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Department of Medical Assistance Services
Department of Medical Assistance Services
Department of Medical Assistance Services
Department of Medical Assistance Services
Department of Medical Assistance Services
Department of Medical Assistance Services
Department of Medical Assistance Services
Department of Medical Assistance Services
Department of Medical Assistance Services
Department of Medical Assistance Services
Department of Medical Assistance Services
Department of Medical Assistance Services
Department of Medical Assistance Services
Department of Medical Assistance Services
Department of Medical Assistance Services
Department of Medical Assistance Services
Department of Medical Assistance Services
Department of Medical Assistance Services
Department of Medical Assistance Services
Department of Medical Assistance Services
Department of Medical Assistance Services
Department of Medical Assistance Services
Department of Medical Assistance Services
Department of Medical Assistance Services
Department of Medical Assistance Services
Department of Medical Assistance Services
Department of Medical Assistance Services
Department of Medical Assistance Services
Department of Medical Assistance Services
Department of Medical Assistance Services
Department of Medical Assistance Services
Department of Medical Assistance Services
Department of Medical Assistance Services
Department of Medical Assistance Services
Department of Medical Assistance Services
Department of Medical Assistance Services
Department of Medical Assistance Services
Department of Medical Assistance Services
Department of Medical Assistance Services
Department of Medical Assistance Services
Department of Medical Assistance Services
Department of Medical Assistance Services
Department of Medical Assistance Services
Department of Medical Assistance Services
Department of Medical Assistance Services
Department of Medical Assistance Services
Department of Medical Assistance Services
Department of Medical Assistance Services
Department of Medical Assistance Services
Department of Medical Assistance Services
Department of Medical Assistance Services
Department of Medical Assistance Services
Department of Medical Assistance Services
Department of Medical Assistance Services
Department of Medical Assistance Services
Department of Medical Assistance Services
Department of Medical Assistance Services
Department of Medical Assistance Services
Department of Medical Assistance Services
Department of Medical Assistance Services
Department of Medical Assistance Services
Department of Medical Assistance Services
Department of Medical Assistance Services
Department of Medical Assistance Services
Department of Medical Assistance Services
Department of Medical Assistance Services
Department of Medical Assistance Services
Department of Medical Assistance Services
Department of Medical Assistance Services
Department of Medical Assistance Services
Department of Medical Assistance Services
Department of Medical Assistance Services
Department of Medical Assistance Services
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Department of Medical Assistance Services

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  • 1. Department of Medical Assistance Services November 2009 www.dmas.virginia.gov Medicaid Eligibility Verification Options & Outpatient Psychiatric and Substance Abuse Services Billing Guidelines
  • 2.
    • 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
    ************
  • 3. 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
  • 4. 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
  • 5. 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.
  • 6. DOB: 05/09/1964 F CARD # 00001 DEPARTMENT OF MEDICAL ASSISTANCE SERVICES COMMONWEALTH OF VIRGINIA V I RG I N I A J. R E C I P I E N T 9 9 9 9 9 9 9 9 9 9 9 9 002286
  • 7. 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 .
  • 8. Eligibility Verification
    • MediCall
    • ARS- Web-Based Medicaid Eligibility
  • 9. 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
  • 10. MediCall
    • 800-884-9730
    • 800-772-9996
    • 804-965-9732
    • 804-965-9733
  • 11. Automated Response System (ARS)
    • Web-based eligibility verification option
      • Free of Charge.
      • Information received in “real time”.
      • Secure
      • Fully HIPAA compliant
  • 12. ARS Registration Process
    • https://uac.fhsc.com/uac/pages/unsecured/common/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’
  • 13. ARS
    • ARS User’s Guide
    • http://www.dmas.virginia.gov/prclaims_billing.htm
    • Web Support Helpline-
    • 800-241-8726
  • 14. Important Contacts
    • Provider Call Center
    • Provider Enrollment
    • Electronic Billing
  • 15. 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)
  • 16. 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
  • 17. Electronic Billing
    • Mailing Address
    • EDI Coordinator-Virginia Operations First Health Services Coordinator 4300 Cox Road Richmond, VA 23060
    • E-mail: [email_address]
    • Phone: (800) 924-6741
    • Fax: (804) 273-6797
  • 18. Billing on the CMS-1500
  • 19. MAIL CMS-1500 FORMS:
    • Dept. of Medical Assistance Services
    • Practitioner
    • P. O. Box 27444
    • Richmond, VA 23261
  • 20. 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
  • 21. TIMELY FILING
    • Submit claims with documentation attached explaining the reason for delayed submission
  • 22. 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
  • 23. 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)
  • 24. MEDICAID (Medicaid #) Block 1 CHAMPUS (Sponsor's SSN) 1. MEDICARE (Medicare #) MEDICAID CLAIM 2. PATIENT'S NAME (Last Name, First Name, Middle Initial) 24 TRICARE
  • 25. GROUP (SSN or ID) Block 1 BKL LUNG (SSN) CHAMPVA (Member ID#) TDO or ECO CLAIM 25 FECA HEALTH PLAN OTHER (ID)
  • 26. 1a. INSURED'S I.D. NUMBER (FOR PROGRAM IN ITEM 1) Block 1a: Recipient ID Number (Be sure to include all 12 digits) 123456789014 26
  • 27. Block 2: Patient's Name 2. PATIENT'S NAME (Last name, First Name, Middle Initial) Smith, Sam 5. PATIENT'S ADDRESS (No., Street) 27
  • 28. Block 10: Accident-Related 10. IS PATIENT'S CONDITION RELATED TO: a. EMPLOYMENT? (CURRENT OR PREVIOUS) b. AUTO ACCIDENT? c. OTHER ACCIDENT? YES NO PLACE (State) YES YES NO NO You MUST check YES or NO for a, b & c 28
  • 29. 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
  • 30. 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
  • 31. 21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY 1. 2. 3. 4. 3441 Block 21: Diagnosis Codes May enter up to 4 codes Omit decimals 2963 31
  • 32. 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
  • 33. KePRO Contacts
    • Questions :
      • KePRO - 888.827.2884
      • Via email at [email_address] or [email_address]
  • 34. 23. PRIOR AUTHORIZATION NUMBER Block 23: Prior Authorization Number - Conditional 34
  • 35. 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
  • 36. 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.
  • 37. 24. A. DATE(S) OF SERVICE From To MM DD YY MM DD YY Block 24A : Dates of Service 05 01 09 05 01 09 05 01 09 05 16 09 1 2 Both FROM and TO dates must be completed Dates must be within same calendar month TPL27.08
  • 38. 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
  • 39. 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
  • 40. 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
  • 41. 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
  • 42. 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.
  • 43. 24. A. DATE(S) OF SERVICE From To MM DD YY MM DD YY Block 24A : Dates of Service 03 31 09 03 31 09 04 01 09 04 16 09 1 2 Both FROM and TO dates must be completed Dates must be within same calendar month 43 TPL27.08 N400026064871
  • 44. B. Place of Service Block 24B: Place of Service 11 11-Office location 21- Inpatient Medicaid accepts the same 2 digit CMS Place of Service codes as Medicare. 44 Note: Type of Service is no longer required
  • 45. 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
  • 46. C. EMG Block 24C: EMG Medicaid will accept a ‘Y’ in this Locator to indicate that the procedure was an emergency 46 Y
  • 47. D. Block 24D: Procedure Codes PROCEDURES, SERVICES, OR SUPPLIES (Explain Unusual Circumstances) CPT/HCPCS MODIFIER 22 90804 47 90804 HF
  • 48. 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.
  • 49. 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.
  • 50. D. Block 24D: Procedure Codes PROCEDURES, SERVICES, OR SUPPLIES (Explain Unusual Circumstances) CPT/HCPCS MODIFIER J0881 GR0.0004 J0881 constitutes 1mcg of a drug, the quantity given was 400 mcg which converts to 0.0004 grams
  • 51. 21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY 1. 2. 3. 4. 34431 Block 24E: Diagnosis Code E. DIAGNOSIS POINTER 1 2963 1,2 Enter the entry identifier of the ICD-9-CM diagnosis code listed in Locator 21. To identify more than one diagnosis code, separate the indicators with a comma. 51
  • 52. F. $ CHARGES Block 24 F: Charges Enter the usual and customary charges 52
  • 53. G. DAYS OR UNITS Block 24G: Days or Units Enter the number of units or hours the procedure, service, or item was provided during the billing period. 1 53 400
  • 54. H. Block 24H: EPSDT/Family Plan 54 1 EPSDT Family Plan 1-EPSDT
  • 55. 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.
  • 56. 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
  • 57. Block 24I: ID. Qual. & 24J: Rendering Provider ID # 57 I. ID. QUAL J. RENDERING PROVIDER ID. # NPI 1D 1234567890-API
  • 58. Block 24I: ID. Qual. & 24J: Rendering Provider ID # 58 I. ID. QUAL J. RENDERING PROVIDER ID. # NPI ZZ Taxonomy (if needed) 12345647890
  • 59. DMAS Service Types May Require A Taxonomy Code on Claims Taxonomy Codes 251B00000X Case Management Services 261QR0405X 276400000X Substance Abuse Clinic 251C00000X 261QM0801X Mental Health-Mental Retardation Community Services Taxonomy Code Service Type
  • 60. 176B00000X Licensed Psychiatric Nurse Practitioner 101YA0400X Substance Abuse Counselor. 106H00000X Licensed Marriage and Family Therapist 104100000X Licensed Social Worker 317400000X Christian Science SNF 103TC0700X Clinical Psychologist 103TH0100X Licensed Psychologist 101YP2500X Licensed Prof. Counselor First 3 digits-204, 207 or 208 Physician 364SP0807X, -08X, -09X, -10X, -11X, -12X, -13X Clinical Nurse Specialist -Psychiatric Taxonomy Code(s) Service Type
  • 61. 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
  • 62. 26. PATIENT ACCOUNT NUMBER Block 26: Patient’s Account Number (Optional) 12345678918765 62 Can not exceed 14 alphanumeric digits
  • 63. Total Charge Block 28
    • DMAS now requires this locator to be completed
    • Enter the total charges for the services in 24F lines 1-6.
  • 64. 28. TOTAL CHARGE Block 28: Total Charges 64 $
  • 65. 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 Block 31: Signature & Date If there is a signature waiver on file, you may stamp, print, or computer-generate the signature. 65
  • 66. Service Facility Location Information Block 32
    • Enter information for the location where services were rendered
      • First line-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
  • 67. 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
  • 68. CHANGE - Block 32: Service Facility Location Information 32. SERVICE FACILITY LOCATION INFORMATION a. b. NPI 68
  • 69. Billing Provider Info & PH # Block 33
    • 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
  • 70. 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
  • 71. Block 33: Billing Provider Info & PH # 33. BILLING PROVIDER INFO & PH # a. b. NPI ( ) 61
  • 72. 22. MEDICAID RESUBMISSION CODE ORIGINAL REF. NO. Block 22 : Adjustments and Voids 1032 xxxxxxxxxxxxxxxx Adjustment or Resubmission Code From original remittance Void Chap. V, Medicaid Physician’s Manual has code list. 72
  • 73. THANK YOU www.dmas.virginia.gov

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