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  1. Department of Medical Assistance Services Medicaid Eligibility Verification Options &Residential Treatment FacilityCMS-1450 (UB-04) Billing Requirements September – October 2010

  2. This presentation is to facilitate training of the subject matter in the Virginia Medicaid Psychiatric Services manual. This training contains only highlights of the manuals and is not meant to substitute for or take the place of the manual. Providers are responsible for reviewing and adhering to all Medicaid manual requirements.

  3. Agenda 1. Medicaid Eligibility VerificationOptions 2. Service Authorizations 3. Timely Filing 4. CMS-1450 (UB-04) Billing Requirements

  4. As a Participating Provider You 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.


  6. Important Contacts • MediCall • ARS- Web-Based Medicaid Eligibility • Provider Call Center • Provider Enrollment • Electronic Claims Coordinator

  7. MediCall/Automated Response System (ARS) • Available 24 hours a day, 7 days a week • Medicaid Eligibility Verification • Claims Status • Service Limits • Service Authorization Information • Primary Payer Information • Medallion Participation • Managed Care Organization Assignment

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

  9. Automated Response System (ARS) • Web-based eligibility verification option • Free of Charge. • Information received in “real time”. • Secure • Fully HIPAA compliant

  10. Registration Process • First Time Users • To establish an user ID and password go to: • By registering you are acknowledging yourself as a staff member with administrative rights for the organization

  11. Registration Process • Established Users- Delegated Administrators • Received a letter containing their NPI and instructions on accessing the Web Portal • Must have accessed the Web Portal and changed their temporary password • Capable of adding or deleting ARS users

  12. ACS Web RegistrationSupport Call Center • Questions regarding new user registration, existing user access letter, or temporary passwords • 1-866-352-0496 • 8 am – 5 pm Monday thru Friday • No holidays •

  13. 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)

  14. Provider Enrollment NPI enrollment, EFT sign-up, update provider email phone contact or change of address: Provider Enrollment Unit P. O. Box 26803 Richmond, VA 23261 888-829-5373 804-270-5105 804-270-7027 - Fax

  15. ARS Prior Authorization Status Codes/Descriptions 15

  16. ARS Prior Authorization Status Codes/Descriptions 16

  17. Service Authorization Log Service Authorization IDHeader Status 1234567890 Rejected Service Line Item Information Procedure Code Begin Date End Date Authorized Units Authorized Amount Units Used Used Amount Remaining Units 90806 09/12/2010 12/12/2010 15 15 Please review the status of your service authorization. Just because an authorization number was assigned to your request, that does not mean it was approved. All requests are assigned a Service Authorization ID. 17

  18. Electronic Billing Electronic Claims Coordinator Phone: (866) 352-0766 Fax: (888) 335-8460 E-mail:

  19. MAIL CMS-1450 (UB-04) FORMS TO: Virginia Medical Assistance Program P. O. Box 27443 Richmond, Virginia 23261


  21. TIMELY FILING • Submit claims with documentation attached (to the back of claim) explaining the reason for delayed submission

  22. Printing • Must be RED OCR dropout ink or the exact match • Computer generated form must match/line up with National Uniform Claim Committee standard • Print 100% of actual size, set page scaling to “none” • Set page scaling to ‘none’ • Margins must be exact • DMAS will not reprocess claims denied for scanning issues as a result of failure to follow the above instructions

  23. CMS-1450CLAIM FORM: Use ONLY the ORIGINAL RED & WHITE UB-04 Invoice Photocopies are not Acceptable Computer generated claims must match NUBC uniform standards

  24. Locator 1: Provider’s Name, Address and Phone Number • Enter the provider’s name, complete mailing address and telephone number of the provider that is submitting the bill and which payment is to be sent. • NOTE: DMAS will need to have the 9 digitzip code on line four, left justified for adjudicating the claim.

  25. Locator 1: Provider Name, Address and Phone Number 1 Our Place Facility 121 Friendly Street Any Town VA 12345-6456 8049781234 25

  26. Locators 3a and 3b • 3aPatient Control Number - Enter the patient’s unique financial account number which does not exceed 20 alphanumeric characters. • 3b Medical/Health Record - Enter the number assigned to the patient’s medical/health record by the provider. This number cannot exceed 24 alphanumeric characters. 26

  27. Locators 3a-Patient Control Number& 3b-Medical/Health Record Number 3a PAT. CNTL # 123456789ABCDEFGH012 b. MED REC. # 987654321HGFEDCBA1234567 Patient Control Number and Medical/Health Record Number are required for all UB-04 claim submissions. 27

  28. Locator 4 :Type of Bill • Enter the code as appropriate. • The Type of Bill field is four digits with a leading zero. • Claims submitted without the required four digit bill type will be denied.

  29. Locator 4: Type of Bill 0161 Original Residential Treatment Invoice 0162 First Interim Residential Treatment Invoice 0163 Subsequent Residential Treatment Invoice (s) 0164 Final Residential Treatment Invoice 0167 Adjustment Residential Treatment Invoice 0168 Void Residential Treatment Invoice Only approved claims can be adjusted or voided. 29

  30. Locator 4: Type of Bill • 0161- • Use this bill type for patients who are admitted and discharged within the same month. • For established patients who leave your facility for admission to an acute care hospital, and return within the same month, two separate claims must be submitted.

  31. Example: Same MonthAdmit/Discharge/Re-Admit • First claim will be a Bill Type 0164, as the patient was discharged to be admitted to the acute care facility. • The second claim, billed for the patient being readmitted to your facility, will be a Bill Type 0162.

  32. Admit/Discharge/Re-Admit Patient admitted to residential facility 08/13/10. Patient developed pneumonia and was admitted to a hospital on 09/12/10. Patient returned to the residential facility on 09/20/10. Bill Type 0164 for dates 09/01/10 – 09/12/10, with a status of 02. Bill Type 0162 for dates 09/20/10 – 09/30/10, with a status code of 30.

  33. 4 TYPE OF BILL Residential Treatment Facility 0162 Locator 4: Type of Bill InterimBill 33

  34. Locator 6:Statement Covers Period • STATEMENT COVERS PERIOD • FROM THROUGH 083110 080110 Enter the beginning and ending service dates reflected by this invoice (include both covered non-covered days). Use both “from” and “to” for a single day. Invoice billing periods cannot overlap months. 34

  35. Locator 8:Patient Name/Identifier 8 PATIENT NAME a b Last First M Enter the last name, first name and middle initial of the patient. 35

  36. Locator 10:Patient Birthdate 10 BIRTHDATE 10011995 Enter the date of birth of the patient using the following format - MMDDYYYY. 36

  37. Locator 11:Sex 11 SEX F Enter the sex of the patient as recorded at admission, outpatient or start of care. M = Male; F = Female; U = Unknown 37

  38. Locator 12:Admission/Start of Care • The start date for this episode of care. For inpatient services this is the date of admission. For all other services, the date the episode of care began: Residential Treatment Facility – Original admission date or new date the patient is re-admitted to the facility.

  39. Locator 12:Admission/Start of Care ADMISSION 12 DATE 080110 39

  40. Locator 13: Admission Hour ADMISSION 13 HR 14 Enter the hour during which the patient was admitted to the facility. Medicaid will allow a default time for Residential Facility patients. NOTE: Military time is used as defined by NUBC. 40

  41. Locator 14: Priority Type of Visit Appropriate PRIORITY TYPE codes accepted by DMAS are: 41

  42. Locator 14:Priority (Type) of Visit ADMISSION 14 TYPE 3 Enter the code indicating the priority of this admission /visit. 42

  43. Locator 15: Source of Referral/Admission 9 Information Not Available

  44. Locator 15:Source of Referral for Admission Visit 15 SRC 6 Enter the code indicating the source of the Referral for this admission or visit. 44

  45. Locator 17:Patient Discharge Status Appropriate codes accepted by DMAS in claims processing: 45

  46. Locator 17: Patient Discharge Status Appropriate codes accepted by DMAS in claims processing: 46

  47. Locator 17:Patient Discharge Status 17 STAT 30 Enter the code indicating the disposition or Discharge status of the patient at the end for the Service period covered on this bill (Statement Covered Period, Locator 6). 47

  48. Locators 18-28: Condition Codes • These codes are used by DMAS in the adjudication of claims: NOTE: Condition CodeA1 is a required for all Residential Facility Claims submitted to DMAS. 48

  49. Locators 18-28: Condition Codes(Required if Applicable) Condition Codes 18 19 20 21 22 23 24 25 26 27 28 A1 Enter the code (s) in alphanumeric sequence Used to identify conditions or events related to this bill that may affect adjudication. 49

  50. Locators 39-41:Value Codes and Amount • Note: DMAS will be capturing the number of covered or non-covered day (s) or units for outpatient services with these required value codes: • Enter the number of covered days for inpatient facility. • Enter the number of non-covered days for facility.