digit Internal Control
                       Number (ICN) of the paid claim you wish to adjust. This is the claim number
                       found on your Remittance Advice.
             Step 7 – Enter all of your claim information.
             Step 8 – Submit claim.




                                                                                                      Appendix A




Note: When doing any adjustment using the WAMedWeb, it is important to re-enter the ENTIRE
claim when making your requested changes, and not just entering the elements or services you are
correcting or changing. The entire claim will be recouped and adjudicated as a new claim with the
information provided.

Note: You can use the same feature that allows you to adjust a paid claim to also refund a paid claim to
DSHS. DSHS will then subtract the paid amount off a future payment and it will be displayed only as a
“CRE” on your RA.
Follow steps 1 through 3 above, then select the “8: Void” option from the Resubmission Type Code
drop down box. Next you will need to enter the claim number (ICN) located on your Remittance and
Status Report (RA) of the paid claim you wish to refund. Finally, re-enter the claim information exactly
as you originally billed DSHS and then submit the claim.


        Every effort has been made to ensure this Guide’s accuracy. However, in the unlikely event of an actual or apparent   23
        conflict between this document and a department rule, the department rule controls.
                                                                                                         Appendix B

          Medical Assistance Customer Service Center and IVR

                   How to Use the IVR to Check Patient Eligibility
         Step 1 – call 1-800-562-3022
         Step 2 – press Option 2 for providers
         Step 3 – press Option 1 for Patient Eligibility
         Step 4 – say or enter your 7 digit provider number
         Step 5 – say “Client Eligibility”
         Step 6 – say or enter the social security number of your patient
         Step 7 – the patient eligibility information will be returned to you

NOTE: The first thing the IVR will state is “This client is not in Managed Care”, if the patient is
eligible for Medical Assistance and not in a Managed Care plan. This statement is easily
confused with the patient not having Medical Assistance.

If you need further assistance while using the IVR, say “transfer” or press “0” to be connected to
a Medical Assistance Customer Service Representative


        The new ProviderOne IVR will be able to assist providers with: Client Eligibility Information, Claims
        Status, Warrant Amount, RA reprint requests, Authorization Request Status, Pharmacy Authorization
        Submissions, Pharmacy Rate Authorization Submissions, and Managed Care Enrollment.




                      Medical Assistance Customer Service Center

The Medical Assistance Customer Service Center (MACSC) is available to assist providers
7:00am to 5:30pm, Monday through Friday. MACSC is able to assist providers with a variety of
issues. These include:
         Research denied claims after reviewing the RA/ WAMedWeb denials
         Check to see the last time a patient received a particular service. (i.e. when they last
          had an eye exam.) This is important for services with limitations.
         Answer questions on policy in the Billing Instructions
         Assist providers without internet access
         Assist with chronic billing issues
         Assist with warrant (check) replacement
         Assist with replacement RA
         Provide direction to DSHS web sites (addresses) to support provider self help
         Review prior authorization request status

You can also e-mail questions to MACSC at ProviderInquiry@dshs.wa.gov.

          Every effort has been made to ensure this Guide’s accuracy. However, in the unlikely event of an actual or apparent   24
          conflict between this document and a department rule, the department rule controls.
                                                                                                      Appendix C




                 Key to the Medical Identification (ID) Card
Field Descriptions
1. Address of CSO/HCS/MEDS
2. Date eligibility begins
3. Date eligibility ends
4. Medical coverage group
Patient Identification Code (PIC) Segments
5. First and middle initials (or a dash (-) if no middle initial)
6. Six-digit birth date, consisting of numerals only (MMDDYY)
7. First five letters of the last name (and spaces if the name is fewer than five letters)
8. Tiebreaker (an alpha or numeric character)
Medical Coverage Information
9. A four-character alphanumeric code (insurance carrier code) in this area indicates the private
insurance plan information.
10. Medicare Xs indicate the patient has Medicare coverage.
11. HMO (Health Maintenance Organization) Alpha code indicates enrollment in an HRSA
managed care organization. This area may also contain the identifier PCCM (primary care case
manager).
12. Detox Xs indicate eligibility for a 3-day alcohol or a 5-day drug detoxification only program.
13. Restriction Xs indicate the patient is on restriction or review due to over utilization or
inappropriate utilization of medical services. The patient is assigned to 1 physician, 1 pharmacist,
and/or 1 hospital for nonemergent care. The words “patient on review” will also be in field 20.
For questions on the Patient Review and Coordination program please call 800-794-4360.
14. Hospice Xs indicate the patient has elected hospice care.
15. DD patient Xs indicates this person is a patient of the DSHS Division of Developmental
Disabilities.



        Every effort has been made to ensure this Guide’s accuracy. However, in the unlikely event of an actual or apparent   25
        conflict between this document and a department rule, the department rule controls.
                                                                                                      Appendix C
16. Other Letters A, D, F, J or R indicate the child is in Foster Care and is eligible for Early
Periodic Screening, Diagnosis and Treatment (EPSDT) screenings.
17. Health Insurance Claim (HIC) Number is shown here to indicate the patient is on Medicare.
18. Name and address of patient, head of household or guardian.
19. Medical program identifier and medical program name.
20. Other messages (e.g., patient on review, delayed certification, emergency hospital only).
21. Telephone number Telephone number and name of PCCM or HRSA managed care
organization.
22. Local field office Local field office (3 digits) and ACES assistance unit # (9 digits).
23. Internal control numbers for DSHS use only.
24. Patient’s signature - May be used to verify identity of patient.
25. Patient’s primary language.

Note: If you notice there is incorrect patient information on the MAID, please refer the patient to
their local Community Service Office.

Note: In many cases, all family members will be on the same MAID. There are circumstances
where they will have separate MAIDs for members of the same family.




        Every effort has been made to ensure this Guide’s accuracy. However, in the unlikely event of an actual or apparent   26
        conflict between this document and a department rule, the department rule controls.
                                                                                                      Appendix D
                                       Covered Services Chart
   Note: DSHS provides funding for a wide range of medical services. The level of medical coverage for
   any given client depends on the medical assistance program for which the client is eligible. This table
   lists services that may be provided under the specific programs if the individual meets all the criteria
   required to receive the service. Some services may require prior authorization from DSHS or from a
   DSHS-contracted managed care plan. This table is provided for general information only and does not in
   any way guarantee that any service will actually be covered. Benefits, coverage, and interpretation of
   benefits and coverage may change at any time. Coverage limitations can be found in federal statutes and
   regulations, state statutes and regulations, state budget provisions, and DSHS billing instructions and
   numbered memoranda. Clients with questions regarding coverage may call the plan number on the front,
   or the 800 number on the back, of their Medical Identification Card.


   LEGEND: Y=Yes, service is usually covered; N=No, service is usually not covered; R=Restricted with
                                        coverage limitations

               Service                          CN        MN        S-CHIP/CHP GAU                     ADATSA            FP/TC
Adult Day Health                                 Y        N             N       N                        N                 N
Ambulance (ground/air)                           Y        Y             Y       Y                        Y                 N
Ambulatory Surgery Center                        Y        Y             Y       R                        R                 N
Blood Processing/Admin.                          Y        Y             Y       Y                        Y                 N
Childbirth Education                             Y        N             Y       N                        N                 N
Dental Services                                  Y        Y             Y       R                        R                 N
   Crowns/Dentures                               R        R             R       N                        N                 N
Detoxification                                   Y        Y             Y       R                        R                 N
Diabetes Education                               Y        Y             Y       Y                        Y                 N
Family Planning Services                         Y        Y             Y       Y                        Y                 Y
Hearing Care (Audiology/Hearing                  Y        N             Y       Y                        Y                 N
Exams/Aids)
Home Health Services                              Y        Y                Y                Y              Y                 N
Hospice/Pediatric Palliative Care                 Y        Y                Y                N              N                 N
Services
Hospital Services –                               Y        Y                Y                Y              Y                 N
Inpatient/Outpatient
Intermediate Care                                 Y        Y                Y                Y              Y                 N
Facility/Services For Mentally
retarded (IMR)
Maternity Supp. Services/Infant                   Y        Y                Y                N              N                 N
Case Management
Medical Equipment. Durable                        Y        Y                Y                Y              Y                 N
(DME)
Medical Equipment, Nondurable                     Y        Y                Y                Y              Y                 N
(MSE)
Medical Nutrition Services                        Y        Y                Y                R              R                 N
Mental Health Services (General)                  Y        Y                Y                N              N                 N
   Inpatient Hospital Care                        Y        Y                Y                Y              Y                 N
   Outpatient Hospital Care                       Y        Y                Y                N              N                 N
Nursing Facility Services                         Y        Y                Y                Y              N                 N
Organ Transplants                                 Y        Y                Y                Y              Y                 N
        Every effort has been made to ensure this Guide’s accuracy. However, in the unlikely event of an actual or apparent       27
        conflict between this document and a department rule, the department rule controls.
Out-of-State Services                             Y        Y                Y                N              N                 N
Oxygen/Respiratory Services                       Y        Y                Y                Y              Y                 N
Personal Care Services                            R        R                R                N              N                 N
Physician Related Services                        Y        Y                Y                Y              Y                 N
Prescription Drugs*                               Y        Y                Y                Y              Y                 R
Private Duty Nursing                              Y        Y                Y                N              N                 N
Prosthetic/Orthotic Devices                       Y        Y                Y                Y                                N
Psychological Evaluations                         Y        Y                Y                N              N                 N
School Medical Services                           Y        Y                N                N              N                 N
Substance Abuse Services                          Y        Y                Y                N              N                 N
Therapy – Occupational, Physical,                 Y        N                Y                Y              Y                 N
Speech/Audiology
Vision Care Services                              Y        Y                Y                Y              Y                 N
* Medicare recipients receive outpatient prescriptions through their Medicare Part D plan.
Other Services

Alien Emergency Medical (AEM)                      The Health and Recovery Services Administration (HRSA)
                                                   covers only those services related to the client’s emergency
                                                   medical condition.
QMB-Medicare Only                                  HRSA covers only the Medicare coinsurance and deductible
                                                   up to the Medicare or HRSA allowed amount, whichever is
                                                   less.
Non Emergency Medical                              HRSA covers non emergency medical transportation for
Transportation (Brokered                           eligible clients to or from covered services through
Transport)                                         contracted brokers. The brokers arrange and pay for trips for
                                                   qualifying DSHS/HRSA clients. Currently, eligible clients
                                                   include Medicaid, S-CHIP, CHP, GAU, ADATSA, and
                                                   AEM.
Interpreter Services -- Spoken                     HRSA covers interpreter service for eligible clients.
languages                                          Requests for spoken language interpreter services are to be
                                                   requested by Medicaid providers or authorized DSHS staff.
Interpreter Services -- Sign                       HRSA covers the cost of sign language services for eligible
Language                                           clients. Requests for sign language interpreter services are to
                                                   be requested by Medicaid providers or authorized DSHS
                                                   staff and provided by DSHS approved contractors.
Psychiatric Indigent Inpatient (PII)               HRSA covers the cost of sign language services for eligible
Program                                            clients. Requests for sign language interpreter services are to
                                                   be requested by Medicaid providers or authorized DSHS
                                                   staff and provided by DSHS approved contractors.

Customer Service Phone Numbers

DSHS clients may call 800-562-3022 (option 1) for more information.
Providers may call 800-562-3022 (option 2) for more information.

Acronyms
ADATSA = Alcohol and Drug Abuse Treatment                        GAU = General Assistance Unemployable
and Support Act                                                  MN = Medically Needy
CHP = Children’s Health Insurance Program                        S-CHIP = State Children’s Health Insurance
CN = Categorically Needy                                         Program
        Every effort has been made to ensure this Guide’s accuracy. However, in the unlikely event of an actual or apparent       28
        conflict between this document and a department rule, the department rule controls.
FP/TC = Family Planning Only/ TAKE
CHARGE




       Every effort has been made to ensure this Guide’s accuracy. However, in the unlikely event of an actual or apparent   29
       conflict between this document and a department rule, the department rule controls.
                                                                                                                         Appendix E

                                                 Expedited Prior Authorization (EPA)
                          EPA is a 9-digit number designed to eliminate the need for written authorization. DSHS
                          establishes authorization criteria and identifies the criteria with specific codes, enablin g
                          providers to create an EPA number using those codes. The first 6 digits of the EPA number
                          must be 870000 and the last 3 digits must be the code number of the diagnostic condition,
                          procedure, or service that meets the EPA criteria. The three number code and criteria can be
                          found in the Billing Instructions. If the patient meets the criteria the EPA can be used. If the
                          patient does not meet the criteria, you will need to contact DSHS and request Prior
                          Authorization.

Procedure codes
15822 and 15823                                                                                                               Mod=Modifier.
require EPA                                                                                                                   NFS=Non Facility Setting
                                                                                                                              FS=Facility Setting
                                                                                                                              PA= Prior Authorization
Procedure code                                                                                                                Global Days= Post Op
15830 requires Prior                                                                                                          Period
Authorization (PA)

                          If a code needs EPA, then you will need to look up the criteria in the program specific
                          Billing Instructions. In this example, we will look up 15822 in the Physician-Related
                          Services Billing Instruction.

                          Here is a link to the program specific Billing Instructions:
                          http://maa.dshs.wa.gov/download/bi.html



                                                                                                                                                QUICK TIP

                                                                                                                                         Billing Instructions are
                                                                                                                                         in Adobe format. You
                                                                                                                                         can download the
                                                                                                                                         Adobe Reader for free.


                                                                                                                                                 Using the
                                                                                                                                         binoculars in Adobe
                                                                                                                                         allows you to search for
                                                                                                                                         things quickly. Click
  EPA code 630 can be                                                                                                                    on the icon and put in
  used if the patient                                                                                                                    the code or key word
  meets these criteria.                                                                                                                  you are looking for.
  The EPA number
  would be
  870000630.


                          Every effort has been made to ensure this Guide’s accuracy. However, in the unlikely event of an actual or apparent   30
                          conflict between this document and a department rule, the department rule controls.
                                                                                                       Appendix F

                                          Medicare Crossovers
Medicare Crossover claim are claims that are billed to DSHS after Medicare paid the service or applied
to the deductible. Claims or services that are billed to DSHS which have been denied by Medicare are
not considered crossovers. Claims paid by a commercial insurance are not considered crossover claims
by DSHS but secondary TPL billings.

MEDICARE PART A

Part A is the hospital (facilities) portion of Medicare and providers bill Medicare on the UB-04 claim
form. Providers would then bill DSHS their Part A crossover claims on the UB-04 also including all
services billed to Medicare on the claim form. The total billed amount to Medicare must match the
billed amount to DSHS on the crossover claim.
Medicare may forward the crossover claim directly to DSHS for consideration of a supplemental
payment. If Medicare does not cross the claim directly to DSHS, then you must bill DSHS the
crossover claim on a paper claim form attaching the EOB. Crossover claims must be billed to DSHS
within 6 months of the Medicare process date printed on their EOB.

If Medicare denies the whole claim, you can bill DSHS for the services with a copy of the Medicare
EOB. DSHS will make a payment decision based on the Medicare denial reason.

NOTE: If the DSHS patients Part A benefits are exhausted or the patient does not have Part A
coverage, you are still eligible for payment of the Part B charges by Medicare included on that
claim. Bill Medicare the Part B services and then bill DSHS for the Part A charges as a non-
crossover claim including the Part A & B charges on the claim. If the claim will pay RCC you
must move the Part B charges to the non-covered form locator on the claim form. If the claim will
pay DRG, DSHS prorates the payment based on the amount Medicare paid on the Part B services.
Always include the EOBs with the claim. See numbered memo 05-91 for billing details.

MEDICARE PART B

Part B services are the professional services portion of Medicare and are billed on the CMS-1500 claim
form. Providers would then bill DSHS the Part B crossover claims on the CMS-1500 including only
Medicare paid lines or lines that Medicare’s allowable is applied to the deductible on the claim. Denied
lines are not considered crossover claims and would be billed as a non-crossover claim with the EOB
attached. Do not mix Medicare paid services and denied services on the same claim form as a delay in
payment will occur.
Medicare may forward the crossover claim directly to DSHS for consideration of a supplemental
payment. If Medicare does not cross the claim directly to DSHS, then you can bill DSHS the crossover
claim on a paper claim form attaching the EOB. Crossover claims must be billed to DSHS within 6
months of the Medicare process date printed on their EOB.

NOTE:
There are some exceptions to these processes and the rule of thumb to follow is if you bill Medicare on
the UB-04 then you bill DSHS the crossover claim on the UB-04. If you bill Medicare on the CMS-
1500 then you bill DSHS the crossover claim on that same form.


        Every effort has been made to ensure this Guide’s accuracy. However, in the unlikely event of an actual or apparent   31
        conflict between this document and a department rule, the department rule controls.
NOTE: Tribal Health providers must bill crossover claims per the detailed instructions in the Tribal
Health Billing Instructions.

                                                                                                       Appendix F
NOTE: Do not place the Medicare paid amount in field 29 on the CMS1500 claim form.

MEDICARE PART C

Medicare Part C is a contracted HMO or Managed Medicare - Medicare Advantage plan that covers
Part A and Part B services. Providers must bill the Managed Medicare - Medicare Advantage plan
primary to DSHS. You would then bill DSHS the crossover claim using the same claim form billed to
the Managed Medicare - Medicare Advantage plan with the notation “Managed Medicare” in the
comments field on your claim form and attach the EOB. These claims are not currently crossed to
DSHS by the plans so claims must be billed to DSHS within 6 months of the Medicare Advantage plan
process date printed on their EOB. On these claims DSHS only considers the deductible or co-pay
amount if any indicated.

PAYMENT METHODOLOGY

Payment from DSHS on any crossover claim is based on comparing the DSHS allowed amount to
Medicare’s allowed amount for the service, selecting the lowest amount then subtracting the Medicare
payment from that lowest amount. If there is a balance due, payment is applied toward the deductible,
co-insurance, or co-payment amount.

NOTE: DSHS cannot pay clients directly for deductible, co-insurance, or co-payment amounts.

You can get your Medicare crossover claims set up to automatically cross over to DSHS from
Medicare electronically by contacting our Provider Enrollment department at 1-800-562-3022, option
2, then option 5. If you need to make adjustments to a crossover claim that came to DSHS
electronically from Medicare, you will need to drop the claim to paper on our adjustment claim form
525-109.

Please see Numbered Memoranda 06-05 for additional information on billing crossovers and EOMB
backup requirements.




        Every effort has been made to ensure this Guide’s accuracy. However, in the unlikely event of an actual or apparent   32
        conflict between this document and a department rule, the department rule controls.
                                                                                                       Appendix G

                                                   RA Example




                                Internal Control Number (ICN)
  The Division of Program Support (DPS) assigns a 17-digit internal control number (ICN)
  to each claim received. The Julian calendar is used to record the date your claims were
  received by DPS. The claim number represents the following information:
                          Example: 0 00 334 11 001 000100
                                     A B C D E                  F

Α Claim Medium:                                                        C Julian Date
   0 = Exam Entry/ Hard copy claim                                     D Placeholder
   1 = Direct entry (Pharmacy)                                         Ε Batch Numbe r
   3 = Electronic media claims                                         F Numbe red Claim in Batch
  4 = State-system (MMIS) generated mass or                              0 = initial claim
gross adjustment                                                         1 = credited claim
Β Year of Claim Submission                                               2 = adjustment to initial or previously
         Every effort has been made to ensure this Guide’s accuracy. However, in the unlikely event of an actual or apparent   33
         conflict between this document and a department rule, the department rule controls.
                                                              Example 100100 – credit/ 200100 repayment




Every effort has been made to ensure this Guide’s accuracy. However, in the unlikely event of an actual or apparent   34
conflict between this document and a department rule, the department rule controls.
                                                                                                    Appendix H

DSHS Medical Assistance Programs

Categorically Needy Program (CNP)


      CNP is a Medicaid program in which eligible individuals have full-scope medical and
      dental coverage


CNP - Qualified Medicare Beneficiaries (CNP-QMB)


      This is a Medicaid program for certain low-income individuals who are eligible for
      Medicare. DSHS may consider payment on some services Medicare does not cover.


CNP - Emergency Medical Only


      This is a Medicaid program for persons who do not meet citizenship requirements but meet
      all other eligibility requirements for CNP. The scope of care is limited to services needed as
      a result of an emergency medical condition.


Family Planning Only


      This is a state-funded program providing an additional 10 months of family planning
      services to eligible women who have just ended a pregnancy or completed a delivery.


General Assistance - Unemployable (GA-U) and Detox


      GA-U and Detox are state-funded programs that provide some medical and emergent dental
      services for general assistance-unemployable clients.


Limited Casualty Program – Medically Needy Program (LCP-MNP)


      This is a Medicaid program that provides a limited scope of medical care for individuals
      who do not meet the eligibility income/resource criteria for income assistance.




      Every effort has been made to ensure this Guide’s accuracy. However, in the unlikely event of an actual or apparent   35
      conflict between this document and a department rule, the department rule controls.
                                                                                                     Appendix H

LCP-MNP - Emergency Medical Only


       This is a Medicaid program for persons who are eligible for MNP but do not meet
       citizenship requirements. The scope of care is limited to services relating to an emergency
       medical condition.


Qualified Medicare Beneficiaries (QMB - Medicare Only)


       This is a Medicaid program for certain low-income individuals who are also eligible for
       Medicare. DSHS pays Part B Medicare premiums for QMB-eligible clients. DSHS will
       only consider copays on services that Medicare covers.


Specified Low-Income Medicare Beneficiary (SLMB)


       This is a DSHS program for certain low income individuals who are also eligible for
       Medicare and meet the income levels. DSHS pays the Part B premiums for the individual.
       There is no additional medical coverage provided and clients are not issued a MAID.



For more information, please visit
http://maa.dshs.wa.gov/Eligibility/OVERVIEW/MedicalOverview.htm#Table%20of%20Contents




       Every effort has been made to ensure this Guide’s accuracy. However, in the unlikely event of an actual or apparent   36
       conflict between this document and a department rule, the department rule controls.
                                                                                                Appendix I




                 This form can be located at the Electronic DSHS Forms website:
                        http://www1.dshs.wa.gov/msa/forms/eforms.html

Every effort has been made to ensure this Guide’s accuracy. However, in the unlikely event of an actual or apparent   37
conflict between this document and a department rule, the department rule controls.
                                                                                                         Appendix J

              Understanding Credit Balances on the Remittance
There may be occasions when a provider owes DSHS money and their account goes into a CREDIT
BALANCE status. This will show up on an RA with the acronym “CRE BAL”. The credit balance
will show up on every remittance advice until enough paid claims have been posted to satisfy the credit
balance requirement or if the provider reimburses DSHS the amount that is due.

Sometimes the credit balance shows up for multiple weeks. Take a look at the following table to see
how credit balances are posted to the RA.
                         Week 1                     Week 2                      Week 3                     Week 4
Balance                  0                          -$500.00                    -$500.00                   -$500.00
Paid Claims              0                          $ 250.00                    $ 350.00                   $ 550.00
                                                    #1 $100.00                  #1 $100.00                 #1 $100.00
                                                    #2 $100.00                  #2 $100.00                 #2 $100.00
                                                    #3 $50.00                   #3 $50.00                  #3 $50.00
                                                                                #4 $100.00                 #4 $100.00
                                                                                                           #5 $100.00
                                                                                                           #6 $50.00
                                                                                                           #7 $50.00
Denied Claims            0                          0                           0                          0
Credit                   -$500.00                   -$250.00                    -$150.00                   0
Amount Due               0                          0                           0                          $50.00

Week 1
Provider goes into a $500.00 Credit balance. For example, a provider might have done an adjustment
to refund a claim or DSHS has recouped funds.

Week 2
There were 3 claims that paid a total of $250.00 that were applied to the -$500.00 credit balance.

Week 3
The 3 paid claims continue to show up on the RA. This is to demonstrate the running total of paid
claims that are being applied to the credit balance. A fourth paid claim was applied.

Week 4
Additional paid claims have been posted to the RA. Again, the paid claims from weeks 2 and 3 are
displayed to show that they are being applied to the credit balance. In week 4, there are more paid
claims than needed to satisfy the credit balance and the provider is reimbursed $50.00.

Notice that the credit balance remains -$500.00 even though the credit balance was partially satisfied
Week #2 and Week #3. The credit balance will remain the same until it is met and then removed from
the RA. Week 5 will not credit balance information.




         Every effort has been made to ensure this Guide’s accuracy. However, in the unlikely event of an actual or apparent   38
         conflict between this document and a department rule, the department rule controls.

				
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