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Department of Medical Assistance Services Medicaid Eligibility Verification Options Outpatient Psychiatric and Substa

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Department of Medical Assistance Services Medicaid Eligibility Verification Options Outpatient Psychiatric and Substa Powered By Docstoc
					                   Department
                        of
           Medical Assistance Services

Medicaid Eligibility Verification Options
                    &
Outpatient Psychiatric and Substance
 Abuse Services Billing Guidelines


          November 2009
        www.dmas.virginia.gov
          ************
This presentation is to facilitate training of the
subject matter in portions of the Virginia Medicaid
Psychiatric Services Manual, Chapter V.

This training contains only highlights of this
manual and is not meant to substitute for or take
the place of the Psychiatric Services Manual.

Providers are responsible for reviewing and
adhering to all Medicaid manual requirements
                                                    2
         Training Objectives
 Upon  completion of this training
 participants should be able to:
 Verify Medicaid Eligibility
 Correctly complete a claim on the
  CMS-1500 (08-05)
 Have a clear understanding of the
  guidelines required for the proper
  submission of forms, i.e. timely filing and
  adjustments/voids
                                            3
       As a Participating Provider
               You must -
   Determine the patient's identity
   Verify the patient's age
   Verify the patient's eligibility
   Maintain records for minimum 5 years

   Accept as payment in full, the amount paid
    by Medicaid
   Bill any and all other third-party carriers   4
          Eligibility:
 Medicaid or Medallion II HMO

Clients enrolled in the Medicaid Program
will be identified by a Virginia Medicaid
Eligibility Card.

Eligibility can be verified by MediCall,
ARS, or other system options.
                                           5
              COMMONWEALTH OF VIRGINIA
               DEPARTMENT OF MEDICAL ASSISTANCE SERVICES




002286


999999999999
V I RG I N I A J. R E C I P I E N T

DOB: 05/09/1964           F           CARD# 00001
          Eligibility:
 Medicaid or Medallion II HMO
You will be able to identify clients enrolled in a
Medallion II HMO by using our MediCall
verification line or their HMO Member ID Card.

Those enrolled in a Medallion II HMO will also
carry a card bearing the name of one of
following plans: Carenet, Optima Family
Care, Healthkeepers Plus, Amerigroup, or
Virginia Premier Health Plan.
                                                7
   Eligibility Verification

 MediCall
 ARS- Web-Based Medicaid
 Eligibility



                              8
       MediCall/ARS- Information
               Available
   Medicaid client eligibility/benefit
    verification
   Service limit information
   Claim status
   Prior authorization
   Provider check log
   Primary Payer Information
   Medallion Participation
   Managed Care Organization Assignment
                                           9
 MediCall

800-884-9730
800-772-9996
804-965-9732
804-965-9733
               10
Automated Response System
          (ARS)
 Web-based    eligibility verification
 option
  Free  of Charge.
  Information received in “real time”.
  Secure
  Fully HIPAA compliant


                                          11
  ARS Registration Process
https://uac.fhsc.com/uac/pages/unsecured/commo
n/home.jsf
  Select the ARS tab on FHSC ARS Home Page
  Choose “User Administration”
  Follow the on-screen instructions for help with
   registration, this is a 3-step process to request,
   register and activate a new account
  Answer the initial „Who are you?‟ question by
   selecting „I do not have a User ID and need to be
   a Delegated Administrator‟                    12
ARS
ARS     User‟s Guide
http://www.dmas.virginia.gov/prclaims_billing.ht
  m
Web     Support Helpline-
          800-241-8726
                                             13
    Important Contacts
 Provider Call Center
 Provider Enrollment
 Electronic Billing




                         14
   Provider Call Center
 Claims, covered services, billing
            inquiries:


       800-552-8627
       804-786-6273
8:30am – 4:30pm (Monday-Friday)
11:00am – 4:30pm (Wednesday)         15
   Provider Enrollment
New provider numbers or change of
 address:

First Health – PEU
P. O. Box 26803
Richmond, VA 23261
888-829-5373
804-270-5105
804-270-7027 - Fax                  16
      Electronic Billing
         Mailing Address
EDI Coordinator-Virginia Operations
  First Health Services Coordinator
            4300 Cox Road
         Richmond, VA 23060
     E-mail: edivmap@fhsc.com
      Phone: (800) 924-6741
        Fax: (804) 273-6797
                                      17
Billing on the CMS-1500




                          18
MAIL CMS-1500 FORMS:



 Dept. of Medical Assistance Services
             Practitioner
           P. O. Box 27444
         Richmond, VA 23261
                                        19
      TIMELY FILING
   ALL CLAIMS MUST BE SUBMITTED AND
    PROCESSED WITHIN ONE YEAR FROM
    THE DATE OF SERVICE
   EXCEPTIONS
      Retroactive/Delayed Eligibility
      Denied Claims
   NO EXCEPTIONS
      Accident Cases
      Other Primary Insurance


                                         20
           TIMELY FILING
   Submit claims with documentation
    attached explaining the reason for delayed
    submission




                                             21
     CMS-1500 CLAIM FORM:
    Use ONLY the ORIGINAL

         RED & WHITE
     CMS-1500 (08-05) Invoice

   Photocopies are not Acceptable

Computer generated claims must match NUCC
            uniform standards          22
                 Block 1
 The locator will now be used to indicate if
  the claim is Medicaid, TDO, or ECO
 Enter an „X‟ in the MEDICAID box for the
  Medicaid Program
 Enter an „X‟ in the OTHER box for
  Temporary Detention Order (TDO) or
  Emergency Custody Order (ECO)

                                                23
                      Block 1


                                               TRICARE
1. MEDICARE             MEDICAID              CHAMPUS
    (Medicare #)          (Medicaid #)         (Sponsor's SSN)



2. PATIENT'S NAME (Last Name, First Name, Middle Initial)



           MEDICAID CLAIM
                                                            24
                     Block 1

               GROU
CHAMPVA        P             FECA       OTHER
               HEALTH PLAN   BKL LUNG
(Member ID#)   (SSN or ID)   (SSN)      (ID)




         TDO or ECO CLAIM
                                                25
 Block 1a: Recipient ID Number


1a. INSURED'S I.D. NUMBER   (FOR PROGRAM IN ITEM 1)


                123456789014

 (Be sure to include all 12 digits)


                                                      26
    Block 2: Patient's Name

2. PATIENT'S NAME (Last name, First Name, Middle Initial)


        Smith, Sam
5. PATIENT'S ADDRESS (No., Street)




                                                            27
Block 10: Accident-Related
           10. IS PATIENT'S CONDITION RELATED TO:




          a. EMPLOYMENT? (CURRENT OR PREVIOUS)

                        YES               NO

         b. AUTO ACCIDENT?             PLACE (State)

                        YES               NO

         c. OTHER ACCIDENT?

                        YES               NO



 You MUST check YES or NO for a, b & c
                                                       28
Is There Another Health Benefit Plan?
              Block11d

 Providers should only check yes if there is
  other third party coverage
 If there is no other coverage check no or
  leave blank



                                            29
Block 11d - Is There Another
Health Benefit Plan?

 d. IS THERE ANOTHER HEALTH BENEFIT PLAN?
       YES       NO   If yes, return to and complete item 9 a-d.




DMAS does not require providers to complete
Blocks 9 a-d. Please indicate “NO” for recipients
who have no other insurance coverage.
                                                                   30
Block 21: Diagnosis Codes

     21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY

1.
      3441
                                    3.


2.
       2963                          4.




           May enter up to 4 codes
                   Omit decimals                    31
    Prior Authorization Number
             Block 23

 If service requires prior authorization,
  enter the eleven digit PA number assigned
  by KePRO
 Enter the number pre-assigned to the TDO
  or ECO form that is obtained from the
  magistrate authorizing the TDO/ECO

                                         32
       KePRO Contacts

 Questions   :
 KePRO   - 888.827.2884
 Via email at
  ProviderIssues@kepro.org or
  PAUR06@dmas.virginia.gov


                                33
Block 23: Prior Authorization
   Number - Conditional


23. PRIOR AUTHORIZATION NUMBER




                                 34
 Blocks 24A thru 24J
 These  blocks have been divided into
  open areas and a shaded red line
  area
 The shaded area is ONLY for
  supplemental information
 Instructions will be given on when the
  use of the shaded area is required for
  claims processing
                                      35
    Block 24A – Shaded Red Area:
    TPL Information Billing Scenarios
   No other insurance
      Check „NO‟ in Locator 11d or leave blank
   Primary Carrier pays covered service
      Provider receives Explanation of Benefits (EOB)
      Check „YES‟ in Locator 11d
      Document primary payment information in the
       shaded red area of 24A on claim form
   DMAS does not require an attached copy of the
    EOB when provider receives payment from
    primary carrier.                              36
Block 24A: Dates of Service
          24.   A.
                  DATE(S) OF SERVICE
            From                  To
          MM DD YY           MM   DD YY

          TPL27.08
      1   05 01 09 05 01 09


      2   05 01 09 05 16 09
       Both FROM and TO dates
          must be completed
Dates must be within same calendar month
 TPL Billing Scenarios
 Primary   carrier does not pay
  Payment   applied to deductible/claim denied
  Provider receives EOB
  Check „YES‟ in Locator 11d
  Attach copy of EOB showing non-payment
   to the back of the DMAS claim form
  Do not document any information in the
   shaded red area of 24A
                                            38
  TPL Billing Scenarios
 Primary   carrier does not pay
  Service  not covered
  Check „YES‟ in Locator 11d
  Attach EOB documenting that services are
   not covered or, attach letter verifying the
   service is not covered
  Do not document any information in the
   shaded red area of 24A
                                            39
TPL Billing Scenarios
 Primary    carrier does not pay
  Carrier will not enroll provider
  Check „YES‟ in Locator 11d
  Attach letter documenting the primary
   carrier will not enroll the provider
  Do not document any information in the
   shaded red area of 24A
                                       40
TPL Billing Scenarios

   Primary carrier does not pay
     Policy is no longer active/coverage terminated
     Check „YES‟ in Locator 11d
     Attach EOB verifying that the policy is not
      active or, attach letter verifying the policy is not
      active
     Advise patient/guardian to contact Local DSS
      with policy termination
      documentation/information
                                                       41
            NDC Information
              Block 24A
   Qualifier ‘N4’ is used followed by the National
    Drug Code (NDC) whenever a HCPCS J-code is
    submitted in 24D.
   No spaces between the qualifier and the NDC
    number
   Must be left justified
   The HCPCS code, J8499 (unclassified non-
    chemotherapeutic drug, oral administration) may
    also be used to bill for the opioid drug.
                                                  42
Block 24A: Dates of Service
          24.   A.
                  DATE(S) OF SERVICE
             From                 To
           MM DD YY          MM   DD YY

          TPL27.08
      1   03 31 09 03 31 09
          N400026064871

      2   04 01 09 04 16 09
       Both FROM and TO dates
          must be completed               43

Dates must be within same calendar month
     Block 24B: Place of Service
                       B.
                     Place
                               Note: Type of Service
                       of      is no longer required
                     Service
11-Office location
  21- Inpatient
                      11


    Medicaid accepts the same 2 digit
     CMS Place of Service codes as
                                                 44
               Medicare.
        Emergency Indicator
           Block 24C
 This locator will be used to indicate
  whether the procedure was an emergency
 DMAS will only accept a „Y‟ for yes in this
  locator
 If there was no emergency leave blank




                                            45
            Block 24C: EMG
                      C.


                     EMG




                     Y
Medicaid will accept a ‘Y’ in this Locator to
   indicate that the procedure was an
                emergency                  46
Block 24D: Procedure Codes
                         D.
      PROCEDURES, SERVICES, OR SUPPLIES
            (Explain Unusual Circumstances)
        CPT/HCPCS              MODIFIER




        90804              22
        90804             HF


                                              47
       J Code Mandate: Block 24D
   When billing a J Code the red shaded area must
    have the unit of measurement (UOM) qualifier.
   Valid qualifiers:
      F2: international unit
      ML: milliliter
      GR: gram
      UN: unit
   The numeric quality of the drug (greater than
    zero) administered to the patient must be
    entered after the qualifier.
                                               48
J-Code Mandate: Block 24D
 Enter the actual metric decimal quantity
  (units) administered to the patient
 If reporting a fraction of a unit, use the
  decimal point
 The maximum number of bytes allowed
  for the quantity is 13, including the
  decimal point.


                                               49
  Block 24D: Procedure Codes
                               D.
            PROCEDURES, SERVICES, OR SUPPLIES
                  (Explain Unusual Circumstances)
              CPT/HCPCS              MODIFIER

            GR0.0004
             J0881



J0881 constitutes 1mcg of a drug, the quantity given
   was 400 mcg which converts to 0.0004 grams 50
 Block 24E: Diagnosis Code
          21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY

   1.    34431                             3.


    2.   2963                              4.
                                                              E.
                                                         DIAGNOSI
                                                         S
                                                          POINTER


Enter the entry identifier of the
ICD-9-CM diagnosis code listed                               1
in Locator 21. To identify more                             1,2
than one diagnosis code,
separate the indicators with a
comma.                                                              51
Block 24 F: Charges
           F.
       $ CHARGES




     Enter the usual
 and customary charges
                         52
Block 24G: Days or Units

      G.
     DAYS
      OR
     UNITS   Enter the number of units or
             hours the procedure,
             service, or item was
             provided during the billing
       1     period.
     400

                                       53
Block 24H: EPSDT/Family Plan
              H.
            EPSDT
            Family
             Plan




             1
          1-EPSDT

                               54
                ID.QUAL
                Block 24I
 Qualifier „1D‟ is to be used in the red
  shaded area for claims being submitted
  using the API.
 Qualifier „ZZ‟ is to be used to indicate the
  taxonomy code-only when the NPI is used
  and only if necessary to adjudicate the
  claim.

                                             55
       Rendering Provider ID #
             Block 24J
 The shaded red area will contain the
  current API
               OR
 The open area will contain the NPI of the
  provider rendering the service



                                              56
       Block 24I: ID. Qual.
& 24J: Rendering Provider ID #
  I.                J.
 ID.            RENDERING
QUAL           PROVIDER ID. #



1D       1234567890-API

 NPI




                                 57
       Block 24I: ID. Qual.
& 24J: Rendering Provider ID #
  I.                J.
 ID.            RENDERING
QUAL           PROVIDER ID. #



ZZ     Taxonomy (if needed)
 NPI   12345647890


                                58
     DMAS Service Types May Require A
        Taxonomy Code on Claims

               Taxonomy Codes
         Service Type              Taxonomy Code

Mental Health-Mental Retardation    251C00000X
      Community Services            261QM0801X
                                    261QR0405X
    Substance Abuse Clinic
                                    276400000X

  Case Management Services          251B00000X
       Service Type                Taxonomy Code(s)
    Clinical Nurse Specialist  364SP0807X, -08X, -09X,
           -Psychiatric          -10X, -11X, -12X, -13X
            Physician         First 3 digits-204, 207 or 208
   Licensed Prof. Counselor            101YP2500X
     Licensed Psychologist             103TH0100X
      Clinical Psychologist            103TC0700X
    Christian Science SNF              317400000X
    Licensed Social Worker             104100000X
Licensed Marriage and Family           106H00000X
            Therapist
Substance Abuse Counselor.             101YA0400X
  Licensed Psychiatric Nurse           176B00000X
           Practitioner
            Taxonomy Codes
 A complete list of the taxonomy codes accepted
  by DMAS can be found at:
http://www.dmas.virginia.gov/downloads/pdfs/npi
  _DMAS_TaxonomyCodeSummary.pdf




                                            61
Block 26: Patient’s Account Number
                  (Optional)

26. PATIENT ACCOUNT NUMBER

              12345678918765


          Can not exceed 14
          alphanumeric digits
                                62
              Total Charge
                Block 28
 DMAS now requires this locator to be
  completed
 Enter the total charges for the services in
  24F lines 1-6.




                                                63
 Block 28: Total Charges


28. TOTAL CHARGE


$




                           64
Block 31: Signature & Date
    31. SIGNATURE OF PHYSICIAN OR SUPPLIER
        INCLUDING DEGREES OR CREDENTIALS
       (I certify that the statements on the reverse
       apply to this bill and are made a part thereof.)




    SIGNED                                       DATE


     If there is a signature waiver
    on file, you may stamp, print,
or computer-generate the signature.
                                                          65
Service Facility Location Information
               Block 32
        Enter information for the location where
         services were rendered
          Firstline-Name
          Second line-Address
          Third line-City, State, 9 digit zip code
        Physicians with multiple offices-the zip
         code must reflect the office location
         where services were rendered
        No punctuation in the address
        Space between city and state
        Include hyphen for the 9 digit zip code      66
Service Facility Location Information
            Block 32a-b
   Enter the 10 digit NPI number of the
    service location in 32a

                  OR

   Enter „1D‟ qualifier with the API in 32b


                                               67
CHANGE - Block 32: Service
Facility Location Information
32. SERVICE FACILITY LOCATION INFORMATION




a.                            b.
           NPI

                                            68
        Billing Provider Info & PH #
                  Block 33
   Enter the information to identify the provider that
    is requesting to be paid
     Firstline-Name
     Second line-Address
     Third line-City, State, 9 digit zip code
   No punctuation in the address
   Space between city and state
   Include hyphen for the 9 digit zip
   Phone number is to be entered in the area to the
    right of the field title, no hyphen or space used
                                                      69
       Billing Provider Info & PH #
                Block 33a-b
   Enter the 10 digit NPI number of the billing
    provider in 33a

                  OR

   Enter „1D‟ qualifier with the API in 33b


                                               70
Block 33: Billing Provider Info
& PH #
33. BILLING PROVIDER INFO & PH #        (   )




a.                                 b.
            NPI


                                                61
 Block 22: Adjustments and Voids

  22. MEDICAID RESUBMISSION
      CODE                    ORIGINAL REF. NO.

   1032           xxxxxxxxxxxxxxxx
    Adjustment            From
        or               original
                        remittanc
       Void                  e
Resubmission Code
 Chap. V, Medicaid Physician’s Manual has code list.
                                                  72
    THANK YOU
www.dmas.virginia.gov

				
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