Department of Medical Assistance Services

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2. 2 As A Participating ProviderYou Must- Determine the patient’s identity. Verify the patient’s age. Verify the patient’s eligibility. Accept, as payment in full, the amount paid by Virginia Medicaid. Bill any and all other third-party carriers.

3. The most visible change will be the implementation of the new plastic Medicaid card. Here is an example of the format. The most visible change will be the implementation of the new plastic Medicaid card. Here is an example of the format.

4. 4 Medicaid Verification Options MediCall ARS- Web-Based Medicaid Eligibility

5. 5 MediCall 800-884-9730 800-772-9996 804-965-9732 804-965-9733

6. 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. 7 Automated Response SystemARS Web-based eligibility verification option Free of Charge. Information received in “real time”. Secure Fully HIPAA compliant

8. 8 ARS- Information Available Medicaid client eligibility/benefit verification Service limit information Claim status Prior authorization Provider check log

9. 9 Automated Response System Registration Registration virginia.fhsc.com Questions concerning registration process Web Support Helpline 800-241-8726

10. 10 ARS User Guide Available Located on the DMAS web-site under Provider Services section General information on ARS eligibility verification Instructions on the using the system “FAQ”(frequently asked questions) section

11. 11 Copay Indicators Code A Under 21- No copay exists Code B Long Term Care, Home or Community Based Waiver Services, Hospice-No copay Code C All other clients – collect all applicable copays

12. 12 Copay Exemptions Enrollees in managed care may not have copays Pregnancy related/family planning services Emergency services Exception-CMM with a pharmacy restriction

13. 13 Copay Amounts Inpatient hospital $100.00 per admission Outpatient hospital clinic $3.00 per visit Clinic visit $1.00 per visit Physician office visit $1.00 per visit Other physician visit $3.00 per visit Eye examination $1.00 per examination

14. 14 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)

15. 15 Billing Inquiries

16. 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. 17 Requests for DMAS Forms and Manuals: DMAS Order DeskCOMMONWEALTH MARTIN1700 Venable StreetRichmond, Virginia 23222

18. 18 Electronic Billing Electronic Claims Coordinator Mailing Address First Health Services CorporationVirginia OperationsElectronic Claims Coordinator4300 Cox RoadGlen Allen, VA 23060 E-mail: edivmap@fhsc.com Phone: (800) 924-6741 Fax: (804) 273-6797

19. 19 DMAS Websitewww.dmas.virginia.gov Current, most up-to-date information on Virginia Medicaid programs Provider memos available for review Access to Medicaid manuals Top 50 Common Error Reason Codes with Resolutions Numeric Insurance Code List Primary Carrier Coverage Code List

20. 20 DMAS Websitewww.dmas.virginia.gov Financial Reason Code Description List State and Local Hospital (SLH) Program Balance Statement Hospital DRG Rates for Fiscal Year 2005 Medicaid Forms 2004 Medicaid /FAMIS-PLUS Handbook

22. 22 Medicaid Programs

23. 23 Medicaid Programs Medicaid Fee-for-Service No Primary Care Physician (PCP) No mandatory referral from the PCP. Medallion Primary Care Physician who directs all care. PCP referral required for all non-emergency services.

24. 24 Medallion II HMO ID Cards Issued by the Managed Care Organizations Client will have both HMO and Medicaid cards Eligibility verification is a REQUIREMENT Each verification option will give the HMO enrollment information if applicable

25. 25 Medallion II HMO ID Cards The Anthem card for Medicaid clients indicates Anthem Healthkeepers Plus (Plus identifies the Medicaid plan). The Optima Card for Medicaid clients indicates Optima Family Care (Family Care identifies the Medicaid plan). Virginia Premier only has a contract for Medicaid HMO- anyone presenting a VAPremier Card is a Medicaid client.

26. 26 Medallion II HMO ID Cards The Southern Health Services card for Medicaid clients indicates CareNet. Unicare Health Plan of Virginia is for Medicaid clients.

27. Virginia Medicaid HMO Contacts

28. 28 Client Medical Management CMM Mandatory Primary Care Physician and Pharmacist who directs all care Responsibilities: coordinating routine medical care making referrals to specialists as necessary arrange 24 hour coverage when not available explain to recipients all procedures to follow when office is closed or there is an urgent or emergency situation

29. 29 Designated Physicians  CMM A Medicaid enrolled hospital will be reimbursed only: in a medical emergency/delay in treatment may cause death, lasting injury or harm on written referral from PCP using the Practitioner Referral Form (DMAS-70), includes covering physicians covered services excluded from CMM program requirements

30. 30 Medicaid Programs FAMIS Medical program for children under 19. First 30 days coverage in the FAMIS fee-for-service program. Mandatory Managed Care Organization (where available) after initial 30 days. Aliens Emergency medical treatment only Eligibility requests should be sent to the local DSS Emergency Medical Certification form required for claim submission

31. 31 ALIENS Section 1903v of the Social Security Act requires Medicaid to cover emergency services for specified aliens when the services are provided in an emergency room or inpatient hospital setting. Hospital outpatient follow-up visits or physician office visits are not included in the covered services.

32. 32 Aliens To be covered, the services must meet emergency treatment criteria and are limited to : Emergency room care Physician services Inpatient hospitalization not to exceed limits established for other Medicaid recipients Ambulance service to the emergency room Inpatient and outpatient pharmacy services related to the emergency treatment

33. 33 State and Local Hospital SLH Covered Services: Acute care inpatient hospital services (excluding rehab and free-standing psychiatric hospitals) Acute care outpatient services. Ambulatory surgical services. Department of Health Clinic Services. SLH claims should be submitted with the Medicaid provider number. Now is the time for all good men to cNow is the time for all good men to c

34. 34 Temporary Detention Order TDO ALL TDO claims must have the TDO form attached to the front of the claim. Claims submitted without the TDO form will be returned to the provider The TDO form must be signed by the law enforcement officer and dated to be valid. TDO is the payer of last resort. SLH is the exception, paying primary over TDO.

35. 35 Temporary Detention Orders TDO Mail all TDO claims to : Department of Medical Assistance Services TDO- Payment Processing Unit 600 East Broad Street, Suite 1300 Richmond, VA 23219

36. Medicaid Benefit Package

37. 37 Qualified Medicare Beneficiaries  QMB Eligible only for payment of Medicare premiums, deductibles, and coinsurance. Medicaid will consider the Medicare deductibles and coinsurance for benefits. If Medicare does not cover the service, the service cannot be billed to Medicaid.

38. 38 Qualified Medicare Beneficiaries- QMB Extended This group is eligible for Medicaid coverage of premiums, deductibles, and coinsurance plus all other Medicaid-covered services. Medicaid will consider the Medicare deductibles and coinsurance for benefits. Clients are also eligible for all Medicaid covered services.

39. 39 Medicaid Benefit Programs Special Low-Income Beneficiaries -This group is only eligible for Medicaid coverage of the Medicare Part B premium only. Breast and Cervical Cancer Prevention and Treatment Act- women who were certified through the Breast and Cervical Cancer Early Detection Program. This group is eligible for the full range of Medicaid services. Family Planning Waiver Services-This group is eligible for Medicaid family planning related services only.

40. 40 Clarification of Family Planning Waiver Any woman enrolled as a Medically Indigent pregnant woman, who received services on or after 10/01/03 is automatically eligible for the waiver at the end of her Medicaid coverage. DMAS notifies women who are eligible to participate in the waiver. The Medicaid client should visit her local DSS to ensure she has been enrolled.

41. 41 Clarification of Family Planning Waiver The Family Planning Waiver provides coverage for only the following services: Annual gynecological exams Family planning education and counseling Over-the-counter birth control supplies and prescription birth control supplies approved by the Federal Food and Drug Administration (FDA).

42. 42 Clarification of Family Planning Waiver Family Planning Waiver covered services, cont’d.: Sterilizations (excluding hysterectomies) and the required hospitalization Testing for sexually transmitted diseases (STDs) during the first family planning visit

43. 43 Clarification of Family Planning Waiver Family Planning Waiver services are reimbursed on a fee-for-service basis. Please refer to the 11/05/04 Medicaid Memo for specific billing guidelines. Because Family Planning Waiver clients receive a limited benefit package, it is important to access each Medicaid participant’s eligibility and service limit status prior to providing services.

44. Billing on the CMS-1450

45. 45 MAIL CMS-1450 FORMS TO: Virginia Medical Assistance Program P. O. Box 27443 Richmond, Virginia 23261

46. 46 TIMELY FILING ALL CLAIMS MUST BE SUBMITTED AND PROCESSED WITHIN ONE YEAR FROM THE DATE OF SERVICE EXCEPTIONS Retroactive Eligibility Delayed Eligibility Denied Claims NO EXCEPTIONS Accident Cases Other Primary Insurance

47. 47 TIMELY FILING Submit claims with documentation attached explaining the reason for delayed submission You must have the word “Attachment” in Locator 84.

51. Locator 4: Enter the code as appropriate. Valid codes for Virginia Medicaid -INPATIENT: 111- Original Inpatient Hospital Invoice 112- Interim Inpatient Hospital Invoice* 113- Continuing Inpatient Hospital Invoice* 114- Last Inpatient Hospital Invoice * 117- Adjustment Inpatient Hospital 118- Void Inpatient Hospital Invoice

54. 54 TDO Bill Types 111-Original Inpatient 117-Adjustment Inpatient 118-Void Inpatient 131-Original Outpatient w/ER report 137-Adjustment Outpatient 138-Void Outpatient NOTE- Adjustments and Voids for TDO were effective 07/01/03.

55. 55 SLH Bill Types 111-Original Inpatient 112-Interim Inpatient 113-Continuing Inpatient 114-Last Inpatient 117-Adjustment Inpatient 118-Void Inpatient

56. 56 SLH Bill Types 131-Original Outpatient 137-Adjustment Outpatient 138-Void Outpatient

59. Locator 6 For hospital admissions on or after January 1, 2000, the billing cycle for general medical surgical services has been expanded to the minimum of 120 days for both children and adults except for psychiatric services. Psychiatric services for adults remains limited to 21 days. Interim claims (bill types 112 or 113) submitted with less than 120 days will be denied. Bill type 111 or 114 submitted with greater than 120 days will be denied.

60. 60 TDO Requirement Enter the beginning and ending dates for the ACTUAL time span for TDO. Dates of service may overlap calendar months but may not cross over the fiscal year end. Claims submitted outside the TDO period will be returned.

61. 61 SLH Requirements Enter the beginning and ending service dates (including covered and non-covered days). Use both “from” and “to” for a single day with the discharge status of 01.

62. 62 SLH Requirements Interim claims (112 or 113) with less that 120 days will be denied Bill type 111 or 114 with more than 120 days will be denied Psychiatric claim which exceed 21 day limitation will be denied. Billing may overlap calendar months

63. Overlapping Eligibility

65. 65 Probable Cause The number of days listed in Locator 7 does not match the number of days listed in Locator 46 for the Room & Board revenue code Resolution Correct the claim information by listing the same number in Locator 7 and Locator 46 for the Room & Board revenue code

70. Locator 15: Sex

76. 76 TDO Requirements Locator 19 for TDO will always be “1”. Locator 20 for TDO will always be “8”.

78. 78 Locator 21 TDO-Enter the hour the patient appeared at the Involuntary Detention Hearing. SLH-Enter the hour the patient was discharged from inpatient care.

80. Locator 22: Patient Status

81. 81 TDO Requirement Code “01” discharged, NOT “30” still a patient, is to be used when the patient remains in the hospital after the TDO hearing.

83. Locators 24-30: Condition CodesRequired if Applicable A1 EPSDT A4 FAMILY PLANNING A7 INDUCED ABORTION DANGER TO LIFE A8 INDUCED ABORTION VICTIM RAPE/INCEST

87. Locator 39-41 82 No Other Coverage- if the enrollee has no insurance coverage other than Medicaid 83 Billed and Paid – if the provider has received payment from the primary carrier(s) other than Medicare Part A, code 83 must be entered, and the amount covered/paid by the primary carrier must be entered in the amount section of the locator.

88. Locator 39-41 85 Billed Not Covered/No Payment- primary insurance has excluded this service, applied the entire amount to the patient’s deductible, coverage has been terminated, or benefits may be exhausted. Code 85 must be entered. Using code 85 will require an attachment containing: the name of the insurance, the date of denial, and the reason for the denial or non-coverage.

89. 89 Probable Cause Patient has other insurance and either no COB indicator was listed in Locator 39 or Cob indicator 82 was listed Resolution Bill primary carrier and once the service is paid or denied, resubmit the claim to Medicaid with the correct COB indicator and/or documentation

90. 90 Probable Cause- The payment information listed in Locator 39 was used to coordinate benefits. Resolution- Review claim submission to verify that the information listed in Locator 39 (amount field) was actually the payment from the primary carrier. If the information was correct adjust the balance to $0.00. If incorrect information was listed, correct the information and resubmit the claim as an adjustment.

92. 92 Probable Cause- Invalid revenue code has been billed Resolution- Compare all revenue codes billed to the Medicaid Revenue Code Table listed in the exhibits of Chapter V in the Hospital Manual. Correct the claim information and resubmit.

93. 93 SLH Outpatient Revenue Codes 0450-Hospital Emergency Room 0510-Hospital Outpatient Clinic 0490-Hospital Ambulatory Surgery Suite

96. 96 Probable Cause There is an approved PA on file and the authorized PA units have not all been used. The claim submission is for more units than the balance of the authorization units. Resolution Review PA approval and patient’s claim history to calculate units billed and approved by Medicaid. This will allow you to know the unit balance for the PA.

99. Locator 46: Units of Service

101. Locator 47: Total Charges (by Revenue Code)

107. 107 Locator 60 TDO-DMAS staff will enter the enrollee’s ID number after eligibility has been determined SLH-Enter the unique SLH ID number assigned by the local Department of Social Services.

109. 109 Probable Cause Billed service requires authorization from WVMI and no PA number was listed in Locator 63. Resolution If authorization was obtained prior to the service being performed, resubmit the claim with the PA number listed in Locator 63.

110. 110 Probable Cause The PA number listed on the claim has expired, has not been entered into the Medicaid system, or the thru dates listed on the claim are after the time period approved for the PA. Resolution Review the PA to make sure the service billed and the dates listed on the claim match the information on the authorization.

111. 111 Probable Cause- The procedure code and procedure type or the revenue code on the PA file does not match the procedure code and procedure type or revenue code on the claim. Resolution Review the PA and correct the claim submission if services provided match the PA information.

112. 112 Probable Cause The from and thru dates of service billed do not fall within the PA’s begin and end dates. Resolution Review PA. If a new period of time has been authorized, the claims submitted should match the time frame approved. Correct and resubmit the claim.

114. MEDICARE PRIMARY/Days Exhausted Preauthorization from WVMI is REQUIRED Proof of exhausted Medicare days must be submitted with preauthorization request MATERNITY CLAIMS/Baby delivered elsewhere – When delivery occurred outside of hospital preauthorization from WVMI is required.

119. 119 Locator 80: Principal  Procedure Code and Date For outpatient claims, a procedure code must appear in this locator when revenue codes 0360-0369, 0420-0429, 0430-0439, and 0440-0449 (if covered by Medicaid) are used in locator 42 or the claim will be rejected.

120. 120 Locator 80: Principal  Procedure Code and Date For inpatient claims, a procedure code or one of the diagnosis codes of V64.1-V64.3 must appear in this locator (or on FL 67) when revenue codes 0360-0369 are used in FL 42 or the claim will be rejected.

121. 121 Locator 80: Principal  Procedure Code and Date Procedures that are done in the Emergency Room (ER) one day prior to the client being admitted for an inpatient hospitalization from the ER may be included on the inpatient claim.

122. 122 SLH For outpatient ambulatory surgical center claims, a CPT procedure code must appear on the same line as the revenue code 0490 in Locator 42 or the claim will be denied

126. 126 Probable Cause The provider number listed in Locator 83 is not the correct Medicaid Provider Number for the patient’s PCP The provider number listed in Locator 83 is a UPIN number Resolution Contact the patient’s PCP for the correct Medicaid Provider Number and resubmit the claim

128. Locator 85: Provider Representative

129. Locator 86: Date

130. 130 Medicaid Claims Correction vs. Appeals Claims submitted to VA Medicaid which have been denied for these claim issues do not meet our definition of an appeal: Claim form not completed correctly Incorrect procedure/diagnosis codes Additional information required and not submitted with claim Authorization not listed or incorrect Provider should correct the information and resubmit as a brand new claim.

131. 131 Medicaid Claims Correction VS. Appeals Claims submitted to Medicaid which have been denied for: Service not covered by Medicaid Authorization denied or service not authorized within specified Medicaid guidelines Service denied as not being medically necessary Repayment of identified overpayments Services denied for these reasons can be appealed.

132. 132 Medicaid Appeal Guidelines Specific Medicaid appeal guidelines can be found the Hospital Manual.

133. TDO Tips

134. 134 TDO Tips Make sure that the TDO order is attached to every claim, a copy is acceptable Make sure the provider number is in Locator 51 Make sure the revenue codes are 4 digit codes

135. 135 TDO Tips When using COB code 83 in Locator 39 make sure the dollar amount listed as paid from the primary carrier is for the TDO period ONLY, not the entire paid amount Locator 46 and 7 should always be the same

136. 136 TDO Tips The TDO period shall not exceed 48 hours, if the 48 hrs ends on a Sat. Sun. or legal holiday it will end on the next work day which is not a Saturday Bill type 131 MUST have the ER Report attached to the claim

137. SLH Tips

138. 138 SLH Tips Claims will no longer pend for reason code 0737- SLH Hospital Review M codes ended as of 12/31/03. Claims can only be adjusted within the same fiscal year

139. 139 SLH Tips If an earlier claim was submitted with documentation you may indicate in Locator 84 that documents were already submitted and indicate the ICN of that claim rather than attaching documentation again

140. 140 Error Reason Code 0291 may be identified when checking the status of SLH claims via the MediCall or ARS system. Claims received after SLH funds are exhausted will be pended with Code 0291- Claim Pended for Budget (SLH Funds) This information is not currently reported on your Remittance Advice (RA).

141. 141 If there are no SLH funds available, claims are placed in the pended status until the end of the program year (SLH Program year runs May 1 – April 30). If the locality’s funds are exhausted, and a previously approved claim payment is retracted, the funds will be made available to be paid on the next claim- from the pended group.

142. Medicare Primary Crossover Claims

143. 143 Medicare Primary  Billing Instructions for CMS-1450 The word “CROSSOVER” must be entered in Block 11 of the UB-92 to identify Medicare crossover claims. Coordination of Benefits (COB) codes 83 and 85 must be accurately printed in Blocks 39-41 of the UB-92.

144. 144 Medicare Primary  Billing Instructions for CMS-1450 The first occurrence code 83 indicates that Medicare paid and there should always be a dollar value associated with this code. The A1 indicates Medicare deductible and code A2 indicates Medicare coinsurance

145. Medicare Primary: Blocks 39-41 Line a 83 = Billed and Paid (enter amount paid by Medicare or other insurance). Line a A1 = Deductible Payer A. (enter Medicare Deductible Amount on the EOMB). Line a A2 = Co-Insurance Payer A. (enter Medicare Co-Insurance amount on the EOMB).

146. 146 Medicare Primary  Billing Instructions for CMS-1450 Note: Complete all information in Locators 39a through 41a first (payments by Medicare or payments by other insurance) before entering information in 39b through 41b locators etc.

147. 147 Medicare Primary Billing Instructions for CMS-1450 COB code 85 is to be used when another insurance carrier is billed and there is no payment from that carrier. For the deductibles and co-insurance due from any other carrier(s) (not Medicare) the code for reporting the amount paid is B1 for the deductibles and B2 for the coinsurance.

148. 148 Medicare Primary Billing Instructions for CMS-1450 Block 77 on the UB-92 is not required. The 10/28/03 Medicaid Memo erroneously listed this as a required field. Block 80 must be left blank for UB-92 Medicare Part B paper claims. If applicable, an ICD-9-CM procedure code should be entered in Block 80 for Medicare Part A claims.

149. 149 Hospital Claims In order to avoid claim denials for outpatient hospital services over $20,000 and inpatient hospital services over $500,000, these claims should be submitted to Medicaid on paper instead of electronically. The paper claim will pend and the attachments to the claim will be reviewed for justification of the charges.

150. 150 DRG DMAS implemented Version 21 of the AP-DRG Grouper effective for hospital discharges on or after October 1, 2004. DMAS will continue using Version 14 for discharges on or before September 30, 2004.

151. 151 Outpatient Surgery For elective outpatient surgical procedures which require Preauthorization by Medicaid Medical Support (Physician’s Manual, Chap. IV, pgs. 89.1-99), submit paper claim. Contact the surgeon and request a copy of his PA letter ( the facility services do not required preauthorization). Attach a copy of the PA letter to the back of your claim form. Do not put the Physician’s PA # on your claim.

152. REMITTANCE VOUCHERSections 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.

153. REMITTANCE VOUCHERSections of the Voucher FINANCIAL TRANSACTION EOB DESCRIPTION ADJUSTMENT DESCRIPTION/REMARKS- STATUS DESCRIPTION REMITTANCE SUMMARY- PROGRAM TOTALS

155. THANK YOU Department of Medical Assistance Services www.dmas.virginia.gov