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 Website 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 Website Financial Reason Code Description List State and Local Hospital (SLH) Program Balance Statement Virginia Medicaid Error Code Crosswalk Listing Hospital DRG Rates for Fiscal Year 2005 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 physician who is not the PCP will be reimbursed only: in a medical emergency/delay in tx 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 a pregnancy related service paid by Medicaid on or after 10/01/03 is automatically eligible for the waiver at the end of her Medicaid coverage. The Medicaid client should visit her local DSS to ensure she has been enrolled. Eligible clients are enrolled for up to 24 months following the end of pregnancy.

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-1500

45. 45 MAIL CMS-1500 FORMS TO: DEPARTMENT OF MEDICAL ASSISTANCE SERVICES PRACTITIONER P. O. Box 27444 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 10d and use modifier “22” in Locator 24D

68. 68 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.

69. 69 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.

70. 70 Medicaid Appeal Guidelines Service specific Medicaid appeal guidelines can be found the Physician’s Manual Chapter II and IV.

71. Medicaid Error Codes Resolutions

72. 72 Probable Cause: Client is in the Medallion Program and the PCP number is not listed or is incorrect Correction: Make sure that the claim form has the correct PCP referral number listed in Locator 17A of the CMS-1500

73. 73 Probable Cause: Provider is billing services for specified aliens with no authorization Correction: Emergency claims for non-resident aliens must be submitted with a copy of the Emergency Medical Certification Form.

74. 74 Probable Cause: Claim was submitted with primary carrier information but no payment amount was indicated on the claim Correction: Claims submitted with COB code 3 in Locator 24J must have the amount paid by the primary carrier in Locator 24K

75. 75 Probable cause: Dates of service were over a year old and provider did not include any justification Correction: Claims for service rendered that exceed the 12 month timely filing requirements (12 months past the date of service) must have documentation attached to waive timely filing

76. 76 Correction (cont’d): Enter the word “attachment” in Block 10d and a modifier “22” in Block 24D of the CMS-1500

77. 77 Correction (cont’d): Include Remit or documentation from DMAS showing the claim was originally denied or rejected with the timely filing limit Letter from the case worker at Social Services both signed and dated verifying retroactive eligibility

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79. 79 Additional Error Codes 0014- Billed Amount Missing or Invalid 0110- Diagnosis Code Does Not Agree with Age 0159- Provider Disagrees with Authorization 0202- Duplicate- Different Provider, Same DOS 0301- Duplicate Payment- Same Provider, Same DOS

80. 80 Additional Error Codes 0302- Duplicate of History - Same Provider, Same DOS 0352- Only Paid Payment Requests Can be Adjusted/Voided 0967- HCPCS/Diagnosis Restriction 1108- Contraindicated Audit - Same Provider /Date of Service 1471- Same as 0302

81. 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.

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

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