Accept as payment in full, the amount paid by Medicaid
Bill any and all other third-party carriers
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.
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
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 .
GROUP (SSN or ID) Block 1 BKL LUNG (SSN) CHAMPVA (Member ID#) TDO or ECO CLAIM 25 FECA HEALTH PLAN OTHER (ID)
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
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) 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
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
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
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
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
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.
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
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.
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
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
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.
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
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
F. $ CHARGES Block 24 F: Charges Enter the usual and customary charges 52
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
H. Block 24H: EPSDT/Family Plan 54 1 EPSDT Family Plan 1-EPSDT
The open area will contain the NPI of the provider rendering the service
Block 24I: ID. Qual. & 24J: Rendering Provider ID # 57 I. ID. QUAL J. RENDERING PROVIDER ID. # NPI 1D 1234567890-API
Block 24I: ID. Qual. & 24J: Rendering Provider ID # 58 I. ID. QUAL J. RENDERING PROVIDER ID. # NPI ZZ Taxonomy (if needed) 12345647890
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
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
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
Service Facility Location Information Block 32
Enter information for the location where services were rendered
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
Service Facility Location Information Block 32a-b
Enter the 10 digit NPI number of the service location in 32a
Enter ‘1D’ qualifier with the API in 32b
CHANGE - Block 32: Service Facility Location Information 32. SERVICE FACILITY LOCATION INFORMATION a. b. NPI 68