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 firstname.lastname@example.org . 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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