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Medicaid Update March 27, 2008
Medicaid Update March 27, 2008
Medicaid Update March 27, 2008
Medicaid Update March 27, 2008
Medicaid Update March 27, 2008
Medicaid Update March 27, 2008
Medicaid Update March 27, 2008
Medicaid Update March 27, 2008
Medicaid Update March 27, 2008
Medicaid Update March 27, 2008
Medicaid Update March 27, 2008
Medicaid Update March 27, 2008
Medicaid Update March 27, 2008
Medicaid Update March 27, 2008
Medicaid Update March 27, 2008
Medicaid Update March 27, 2008
Medicaid Update March 27, 2008
Medicaid Update March 27, 2008
Medicaid Update March 27, 2008
Medicaid Update March 27, 2008
Medicaid Update March 27, 2008
Medicaid Update March 27, 2008
Medicaid Update March 27, 2008
Medicaid Update March 27, 2008
Medicaid Update March 27, 2008
Medicaid Update March 27, 2008
Medicaid Update March 27, 2008
Medicaid Update March 27, 2008
Medicaid Update March 27, 2008
Medicaid Update March 27, 2008
Medicaid Update March 27, 2008
Medicaid Update March 27, 2008
Medicaid Update March 27, 2008
Medicaid Update March 27, 2008
Medicaid Update March 27, 2008
Medicaid Update March 27, 2008
Medicaid Update March 27, 2008
Medicaid Update March 27, 2008
Medicaid Update March 27, 2008
Medicaid Update March 27, 2008
Medicaid Update March 27, 2008
Medicaid Update March 27, 2008
Medicaid Update March 27, 2008
Medicaid Update March 27, 2008
Medicaid Update March 27, 2008
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Medicaid Update March 27, 2008

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  • 1. Medicaid Update March 27, 2008 www.dmas.virginia.gov Department of Medical Assistance Services MD Liaison Services 2008 Richmond Insurance Network Meeting
  • 2. National Provider Identifier (NPI) Compliance- 03/05/08 Memo
    • Effective May 23, 2008, DMAS will only process claims having an NPI or API
    • Legacy (9-digit) Medicaid Provider Identification Numbers (PINS) will no longer be used to adjudicate claims, and therefore should not be placed on claims submitted to DMAS
    • Claims received on or after May 22, 2008 with only the Legacy Medicaid PIN will be denied.
  • 3. NPI Compliance
    • Providers who have not shared their NPI with DMAS should do so immediately
    • The completed NPI Re-Enrollment Packet must be received by May 5, 2008 to ensure it is processed prior to the May 23, 2008, cutoff date.
    • For a replacement copy of your NPI Re-Enrollment Packet, contact the First Health Provider Enrollment Unit (PEU) at:
    • (888)829-5373
  • 4. NPI Compliance
    • DMAS is requiring the use of nine-digit ZIP codes on all claim submissions for all locations where an address is required.
    • Effective May 23, 2008, DMAS will only accept the Legacy Medicaid PIN in limited situations from providers who do not have an NPI (i.e., because the provider retired) and if the date(s) of service on the claim is prior to May 23, 2008.
  • 5. NPI Compliance
    • These claim submissions will be researched and handled in an individual basis. In this situation, a claim or adjustment with the Legacy Medicaid PIN must be submitted on a paper claim form and mailed to :
    • Department of Medical Assistance Services
    • Manager , Payment Processing Unit
    • Division of Program Operations
    • 600 East Broad Street, Suite 1300
    • Richmond, VA 23219-1856
  • 6. NPI Compliance
    • Group Practices must begin billing as groups no later than May 23, 2008.
    • Providers must submit the Group’s organization Type-2 NPI as the Billing Provider and the practitioner’s individual Type-1 NPI as the Rendering (Servicing) Provider on all claim submissions
    • Groups billing incorrectly will have their claims denied effective May 23, 2008.
  • 7. NPI Compliance
    • A taxonomy code should never be sent for the Billing Provider when the billing provider is a Group Practice.
    • If sent, the taxonomy code should be associated with the Rendering (Servicing) Provider.
    • Sending a taxonomy code for a Group Practice provider on an electronic claim will result in the rejection of the claim(s).
  • 8. NPI Compliance
    • Medicare Crossover claims processed with NPIs that are not enrolled with DMAS will be denied effective May 23, 2008.
    • In Medicare Crossover claims to be paid, NPIs used on the claims submitted to Medicare must be enrolled with DMAS.
    • Providers enrolled with DMAS as a Group Practice, must also use the Group Practice Billing Provider NPI when billing Medicare.
  • 9. NPI Compliance
    • A Prior Authorization (PA) obtained with a Legacy Medicaid PIN that spans over May 23, 2008, must be billed using the NPI for claims received by DMAS on or after May 22, 2008.
    • A crosswalk is in place to match claims submitted with an NPI to PAs obtained with a Legacy Medicaid PIN.
    • A PA obtained with an NPI must be billed with the NPI regardless of the date of service or the date received by DMAS.
  • 10. NPI Compliance
    • All PAs should be requested using the Rendering (Servicing) Provider’s NPI. PAs should not be requested using the Group Practice organization NPI; and claims will deny if it is obtained with a Group NPI.
    • Effective May 23, 2008, the web-based Automated Response System (ARS), MediCall and the EDI Batch 276/277 must be accessed using your NPI/API.
  • 11. NPI Compliance
    • DMAS has identified outstanding provider negative balances associated with Legacy Medicaid PINs that have not yet been transferred to the newly assigned NPI and/or API in the DMAS claims system.
    • DMAS will automatically transfer all outstanding negative balances from Legacy Medicaid PINs to your NPI/API effective May 23, 2008.
    • Questions regarding negative balances should be directed to :
    • Provider Helpline (800) 552-8627
  • 12. NPI Compliance
    • Please register for upcoming WebEX, web-based training sessions at:
    • http://www.dmas.virginia.gov/LN-upcoming_events.htm
  • 13. CHANGE- 02/14/08 Memo
    • Physician Assistant (PA)
    • Supervision Requirements
  • 14. PA Supervision Requirements
    • Medicaid will now accept the standards of “direct and personal” physician supervision requirements currently required in state regulations as defined by the Virginia Board of Medicine.
    • The “direct and personal” supervisory requirement has been eliminated where it is not otherwise required under Virginia law or regulation.
  • 15. PA Supervision Requirements
    • An exception regarding direct supervision is found in Section 54.1 – 2952 of the Code of Virginia applying to the additional supervisory and oversight requirements place on Physician Assistants in hospitals and emergency departments.
    • DMAS policy will conform with the standards stipulated in State law regarding the provision of care in a Hospital setting by Physician’s Assistants.
  • 16. PA Supervision Requirements
    • DMAS requires that the patient’s medical records must be documented sufficiently to clearly show that these unique practice standards have been met.
    • DMAS does not directly enroll Physician Assistants in the Virginia Medicaid Program.
  • 17. PA Supervision Requirements
    • Physician Assistants are allowed to bill for Medicaid covered services within their scope of practice through their supervising Physician’s National Provider Identifier (NPI), as long as the Physician is enrolled in the Virginia Medicaid program.
    • DMAS has not changed the covered services for which Physician’s Assistants are authorized to bill and receive reimbursement.
  • 18. Plan First- 12/26/07 Memo
    • New Medicaid fee-for-service family planning waiver program
    • Effective January 1, 2008
    • Men and women ages 19 years and older may be eligible
    • Participant income must be less than or equal to 133% of federal poverty level
    • Must meet citizenship and identity requirements
  • 19. Plan First
    • Not eligible for the waiver:
      • Individuals who have major medical insurance
      • Individuals who are eligible for full Medicaid benefits coverage
      • Individuals who have had a sterilization procedure
  • 20. Plan First- Covered Services
    • Plan First covers routine and periodic family planning office visits and related services (detailed in the 12/26/07 Memo).
    • Medicaid will only reimburse approved procedure codes and the code must be accompanied with a V25 category (family planning) as a primary diagnosis on the claim.
  • 21. Plan First – Service Limits
    • Services must be performed in an office or clinic setting, except for sterilization procedures which can be covered in an outpatient or inpatient setting.
    • Cervical cancer screenings can be offered every 6 months depending on the method contraception.
  • 22. Plan First – Services Not Covered
    • Performance of , counseling for or recommendations of abortions
    • Infertility treatments
    • Hysterectomy or partial hysterectomy
    • Follow up services to a family planning visit
    • Repeat cervical cancer screens due to abnormal results
    • Transportation
    • Primary care, acute care and chronic care including outpatient, inpatient and RX drugs
  • 23. Tamper Resistant Prescription Pad- 02/29/08 Memo
    • Congress has mandated effective April 1, 2008, all prescriptions for Medicaid Fee-for-Service recipients must be written on tamper-resistant pads.
    • The requirement applies to all non-electronic, outpatient prescriptions.
  • 24. J-CODE MANDATE- 05/31/07 Memo
    • Beginning July 1, 2007 – DMAS required that whenever a J-code is billed, the National Drug Code (NDC) must be included in the claim submission
    • CMS-1500 (08-05) Locator 24A, red-shaded line
    • N4- is the qualifier used to tell DMAS the next digits are the NDC
  • 25. J-Code Mandate
    • Effective January 1, 2008-the quantity of each NDC and unit of measure qualifier (F2, ML, GR or UN) will be required
    • Claims submitted on or after January 1, 2008 will be denied if this additional information is not listed on your claim
  • 26. 24. A. DATE(S) OF SERVICE From To MM DD YY MM DD YY Block 24A : Dates of Service 03 01 08 03 01 08 03 01 08 04 15 08 1 2 Both FROM and TO dates must be completed Dates must be within same calendar month N400026064871
  • 27. J Code Mandate: Block 24D
    • In the red shaded area, enter 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.
  • 28. 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.
    • Nine numbers may precede the decimal point and three numbers may follow the decimal
  • 29. D. Block 24D: Procedure Codes PROCEDURES, SERVICES, OR SUPPLIES (Explain Unusual Circumstances) CPT/HCPCS MODIFIER J0881 GR0.0004
  • 30. G. DAYS OR UNITS Block 24G: Days or Units 400 Enter the number of times or hours the procedure, service, or item was provided during the service period.
  • 31. Medicare Advantage Plans
    • VA Medicaid handles and processes Medicare Advantage Plans the same way as traditional Medicare.
    • DMAS does not process the Medicare Advantage Plans as Third Party Liability (TPL)
    • Providers should submit claims for Medicare Advantage Plan deductibles and coinsurance on the Title XVIII Form (DMAS-30 R-5/06)
  • 32. Medicare Advantage Deductibles
    • Some patients who were originally enrolled in the traditional Medicare Plan and later in the same calendar year enroll in a Medicare Advantage Plan have been charged 2 Medicare Part B deductibles.
    • VA Medicaid will allow only 1 Medicare Part B deductible to be consider for payment per calendar year.
  • 33. Medicare Advantage Deductibles
    • Error Reason Code 0922: Limitation Audit- Medicare Deductible Per Year
    • The total Medicare deductible billed per year for Part B, should not exceed the designated deductible for that payment request type for that period.
    • Providers receiving this denial should contact VA Medicaid for a file review
    • VA Medicaid can resolve deductible errors due to incorrect completion of claim forms.
  • 34. Medicare Advantage Deductibles
    • For file reviews showing the patient’s deductible was previously considered from the traditional Medicare Plan and a second deductible was applied to the Medicare Advantage Plan, the 0922 denial is correct.
    • The deductible issue must be resolved between the two Medicare Plans.
    • Providers should contact the Medicare Advantage Plan and the traditional Medicare Plan and have them research the application of the Part B deductible(s).
  • 35. Crossover Claims
    • Effective March 1, 2008 – ALL claims sent to Medicare must have an NPI.
    • What does this mean for your VA Medicaid Crossover Claims? Medicare will not process claims without the NPI
    • The claim will not crossover to VA Medicaid for secondary to Medicare consideration/payment
  • 36. Crossover Claims
    • Providers should review their Medicare Explanation of Benefits
    • Claims that crossed over to Medicaid from Medicare will have a message stating “Your claims were sent to Medicaid”
    • For claims listed without the message, the provider should contact Medicare since the claim was not sent to Medicaid
  • 37. ICD-9 Codes
    • DMAS has noticed an increase in the number of invalid ICD-9 diagnosis codes submitted on the CMS-1500 (08-05) claim form.
    • Submission of invalid ICD-9-CM diagnosis codes can result in claim denial.
    • Providers show review data to make sure the diagnosis codes are accurate and valid for date of service billed.
  • 38. DMAS Procedure Fee File
    • The DMAS Procedure Fee File have been revised and is now more “ USER” friendly.
    • Providers will now be able to select the range of CPT codes they would like to review.
    • The Procedure Fee File can be viewed in either Comma Separated Value (CSV) Format or Text (TXT) Format.
  • 39. DMAS Procedure Fee File
    • CPT Codes –
    • Medical Procedures Billed by Physicians or Other Practitioners.
    • Medical Fee File - CPT Part 1  contains CPT Codes 0001F - 29999
    • Medical Fee File - CPT Part 2  contains CPT Codes 3000F - 49999
    • Medical Fee File - CPT Part 3  contains CPT Codes 50010 - 79999
    • Medical Fee File - CPT Part 4  contains CPT Codes 80002 – 99602
  • 40. NPI: Error Reason Code 1332 Billing Provider Number Not on File
    • The NPI listed in Block 33a of the CMS-1500 (08-05) is not on file with VA Medicaid’s Provider Enrollment Unit (PEU)
    • Provider must contact the PEU and share NPI with VA Medicaid
      • 888-829-5373
  • 41. NPI: Error Reason Code 1357 NPI Servicing Provider Not on File
    • The NPI for the Rendering provider listed in Block 24J of the CMS-1500 (08-05) is not on file with VA Medicaid’s Provider Enrollment Unit (PEU)
    • Provider must contact the PEU and share NPI with VA Medicaid
      • 888-829-5373
  • 42. NPI: Error Reason Codes 1332 and 1357
    • The provider does not have to resubmit the claim unless a denial has been received
    • The provider has 21 days to contact the VA Medicaid PEU and share the NPI
    • Claims in the pended status will automatically recycle (reprocess) in 21 days
    • Providers who do not contact the PEU within 21 days with the NPI information will receive claim denials
  • 43. Top Reasons Claims Are Returned to Providers
    • Do Not Enter Legacy Provider Number If Billing With NPI (1018 claims returned)
    • Comments Interferes With Processing Of The Data To Be Keyed (734 claims returned)
    • Billing Information Not Confined To Available Space/Data Not Aligned (433 claims returned)
  • 44. Top Reasons Claims Are Returned To Providers
    • Third Party Liability (TPL) In Shaded Area …..No 0 with / or YES $0.00 (239 claims returned)
    • Margins Not Aligned Properly- Does Not Match Original Claim Form (199 claims returned)
    • Print Is Too Light For Imaging or Scanning (69 claims returned)
  • 45. THANK YOU www.dmas.virginia.gov

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