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CMS-1500 (08-05) Billing Guidelines

CMS-1500 (08-05) Billing Guidelines. Department of Medical Assistance Services February 2010 www.dmas.virginia.gov. This presentation is to facilitate training of the subject matter in Chapter V of the Virginia Medicaid Physicians Manual.

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CMS-1500 (08-05) Billing Guidelines

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  1. CMS-1500 (08-05)Billing Guidelines Department of Medical Assistance Services February 2010 www.dmas.virginia.gov

  2. This presentation is to facilitate training of the subject matter in Chapter V of the Virginia Medicaid Physicians Manual. This training contains only highlights of this manual and is not meant to substitute for or take the place of the PhysiciansManual. Providers are responsible for reviewing and adhering to the Physicians Manual requirements.

  3. Objectives • To familiarize the providers with the billing guidelines of the CMS-1500 claim form. • To give the providers clear instructions on the requirements of DMAS for the completion of the CMS-1500 claim form.

  4. Participating Providers 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.

  5. COMMONWEALTH OF VIRGINIA DEPARTMENT OF MEDICAL ASSISTANCE SERVICES 002286 999999999999 VIRGINIA J. RECIPIENT DOB: 05/09/1994F CARD# 00001

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

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

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

  9. ARS Registration Process https://uac.fhsc.com/uac/pages/unsecured/common/home.jsf • Select the ARS tab on FHSC ARS Home Page • Choose “User Administration” • Follow the on-screen instructions for help with registration, this is a 3-step process to request, register and activate a new account • Answer the initial ‘Who are you?’ question by selecting ‘I do not have a User ID and need to be a Delegated Administrator’

  10. ARS – Users • ARS User’s Guide http://www.dmas.virginia.gov/prclaims_billing.htm • Web Support Helpline- 800-241-8726

  11. Important Contacts • Provider Call Center • Provider Enrollment • Electronic Claims Coordinator

  12. Provider Helpline Claims, covered services, billing inquiries: 800-552-8627 804-786-6273 8:30am – 4:30pm (Monday-Friday) 11:00am – 4:30pm (Wednesday)

  13. Provider Enrollment New provider enrollment, Electronic Fund Transfer (EFT) or change of address: First Health – PEU P. O. Box 26803 Richmond, VA 23261 888-829-5373 804-270-5105 804-270-7027 - Fax

  14. 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

  15. Claim Attachment FormDMAS-3 The DMAS-3 form is to be used by Electronic Data Interchange (EDI) billers only to submit a non-electronic attachment to an electronic claim. See Chap. V Exhibits pg. 5 Attachment Control Number (ACN) should be indicated on the electronic claim submitted. The ACN number is the combined information from: Patient Account Number Date of Service Sequence Number

  16. Claim Attachment FormDMAS 3 – Sample ACN# Patient Account Number 123456789 Date of Service 09/11/2009 Sequence Number 12345 ACN number listed on form will be- 1234567890911200912345

  17. Billing on the CMS-1500 7

  18. MAIL CMS-1500 FORMS TO: DEPARTMENT OF MEDICAL ASSISTANCE SERVICES PRACTITIONER P. O. Box 27444 Richmond, Virginia 23261

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

  20. TIMELY FILING • Submit claims with documentation attached to the back of the claim form, explaining the reason for delayed submission

  21. Block 1 • The locator will now be used to indicate if the claim is Medicaid, TDO, or ECO. • Enter an ‘X’ in the MEDICAID box for the Medicaid Program • Enter an ‘X’ in the OTHER box for Temporary Detention Order (TDO) or Emergency Custody Order (ECO)

  22. Block 1 TRICARE MEDICAID 1.MEDICARE CHAMPUS (Medicare#) (Medicaid#) (Sponsor'sSSN) 2.PATIENT'SNAME(LastName,FirstName,MiddleInitial) MEDICAID CLAIM 13

  23. Block 1 GROUP CHAMPVA FECA OTHER HEALTH PLAN BKLLUNG (ID) (MemberID#) (SSNorID) (SSN) TDO or ECO CLAIM 14

  24. Block 1a: Recipient ID Number 1a.INSURED'SI.D.NUMBER(FORPROGRAMINITEM1) 123456789014 (Be sure to include all 12 digits) 15

  25. Block 2: Patient's Name 2.PATIENT'SNAME(Lastname,FirstName,MiddleInitial) Smith, Sam 5.PATIENT'SADDRESS(No.,Street) 16

  26. Is Patient’s Condition Related To? Block-10 • If the condition is related to an auto accident, and you have this information, place the postal code (i.e. VA, TN, WV) of the state in which the accident occurred.

  27. Block 10: Accident-Related 10.ISPATIENT'SCONDITIONRELATEDTO: a.EMPLOYMENT?(CURRENTORPREVIOUS) YES NO PLACE(State) b.AUTOACCIDENT? WV YES NO c.OTHERACCIDENT? NO YES You MUST check YES or NO for a, b & c 18

  28. Insurance Plan Name or Program NameBlock-11c • Providers that are billing for non-Medicaid Managed Care Organizations (MCO) co-pays please insert ‘HMO COPAY’ • The amount billed to Medicaid in 24F (Charges) must represent only the enrollees co-payment amount for the HMO, and the Explanation of Benefits (EOB) must be attached. • Use the CPT or HCPCS procedure code that was billed as the primary procedure to the HMO. • This does not apply to enrollees in a Medicaid HMO, e.g., Medallion II.

  29. Block 11c - Insurance Plan Name or Program Name c. INSURANCE PLAN NAME OR PROGRAM NAME HMO COPAY 21

  30. CHANGE – Is There Another Health Benefit Plan?Block-11d • Providers should always check ‘YES’ if there is verification of Third Party Liability • If there is no other coverage check no or leave blank

  31. Block 11d - Is There Another Health Benefit Plan? d. IS THERE ANOTHER HEALTH BENEFIT PLAN? If yes, return to and complete item 9 a-d. NO YES DMAS does not require items9 a-dto be completed. 23

  32. Blocks 17 and 17b- Conditional 17. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE 17- Name of the Recipient’s PCP 17b- PCP’s NPI 17a. 1234567890 17b. NPI 58

  33. Block 19- Conditional Use 19. RESERVED FOR LOCAL USE Clinical Laboratory Improvement Amendment (CLIA) Number of the physician office laboratory (POL) performing the service. 28

  34. Block 21: Diagnosis Codes 21.DIAGNOSISORNATUREOFILLNESSORINJURY 3441 1. 3. 2963 2. 4. May enter up to 4 codes Omit decimals 29

  35. Prior Authorization NumberBlock-23 • If service requires prior authorization, enter the eleven digit PA number assigned by KePRO • Enter the number pre-assigned to the TDO or ECO form that is obtained from the magistrate authorizing the TDO/ECO.

  36. Block 23: Prior Authorization Number - Conditional 23.PRIORAUTHORIZATIONNUMBER 31

  37. Blocks 24A thru 24J • 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

  38. TPL Information Block 24A-shaded red area • Qualifier ‘TPL’ will be used followed by dollars/cents amount whenever an actual payment is made by a third party carrier • No spaces between the qualifier and dollars and no $ symbol used • Decimal between dollars and cents is required to read paid amount correctly • Must be left justified

  39. Block 24A: Dates of Service 24.A. DATE(S)OFSERVICE From To amount paid by primary carrier $27.08 MMDDYY MMDDYY TPL27.08 09 09 12 01 12 01 1 09 09 12 01 12 31 2 TPL Information 68

  40. TPL Billing Scenarios No other insurance Check ‘NO’ in Locator 11d or leave blank Do not document any information in the shaded red area of 24A 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

  41. TPL Billing Scenarios Primary carrier does not pay Payment applied to deductible/claim denied Provider receives EOB Check ‘YES’ in Locator 11d Attach copy of EOB showing non-payment to the back of the DMAS claim form Do not document any information in the shaded red area of 24A

  42. TPL Billing Scenarios Primary carrier does not pay Service not covered Check ‘YES’ in Locator 11d Attach EOB documenting that services are not covered or, attach letter verifying the service is not covered Do not document any information in the shaded red area of 24A

  43. TPL Billing Scenarios Primary carrier does not pay Provider not enrolled with carrier Check ‘YES’ in Locator 11d Attach letter documenting the provider is not enrolled with the primary carrier Do not document any information in the shaded red area of 24A

  44. TPL Billing Scenarios Primary carrier does not pay Policy is no longer active/coverage terminated Check ‘YES’ in Locator 11d Attach EOB verifying that the policy is not active or, attach letter verifying the policy is not active Do not document any information in the shaded red area of 24A

  45. NDC Information Block-24A • 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

  46. Block 24A: Dates of Service 24. A. DATE(S) OF SERVICE From To MM DD YY MM DD YY N400026064871 09 09 12 01 12 01 1 12 01 09 12 16 09 2 NDC Information 37

  47. Block 24A: Dates of Service 24.A. DATE(S)OFSERVICE If both NDC and TPL apply to a single procedure both must be placed on the same line, it does not matter which comes first From To MMDDYY MMDDYY N400026064871 TPL27.08 09 09 12 01 12 01 1 12 01 09 12 31 09 2 TPL and NDC information 31

  48. Block 24A: Dates of Service 24.A. DATE(S)OFSERVICE From To MMDDYY MMDDYY 09 09 12 01 12 01 1 12 01 09 12 16 09 2 BothFROMandTOdates must be completed 36 Dates must be within same calendar month

  49. Block 24B: Place of Service Note: Type of Service is no longer required B. Place of Service 11-Office location 21- Inpatient 11 Medicaid accepts the same 2 digit CMS Place of Service codes as Medicare. 37

  50. Emergency IndicatorBlock 24C • This locator will be used to indicate whether the procedure was an emergency • DMAS will only accept a ‘Y’ for yes in this locator • If there was no emergency leave blank

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