Medicaid Eligibility Verification Options _ CMS-1500 _08-05

Document Sample
Medicaid Eligibility Verification Options _ CMS-1500 _08-05 Powered By Docstoc
					  Department of Medical Assistance Services

Medicaid Eligibility Verification Options
                    &
 CMS-1500 (08-05) Billing Guidelines
Community Mental Health Rehabilitative Services
                For Adults
          September-October 2008
           www.dmas.virginia.gov
                ************

This presentation is to facilitate training of the subject matter
in Chapter V of the Virginia Medicaid Community Mental
Health Rehabilitative Services Manual

This training contains only highlights of this manual and is
not meant to substitute for or take the place of the Community
Mental Health Rehabilitative Services Manual.
                                                              2
Objectives

    Upon completion of this training you should
    be able to :
   Correctly utilize Medicaid options to verify
    eligibility
   Understand timely filing guidelines
   Properly submit Medicaid claims,
    adjustments and voids
                                             3
              COMMONWEALTH OF VIRGINIA
               DEPARTMENT OF MEDICAL ASSISTANCE SERVICES




002286


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

DOB: 05/09/1994          F            CARD# 00001
                                                      4
Important Contacts
   MediCall
   ARS- Web-Based Medicaid Eligibility
   Provider Call Center
   Provider Enrollment



                                          5
MediCall

     800-884-9730
     800-772-9996
     804-965-9732
     804-965-9733
                    6
MediCall
   Available 24 hours a day, 7 days a week
   Medicaid Eligibility Verification
   Claims Status
   Prior Authorization Information
   Primary Payer Information
   Medallion Participation
   Managed Care Organization Assignment
                                              7
Automated Response System ARS
    Web-based eligibility verification option
        Free of Charge.
        Information received in “real time”.
        Secure
        Fully HIPAA compliant



                                                 8
UAC Registration Process
    Go to https://virginia.fhsc.com
   Select the ARS tab on FHSC ARS Home Page
   Choose “User Administration”
   Follow the on-screen instructions for help with
    registration, this is a 3-step process to request,
    register and activate a new account
   Answer the initial „Who are you?‟ question by
    selecting „I do not have a User ID and need to be a
    Delegated Administrator‟                         9
ARS –Users

 Web   Support Helpline-


        800-241-8726
                            10
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)           11
Provider Enrollment
New provider enrollment, Electronic Fund
Transfer (EFT) or change of address:
 First Health – PEU
 P. O. Box 26803
 Richmond, VA 23261
 888-829-5373
 804-270-5105
 804-270-7027 - Fax                        12
Electronic Billing
      Electronic Claims Coordinator
             Mailing Address
     First Health Services Corporation
             Virginia Operations
        Electronic Claims Coordinator
                4300 Cox Road
            Glen Allen, VA 23060
        E-mail: edivmap@fhsc.com
           Phone: (800) 924-6741
                                         13

            Fax: (804) 273-6797
Billing on the CMS-1500




                          14
MAIL CMS-1500 FORMS TO:




DEPARTMENT OF MEDICAL ASSISTANCE
             SERVICES
          PRACTITIONER
           P. O. Box 27444
      Richmond, Virginia 23261 15
    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
                                          16
TIMELY FILING
   Submit claims with documentation attached (to
    the back of claim) explaining the reason for
    delayed submission




                                                17
                  Block 1


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




                                                 18
Block 1a: Recipient ID Number


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


                123456789014

 (Be sure to include all 12 digits)


                                                      19
      Block 2: Patient's Name


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


        Smith, Sam




                                                            20
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
                                                      21
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.




Please indicate “NO” for recipients who have no
other insurance coverage. DMAS does not require
providers to complete Blocks 9 a-d.
                                                                      22
      Block 21: Diagnosis Codes
            (Current ICD.9 Code)
     21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY

1.    3139                          3.


2.    2963                           4.




           May enter up to 4 codes
                   Omit decimals                    23
Block 23: Prior Authorization
          Number
              (Conditional)

23. PRIOR AUTHORIZATION NUMBER




                                 24
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
                                                 25
TPL Information Block 24A
    Qualifier „TPL‟ will be used followed by
     dollars/cents amount whenever an actual
     payment is made by a third party carrier
    No spaces between the qualifier and dollars
     and no $ symbol used
    Decimal between dollars and cents is
     required to read paid amount correctly
    Must be left justified
                                                   26
TPL Information Block 24A
   DMAS will set COB code based on the
    information given in locator 11d.
       No, or nothing indicated-no other carrier-old
        COB code 2
       No, or nothing indicated/system has other
        insurance-claim will deny bill other insurance
       No, or nothing indicated/„TPL‟ qualifier with
        payment in 24a red area-old COB code 3
                                                         27
TPL Information Block 24A
   DMAS will set COB code based on the
    information given in locator 11d.
       Yes, but nothing in 24a red area-other carrier
        billed and made no payment-old COB code 5
       Yes, and „TPL‟ qualifier with payment in 24a
        red area-other carrier billed and paid-old COB
        code 3


                                                     28
Block 24A: Dates of Service
          24.   A.
                  DATE(S) OF SERVICE
            From                  To
          MM DD YY           MM   DD YY

          TPL27.08
      1   08 01 08 08 01 08


      2   08 01 08 08 31 08
       Both FROM and TO dates
          must be completed
Dates must be within same calendar month
      Block 24B: Place of Service
                       B.
                     Place
                               Note: Type of Service
11-Office location     of      is no longer required
                     Service
12- Patient’s Home
 53 – Community
  Mental Health       11
    Center


     Medicaid accepts the same 2 digit
      CMS Place of Service codes as
                                                  30
                Medicare.
Emergency Indicator-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


                                                    31
            Block 24C: EMG
                      C.


                     EMG




Medicaid will accept a ‘Y’ in this Locator to
   indicate that the procedure was an
                emergency                    32
Procedure Codes

   Crisis Intervention Services - H0036
   Crisis Stabilization - H2019
   Intensive Community Treatment - H0039
   Mental Health Support Services - H0046
   Mental Health Case Management - H0023

                                         33
Block 24D: Procedure Codes
                        D.
     PROCEDURES, SERVICES, OR SUPPLIES
           (Explain Unusual Circumstances)
       CPT/HCPCS              MODIFIER




     H0046
     H0023



                                             34
    Block 24E: Diagnosis Code
         21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY

   1.   3139                              3.


   2.   2963                              4.
                                                             E.
                                                        DIAGNOSI
                                                        S
                                                         POINTER



Enter the identifier of the ICD-9-                          1
CM diagnosis code listed in                                1,2
Locator 21. To identify more than
one diagnosis code, separate the
indicators with a comma.                                           35
Block 24 F: Charges

          F.
      $ CHARGES




    Enter the usual
and customary charges
                        36
Block 24G: Days or Units

     G.
    DAYS
     OR
    UNITS   Enter the number of times or
            hours the procedure,
            service, or item was
     1      provided during the service
            period.
    31

                                       37
ID.QUAL Block-24I
   Qualifier „1D‟ is to be used in the red shaded
    area for claims being submitted using the
    Atypical Provider Identifier (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.


                                                 38
Rendering Provider ID # Block-24J

   The shaded red area will contain the API

                 OR-

   The open area will contain the NPI of the
    provider rendering the service.
                                                39
       Block 24I: ID. Qualifier
& 24J: Rendering Provider ID #
  I.                    J.
 ID.                RENDERING
QUAL               PROVIDER ID. #

             Atypical Provider Identifier
1D                      (API)


 NPI




                                            40
       Block 24I: ID. Qualifier
& 24J: Rendering Provider ID #
  I.                  J.
 ID.              RENDERING
QUAL             PROVIDER ID. #



1D           001234567
 NPI




                                  41
       Block 24I: ID. Qualifier
& 24J: Rendering Provider ID #
  I.                  J.
 ID.              RENDERING
QUAL             PROVIDER ID. #



ZZ Taxonomy (if needed)
 NPI
          1234567890

                                  42
Block 26: Patient’s Account Number

  26. PATIENT ACCOUNT NUMBER

                12345678918765


            Can not exceed 14
            alphanumeric digits
                                  43
      Block 28: Total Charges


     28. TOTAL CHARGE


      $




Please list the total all charges in Block 28.

                                                 44
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.
                                                         45
Block 32
Service Facility Location Information
   Enter information for the location where
    services were rendered
     First line-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 code
                                                 46
Block 32, cont‟d.
Service Facility Location Information

    Providers with multiple offices/locations -
     the zip code must reflect the office/
     location where services were rendered
    Enter the 10 digit NPI number of the service
     location in 32a.
                      OR-
    Enter „1D‟ qualifier with the API in 32b
                                                    47
Block 32: Service Facility Location
Information

32. SERVICE FACILITY LOCATION INFORMATION




a.                            b.
           NPI


                                            48
    Block 33
    Billing Provider Info & PH #-
   Enter the information to identify the provider that is
    requesting to be paid
       First line-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          49
Billing Provider Info & PH #-Block-33a-b

    Enter the 10 digit NPI number of the service
     location in 33a.

                  OR-

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

                                                    50
Block 33: Billing Provider Info & PH #
  33. BILLING PROVIDER INFO & PH #        (   )




  a.                                 b.
              NPI


                                                  51
 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, Community Mental Health Rehabilitative
   Services Manual has resubmission code list.     52
REMITTANCE VOUCHER
Sections of the Voucher
     APPROVED     for payment.
     PENDING      for review of claims.
     DENIED       no payment allowed.
     DEBIT (+)    Adjusted claims creating
                   a positive balance.
     CREDIT (-)   Adjusted/Voided claims
                   creating a negative
                   balance.               53
REMITTANCE VOUCHER
Sections of the Voucher
     FINANCIAL TRANSACTION
     EOB DESCRIPTION
     ADJUSTMENT
      DESCRIPTION/REMARKS- STATUS
      DESCRIPTION
     REMITTANCE SUMMARY-
      PROGRAM TOTALS

                                    54
     THANK YOU
Department of Medical Assistance Services


      www.dmas.virginia.gov

				
DOCUMENT INFO
Shared By:
Categories:
Tags:
Stats:
views:7
posted:8/14/2011
language:English
pages:55