HOW TO OPTIMIZE YOUR MEDICAID
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HOW TO OPTIMIZE YOUR MEDICAID

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HOW TO OPTIMIZE YOUR MEDICAID HOW TO OPTIMIZE YOUR MEDICAID Presentation Transcript

  • HOW TO OPTIMIZE YOUR MEDICAID DENTAL BILLING www.cns.state.va.us/dmas
  • Training Objectives
    • How to use the provider manual to assist with questions in regards to covered services, billing and utilization review.
    • How to properly submit claims and resolve claim problems including:
      • Adjustments and Voids
      • Resolving your own rejects and denials
  • Participating Provider
    • Licensed to practice dentistry in the Commonwealth of Virginia (or in the state in which he or she practices)
    • Meets the standards of requirements set forth by DMAS and has a current, signed participation agreement with DMAS.
  • Provider Enrollment Unit For enrollment agreements, change of address and enrollment questions : First Health Provider Enrollment Unit P. O. Box 26803 Richmond, VA 23261 Helpline 804-270-5105 Toll Free 804-829-5373 Fax 804-270-7027
  • DMAS Order Desk Commonwealth Martin 1700 Venable Street Richmond, VA 23223 Order Desk 804-780-0076 Fax Number 804-782-9876 Medicaid Dental Manual
  • Eligibility: Medicaid or Medallion II HMO Recipients enrolled in the traditional Medicaid Program will be identified by a Virginia Medicaid Eligibility Card. Eligibility can be verified by AVRS, Provider Helpline or other system options.
  • CASE I.D. NUMBER PLUS I.D. NUMBER 123-456789 01-5 02-3 03-8 04-6 05-4 Recipient Eligibility Card
  • BIRTH DATE SEX F M M M F 10 31 1953 09 22 1951 04 05 1975 01 14 1979 11 02 1990 Recipient Eligibility Card
  • C B A A A DOE, JANE DOE, SAM DOE, TED DOE, ALLEN DOE, ANN SI NAME THE FOLLOWING INDIVIDUALS ARE ELIGIBLE THROUGH THE LAST DAY OF JUNE 2001 Recipient Eligibility Card
  • Recipient Eligibility Card Special Indicator Code (SI)
    • A Under 21 -No co-pay exists.
    • B Individuals Receiving Long-Term Care Services or Hospice Care - No co-pay is required for any service.
    • C All Other Recipients- Co-pays apply for inpatient hospital admissions, outpatient hospital clinic visits, clinic visits, physician office visits, eye exams, prescriptions, home health visits, and rehab service visits.
  • THE FOLLOWING INDIVIDUALS ARE ELIGIBLE FROM 06 01 01 06 01 01 06 01 01 06 01 01 06 01 01 BEGIN DATE Recipient Eligibility Card
  • C B A A A DOE, JANE DOE, SAM DOE, TED DOE, ALLEN DOE, ANN SI NAME THE FOLLOWING INDIVIDUALS ARE ELIGIBLE THROUGH THE LAST DAY OF JUNE 2001 Recipient Eligibility Card
  • CASE I.D. NUMBER PLUS I.D. NUMBER 123-456789 02-3 02-3 CARRIER BEGIN DATE 06 01 01 06 01 01 001 001 Recipient Eligibility Card Insurance Information Chap. 3
  • TYP POLICY # / MEDICARE # Recipient Eligibility Card Insurance Information Chap. 3 12345678A 12345678A J H
  • Eligibility: Medicaid or Medallion II HMO You will be able to identify recipients enrolled in a Medallion II HMO by their Member ID Card. Those enrolled in a Medallion II HMO will carry a card bearing the name of one of following plans: Carenet, Sentara Family Care, Healthkeepers or Virginia Premier Health Plan .
  • Important Contacts:
    • REVS- Medicaid Eligibility
    • Provider Call Center
    • Billing Inquiries
  • AUTOMATED RESPONSE SYSTEM
    • Automated Response System (ARS)
      • Claim Status
      • Check Status
      • Recipient Eligibility-REVS
    800-884-9730 804-965-9732 804-965-9733
  • PROVIDER CALL CENTER
    • Claims, covered services, billing inquiries:
    • DEPARTMENT OF MEDICAL ASSISTANCE SERVICES
    • 600 East Broad Street, Suite 1300
    • Richmond, Virginia
    • 800-552-8627
    • 804-786-6273
  • BILLING INQUIRIES Customer Services Department of Medical Assistance Services 600 East Broad Street, Suite 1300 Richmond, VA 23219
  • Dental Treatment Covered by Virginia Medicaid
    • Dental services for recipients under 21 years old
    • Limited oral surgery for recipients age 21 and older, when pre-authorized by DMAS Medical Support
  • PRE-AUTHORIZATION Under Age 21 Department of Medical Assistance Services Dental P.O. Box 27431 Richmond, Virginia 23261-7431
  • PRE-AUTHORIZATION Age 21 and Over Department of Medical Assistance Services Medical Support 600 East Broad Street, Suite 1300 Richmond, Virginia 23219
  • Dental Billing
  • As a Participating Provider You must -
    • Accept, as payment in full, the amount paid by Medicaid.
    • Bill any and all other third-party carriers.
    • Determine the patient's identity.
    • Verify the patient's age.
    • Verify the patient's eligibility .
    • Maintain records for minimum 5 years.
  • Claims Address Department of Medical Assistance Services Dental P. O. Box 27431 Richmond, VA 23261-7431
  • TIMELY FILING
    • ALL CLAIMS MUST BE SUBMITTED WITHIN ONE YEAR FROM THE DATE OF SERVICE
      • EXCEPTIONS: Retroactive Eligibility/Delayed Eligibility Previously rejected or denied claims
    • Submit claims with documentation attached explaining the reason for delayed submission.
  • 1994 ADA Billing Instructions 1994 ADA
  • Locator 1 1. Dentist’s pre-treatment estimate Dentist’s statement of actual services Provider ID # Provider ID # - Enter the seven-digit Medicaid provider ID number of the billing provider.
  • Locator 2 2. Medicaid Claim EPSDT Prior Authorization # Patient ID # Patient ID # - Enter the 12-digit number that is found on the recipient’s Medicaid Identification Card. An “A” in the Special Indicator (SI) Block of the ID card indicates the recipient is under 21 and eligible for dental services through the period the card is valid. Recipient’s birth date is indicated for age validation.
  • Locator 3 3. Carrier name and address Carrier Name and Address - This block is used for the transmission code. Enter 181 for Original Claim, 182 for Adjustment, or 184 for Void.
  • Locator 4 4. Patient name first m.i. last Patient’s Name - The last name and first name of the patient must be entered as they appear on the recipient’s eligibility card.
  • Locator 7: Conditional 7. Patient birth date MM DD YYYY Patient’s Birth Date - If the transmission code entered in Block 3 is 182 or 184, enter the 3-digit code for the reason for the adjustment or void. Digit 1 should be placed in the MM, digit 2 in the DD, and digit 3 in the YYYY.
  • Locator 8 : Conditional 8. If full time student school city If full time student - If the transmission code entered in Block 3 is 182 or 184, enter the reference number (found on the remittance voucher) of the claim that is being adjusted or voided.
  • Locator 30-32: Conditional 30. Is treatment result of occupational illness or injury? 31. Is treatment result of an auto accident? NO YES Is treatment result of occupational illness or injury ? - When the patient has other dental coverage, Medicaid is a last-pay program. Therefore if treatment is required due to an accident, check yes in this block and note under the Remarks section all available information concerning the accident and possibility of other insurance carriers. Leave blank if treatment is not the result of an accident. 32. Other accident?
  • Locator 37
    • Tooth # or letter
    • Surface
    • Description of service
    • Date Service Performed
    • Procedure Number
    • Fee
    • For administrative use only
  • Locator 37: Tooth # or Letter Tooth # or letter Tooth # or letter - Enter the tooth number (1-33) or (A-T) or quadrant (UL, UR, LL, LR) relating to the procedure being performed (if applicable)
  • Locator 37: Surface Surface Surface - Enter the surface of the tooth (if applicable). Refer to the Medicaid Dental Manual for the valid surface codes.
  • Locator 37: Description of Service Description of service (including x-rays, prophylaxis, materials, etc. Description of Service - Enter the 9-digit authorization number assigned by DMAS after approval of any pre-authorized service. Refer to the Dental Manual for the special procedures requiring pre-authorization.
  • Locator 37: Date Service Performed Date service performed Mo. Day Year Date Service Performed (month/day/year) - Enter the date of service for each individual line item. Do not leave this block blank.
  • Locator 37: Procedure Number Procedure number Procedure Number - Enter the number of units and the 5-digit dental procedure code performed. (Use the codes listed in Appendices B and C of the Dental Manual .) For Dental Clinics associated with Federally Qualified Health Centers and Rural Health Clinics, enter the DMAS assigned dental encounter code. Only nine lines can be submitted per claim form due to system constraints. If more than nine lines are submitted, the entire claim will be returned.
  • Locator 37: Fee Fee Fee - Enter your usual and customary charge for the procedure performed.
  • Locator 37: For Administrative Use Only For administrative use only For Administrative Use Only - If a recipient has other dental coverage ( e.g. Champus, school insurance, etc.) and this insurance has paid a portion of the care, enter any payment from primary carrier other than Medicare. Include a copy of the explanation of benefits from the other carrier with the invoice.
  • Locator 38: Conditional 38. Remarks for unusual services Remarks For Unusual Services - If treatment is related to an accident, provide any additional information in the block. See instructions for Blocks 30-32. Please note that any information that is placed in this block or any document that is attached to the claim will cause all lines of the claim to pend for manual review even if the “Remarks” or the attachment applies to one line of the claim.
  • Locator 38: Continued Therefore, if you have multiple lines of a claim to complete and only one line requires that you provide DMAS with additional information, (either in “Remarks” or with an attachment) you should bill the one line on a separate claim form so that all lines of your claim will not pend unnecessarily and cause a delay in reimbursement.
  • Locator 39 39. I hereby certify that the procedures as indicated by date have been completed and that the fees submitted are the actual fees I have charged and intend to collect for those procedures. >______________________________________________________________ Signed (Treating Dentist) License Number Date Signature of dentist, license number, and date.
  • ADJUSTMENT OR VOID INVOICE FOR ADA 1994
  • Instructions The ADA (1994) form can be used for adjusting or voiding payments previously approved on Remittance Vouchers. Only one line can be billed on an ADA (1994) form used for adjustments or voids. Continue to follow the instructions in the Dental Manual for submitting claims. Specific information for adjustments or voids:
  • Locator 3
    • Carrier Name and Address-
      • Enter code 182 to indicate adjustment
      • Enter code 184 to indicate a void
  • Locator 7
    • 528- correcting procedure/service code
    • 530- correcting charge
    • 538- correcting tooth
    • 539- correcting site
    Patient’s Birth Date - Enter the first digit of the code in the MM, the second digit in the DD and the third digit in the YYYY. Adjustment Codes
  • Locator 7
    • 552- Date of service correction
    • 544- Provider ID correction
    • 545- Recipient ID correction
    Patient’s Birth Date - Enter the first digit of the code in the MM, the second digit in the DD and the third digit in the YYYY. Void Codes
  • Locator 8
    • If Full Time Student
      • Enter the reference number of the claim that is being adjusted or voided. (This information can be found on the Remittance Voucher.)
  • REMITTANCE VOUCHER Sections of the Voucher
    • APPROVED - for payment.
    • PENDING - for review of claims.
    • DENIED - no payment allowed.
    • CREDIT - Adjusted claims creating a positive balance.
    • DEBIT - Adjusted/Voided claims creating a negative balance .
    51
  • REMITTANCE VOUCHER Columns of the Voucher
    • Recipient's Identification Number
    • Reference Number
    • Visits/Units/Studies
    52
  • Thank You www.cns.state.va.us/dmas